Prothrombin Complex Concentrate vs Factor VII for Refractory Bleeding in Cardiac Surgery

Perioperative bleeding remains an important complication of cardiac surgery. Current guidelines support goal-directed use of coagulation factor concentrates in refractory bleeding, but the optimal strategy is unclear. Four-factor prothrombin complex concentrate (4F-PCC) has theoretical advantages over recombinant activated factor VII (rFVIIa) because of expanded mechanistic targets and lower rates of adverse events, but comparative data are limited.

We pursued a retrospective cohort study assessing the implementation of an institutional treatment algorithm for refractory bleeding in cardiac surgery that mediated a practice change in preferred factor product from rFVIIa to 4F-PCC. All cardiac surgery patients at 2 large community hospitals who received 4F-PCC or rFVIIa during 2019-2020 were assessed for inclusion. The primary outcome was all-cause in-hospital mortality.

A total of 42 patients met study criteria. Mortality was nonsignificantly lower in the 4F-PCC group (7.1% vs 28.6%; P = .16), as were median total blood products transfused (15 vs 25.5 units; P = .11), although median units of cryoprecipitate were significantly lower (0.5 vs 2 units; P = .01). Average factor product medication charge per patient was significantly lower in the 4F-PCC group ($9772 vs $50,293; P < .001).

A 4F-PCC-based strategy for refractory bleeding in cardiac surgery was associated with reduced cryoprecipitate transfusion and medication costs without significant differences in inpatient mortality or total transfusion exposure. Trends toward decreased mortality and transfusions observed in this quality improvement study should be explored in larger prospective trials.