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Coagulopathy in Cardiac Surgery: A Scoping Review of Prothrombin Complex Concentrate
Stanislaw Vander Zwaag1, Imre Kukel1, Jens Fassl1
1Institute of Cardiac Anaesthesiology, Heart Centre and Medical Faculty, TUD Dresden University of Technology, Dresden, Germany.
Insights
Four-factor prothrombin complex concentrate (PCC) effectively reduces bleeding and transfusion needs after cardiac surgery compared to fresh frozen plasma (FFP). However, optimal dosing and timing remain unclear, necessitating further research.
Area of Science:
- Anesthesiology and Critical Care Medicine
- Hematology
- Cardiovascular Surgery
Background:
- Post-cardiopulmonary bypass coagulopathy increases bleeding, transfusion needs, and mortality.
- Fresh frozen plasma (FFP) is traditional, but four-factor prothrombin complex concentrate (PCC) is an emerging alternative.
Purpose of the Study:
- To systematically review evidence on the efficacy, safety, and optimal use of four-factor PCC in adult cardiac surgery.
- Identify knowledge gaps regarding dosing, timing, cost-effectiveness, and safety of PCC.
Main Methods:
- A comprehensive scoping review following PRISMA-ScR guidelines.
- Systematic search of multiple databases without language or date restrictions.
- Independent data extraction and charting by two blinded reviewers.
Main Results:
- PCC consistently reduces postoperative chest tube output and transfusion requirements versus FFP.
- Dosing varied widely (500-4000 IU fixed or 15-30 IU/kg weight-based).
- Viscoelastic testing guides use, but standardized thresholds are absent; PCC may be cost-effective and safe.
Conclusions:
- Significant evidence gaps exist for optimal PCC dose, timing, viscoelastic targets, and sequencing with fibrinogen concentrate.
- Further high-quality randomized trials are essential to refine clinical guidelines for PCC in cardiac surgery.
Background:
Coagulopathy after cardiopulmonary bypass substantially contributes to postoperative bleeding, transfusion requirements, morbidity, and mortality. The traditional treatment option is fresh frozen plasma (FFP), but prothrombin complex concentrate (PCC) has become an alternative in the past years.
Aim:
This study aimed to systematically map the current evidence and identify critical knowledge gaps regarding the efficacy, optimal timing, dosing regimens, point-of-care testing guidance, administration order, cost-effectiveness, and safety of 4-factor PCC in adult patients undergoing on-pump cardiac surgery, thereby informing future research priorities.
Method:
A scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. A search of several databases was conducted on 8 April 2025 without restrictions on the language or date of the publications. Study selection, data extraction, and charting were performed independently by two mutually blinded reviewers.
Results:
A total of 57 primary studies (seven randomised controlled trials, 36 retrospective cohorts, five prospective cohorts, and nine experimental investigations) and 15 reviews with or without meta-analyses were identified. Evidence consistently indicates that PCC reduces postoperative chest tube output and transfusion requirements compared with FFP, although the effect sizes vary. Reported dosing ranged from fixed 500-4000 IU to weight-based 15-30 IU kg-1. Viscoelastic testing guides PCC administration; however, standardised thresholds are lacking. Limited data suggest that PCC may be more cost-effective than FFP, and serious adverse events appear to be rare. No study has directly compared different PCC dosing regimens or prophylactic use in high-risk patients.
Conclusions:
Substantial evidence gaps remain concerning the optimal dose, timing, viscoelastic targets, sequencing with fibrinogen concentrate, and health economic analyses of PCC use in cardiac surgery. High-quality randomised trials addressing these unanswered questions are warranted to refine the clinical guidelines.
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