Impact of Prothrombin Complex Concentrate on Blood Use, Cost, and Outcomes in Heart Transplantation

Abstract

Left ventricular assist device (LVAD) recipients undergoing heart transplantation have increased bleeding risk. We compared conventional warfarin reversal with fresh frozen plasma vs 4-factor prothrombin complex concentrate (PCC) and the effect on transfusion requirements, blood bank costs, and clinical outcomes. A retrospective review identified 60 consecutive LVAD recipients undergoing heart transplantation divided into two groups: 30 (no PCC) received fresh frozen plasma and 30 (PCC) received PCC. Patient characteristics, intraoperative and postoperative transfusion requirements, short-term clinical outcomes, and blood bank costs were compared. PCC association with transfusion requirements was assessed by multivariate linear regression. Patients who received PCC were younger (50 ± 11 vs 57 ± 13 years, p= 0.02), fewer had ischemic cardiomyopathy (23% vs 60%, p= 0.01), had more than one prior sternotomy (7% vs 30%, p= 0.04), and had higher preoperative hemoglobin (11.8 ± 1.8 vs 10.4 ± 1.8 g/dL, p= 0.01). The PCC group had a significantly shorter bypass time (185 vs 217 minutes, p= 0.01), received less fresh frozen plasma (2 vs 5 units, p= 0.03), cryoprecipitate (0 vs 2 units, p= 0.05), and total blood products (9 vs 13.5 units, p= 0.03) intraoperatively, and was less likely to require delayed sternal closure (3% vs 23%, p= 0.05). On multivariate linear regression, PCC was significantly associated with decreased intraoperative transfusion (β= -6.09, p= 0.02). There was no difference in thromboembolic events or in-hospital death. Total blood bank costs were $4,949 for PCC and $3,677 for no PCC (p= 0.01). Although more costly, PCC reduced transfusion requirements and delayed sternal closure in heart transplant recipients bridged with LVAD, justifying its use over traditional warfarin reversal.