190Factor VIII inhibitor bypassing activity (FEIBA) as an adjunct in post-cardiotomy bleeding

Abstract

Refractory bleeding after cardiac surgery continues to be a significant challenge. Post-bypass coagulopathy requiring multiple transfusions is associated with higher levels of morbidity and mortality. This problem has been exacerbated in recent years by the increased use of antiplatelet agents and the loss of aprotinin. Factor eight inhibitor bypassing activity (FEIBA) is a coagulation factor concentrate commonly used in haemophelia, but it has also shown some promise in postoperative hemostasis. We report on the largest known series of its use in post-cardiotomy coagulopathy. A retrospective review of 81 consecutive cases involving the use of FEIBA at a provincial cardiac surgical program was performed. From Jan 1, 2008 to Sep 30, 2010, a total of 81 patients received FEIBA for bleeding refractory to routine adjunct therapy such as platelets, fresh frozen plasma (FFP) and cryoprecipitate administration. 28 patients received intra-operative doses only, 44 received postoperative doses only, and 9 received both intra- and post-operative doses. Average age was 66.5 years, with 50 males and 31 females. 18 cases were isolated CABG with all other cases being concomitant procedures or complex urgent cases. For the 37 patients who received intra-operative FEIBA, average CPB time was 237 minutes (S.D. ± 82) and all patients were still bleeding after receiving standard coagulation factors. The average FEIBA dose was 939 Units (S.D. ± 203) and adequate hemostasis allowed for sternal closure in all patients. 28 patients did not receive additional FEIBA, average blood loss over first 12 hours was 677 mls (S.D. ± 314), and only 1 patient required re-exploration. 9 patients were given a second dose postoperatively and 4 patients required re-exploration (4/37, 10.8%). For patients receiving post-operative FEIBA only, average CPB time was 139 minutes (S.D. ± 57), average blood loss was 1271 mls ( ± 455) before FEIBA and 121 mls in the first hour after FEIBA. 9 of those patients required re-exploration. In all 81 patients, there were no strokes or perioperative myocardial infarctions, and 1 mortality (1.2%). Renal insufficiency developed in 12 patients (14.8%). Intra- or post-operative use of FEIBA appears to be effective in controlling refractory bleeding post-cardiotomy, with acceptable rates of complications in a high risk surgical cohort. A prospective randomized trial to further determine this drug's efficacy may be warranted.