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Clinical Specialist, Assistant Professor, College of Pharmacy, University of Kentucky Chandler Medical Center, Lexington, KY
Critical Care Pharmacy Resident, University of Kentucky Chandler Medical Center
Assistant Professor, College of Medicine, University of Kentucky
Assistant Professor, College of Medicine, University of Kentucky
Assistant Professor, College of Medicine, University of Kentucky
Associate Professor, College of Pharmacy, University of Kentucky
Reprints: Jeremy D Flynn PharmD, College of Pharmacy, University of Kentucky Chandler Medical Center, 800 Rose St., Room C-117, Lexington, KY 40536-0293, fax 859/323-2049, jdflyn0{at}email.uky.edu
OBJECTIVE: To report a case of successful use of recombinant factor VIIa (rFVIIa) for the treatment of refractory bleeding in a patient undergoing orthotopic heart transplantation.
CASE SUMMARY: A 57-year-old white male with idiopathic cardiomyopathy was taken to the operating room for explantation of his left-ventricular assist device and orthotopic heart transplantation. He experienced excessive generalized oozing that required transfusions of multiple units of blood products and significant amounts of Cellsaver (washed red blood cells via autotransfusion) without achieving adequate hemostasis. After ruling out any obvious surgical sources of bleeding and attempting to correct all coagulation deficiencies, the clinicians administered rFVIIa 90 µg/kg. The oozing rapidly declined to a negligible level, chest tubes and sternal wires were placed, and the chest was closed. The patient was on minimal inotropic support and was transferred to the intensive care unit in stable condition.
DISCUSSION: Cardiac surgery is often associated with significant disruption of the coagulation system, particularly in high-risk patients, such as those undergoing removal of a ventricular assist device and subsequent orthotopic heart transplantation. This can lead to life-threatening bleeding that can require multiple hemostatic agents and significant transfusions to restore hemostasis. Recently, rFVIIa has been utilized as an alternative to massive transfusion for treatment of refractory bleeding in several patient populations, including some cardiac surgery patients.
CONCLUSIONS: rFVIIa appears to be a viable option as rescue therapy for treatment of refractory bleeding following orthotopic heart transplantation. Despite the anecdotal success of rFVIIa in this setting, further clinical research is needed.
Key Words: bleeding, factor VIIa, heart transplantation, ventricular assist device
Published Online, August 31, 2004. www.theannals.com, DOI 10.1345/aph.1E123
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