Prothrombin Complex Concentrates for Warfarin Reversal Before Heart Transplantation.

Abstract

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.