Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio.
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
Ann Thorac Surg. 2019 May;107(5):1409-1415. doi: 10.1016/j.athoracsur.2018.10.032. Epub 2018 Nov 23.
Anticoagulation therapy with warfarin is common before heart transplantation and complicates perioperative management.
This single-center, noninterventional, retrospective cohort study evaluated heart transplant patients before and after institution of a prothrombin complex concentrates-based preoperative warfarin reversal protocol for heart transplantation. Patients with international normalized ratio (INR) greater than 1.5 who received prothrombin complex concentrate (PCC) before heart transplant surgery were compared with a control group before implementation of a PCC protocol. Coprimary endpoints were utilization of individual blood products. Secondary endpoints included in-hospital mortality, reoperation for bleeding, delayed sternal closure, thromboembolic events, duration of chest tube use, time to extubation, intensive care unit length of stay, and hospital length of stay.
The study included 106 consecutive heart transplant patients (PCC cohort = 57, historical control cohort = 49). There was a significant reduction in fresh frozen plasma utilization in the PCC cohort (6 units versus 8 units, p = 0.002). Rates of packed red blood cells and platelet transfusion were similar between groups. There was a significant increase in the incidence of cryoprecipitate utilization in the PCC cohort, which can likely be attributed to decreased antifibrinolytic utilization. There were no differences in secondary endpoints between groups, including thromboembolic events.
This study found that a PCC-based warfarin reversal protocol significantly reduced fresh frozen plasma utilization compared with historical controls without affecting other clinically important surgical outcomes. These data suggest that PCC is a valuable tool for INR normalization that could safely reduce fresh frozen plasma administration and offer a practical alternative to traditional approaches for INR reversal before heart transplantation.
华法林抗凝治疗在心脏移植前很常见，这增加了围手术期管理的复杂性。
本单中心、非干预性、回顾性队列研究评估了在建立基于凝血酶原复合物浓缩物的术前华法林逆转方案后心脏移植患者的情况。国际标准化比值（INR）大于 1.5 并在心脏移植手术前接受凝血酶原复合物浓缩物（PCC）的患者与在实施 PCC 方案之前的对照组进行比较。主要终点是个体血液制品的使用情况。次要终点包括院内死亡率、出血再手术、延迟胸骨闭合、血栓栓塞事件、胸腔引流管使用时间、拔管时间、重症监护病房住院时间和住院时间。
这项研究包括 106 例连续心脏移植患者（PCC 队列=57 例，历史对照队列=49 例）。在 PCC 队列中，新鲜冷冻血浆的使用量显著减少（6 单位与 8 单位，p=0.002）。两组之间的红细胞和血小板输血率相似。PCC 队列中冷沉淀的使用率显著增加，这可能归因于抗纤维蛋白溶解药物的使用减少。两组之间的次要终点没有差异，包括血栓栓塞事件。
本研究发现，与历史对照组相比，基于 PCC 的华法林逆转方案可显著减少新鲜冷冻血浆的使用，而不会影响其他重要的临床手术结果。这些数据表明，PCC 是一种用于 INR 正常化的有价值的工具，它可以安全地减少新鲜冷冻血浆的使用，并为 INR 逆转提供一种实用的替代传统方法，可用于心脏移植前。
