4-Factor Prothrombin Complex Concentrate (PCC4, Kcentra®) Protocol Reduces Blood Requirements for Heart Transplantation:A Novel Protocol

BACKGROUND All patients with a ventricular assist device (VAD) awaiting heart transplantation are anticoagulated with warfarin to prevent thromboembolism. The use of 4 factor prothrombin complex concentrate (PCC4, Kcentra®) for anticoagulation reversal prior to surgery may include benefits such as quicker reversal, longer duration of action, and a reduction in total volume of blood products used compared to other reversal practices. The study objective is to evaluate benefits of using an anticoagulation reversal protocol featuring PCC4, over standard of care in heart transplant patients requiring anticoagulation. MATERIAL AND METHODS This is a single center, combined retrospective and prospective, time-matched cohort study compared 12 patients transplanted pre-protocol and 11 patients transplanted post-protocol. The primary outcome was the total volume of blood and blood products used. Secondary outcomes included length of hospital and ICU stay, safety and adverse events, primary chest closure, and a cost comparison. RESULTS The PCC4 reversal protocol showed a significant reduction in total blood volume received with an overall decrease of 1.76L (4.20L pre-protocol, 2.45L post-protocol, P=0.037), total units of blood products infused (20 units pre, 12 units post, P=0.033), and units of packed red blood cells (7 units pre, 3 units post, P=0.033). All heart transplant recipients were listed Status 1A with the primary indication being infection (n=12; 52%). Baseline characteristics, survival, and cost were not different between the two groups. There were no thrombotic events or patient that experienced serious reactions to PCC4. Secondary outcomes were only significant to time to INR reversal. CONCLUSIONS Patients treated with the PCC4 protocol demonstrated a significant decrease in volume of blood and units of blood products required prior to chest closure for heart transplant patients. PCC4 was found to be a safe and beneficial agent in anticoagulation reversal for patients on anticoagulation prior to heart transplantation.