Prothrombin Complex Concentrate for Emergent Reversal of Intracranial Hemorrhage in Patients with Ventricular Assist Devices. (16th November 2020)

• Record Type: Journal Article
• Authors: Lai, Grace Y; Leong, Christopher; Pham, Duc Thinh; Rich, Jonathan D; Jahromi, Babak S; Potts, Matthew B
• Is Part Of: Neurosurgery. Volume 67(2010)Supplement 1
• Publication Date: 2020-11-16
• Subjects: Nervous system -- Surgery -- Periodicals; 617.48005
• DOI: 10.1093/neuros/nyaa447_357
• Languages: English
• ISSNs: 0148-396X

Abstract

Abstract: INTRODUCTION: Intracerebral hemorrhage (ICH) is a devastating complication for patients with ventricular assist devices (VADs). Rapid anticoagulation reversal with prothrombin complex concentrates (PCCs) is recommended but the risks and optimal timing are not well defined. METHODS: We retrospectively reviewed consecutive VAD patients presenting between 2014–2020 with ICH who were administered four-factor PCC. We examined timing of PCC administration and anticoagulation resumption, survival, occurrence of thromboembolic events, and lactate dehydrogenase (LDH) trends. RESULTS: 16 cases of rapid reversal using PCCs were identified in 14 VAD patients with ICH (two patients had recurrent ICH). Eleven were intraparenchymal hemorrhage, four subdural hemorrhage, and one subarachnoid hemorrhage. PCCs were administered a mean of 3.33 hours after imaging diagnosis of ICH. Overall mortality was 62.5%. No relationship between time to PCC administration and survival was noted, although patients with greater degree of hematoma progression tended to have received PCC later. Anticoagulation was resumed in survivors at a mean of 11.3 days after reversal. There were no acute thromboembolic events or precipitous elevations in LDH prior to resumption of anti-coagulation. One patient who was on heparin for VAD thrombosis when ICH occurred had persistent thrombosis requiring VAD exchange 44 days after anti-coagulation was resumed and eventually had a heart transplant. One patient suffered a stroke 20 days after anti-coagulation was resumed and eventually had VAD explant for recovery of ventricular function. One final patient was readmitted for elevated LDH in the setting of low INR 51 days after anti-coagulation was resumed. CONCLUSION: Four-factor PCC can be safely used for rapid reversal of anticoagulation in the management of acute ICH in VAD patients. Despite a trend towards lesser degree of hematoma progression with use of PCC, we did not demonstrate a mortality benefit in this small cohort. However, no immediate thromboembolic complications were noted between anticoagulation reversal with PCC and subsequent resumption of anticoagulation. PCC may therefore be a reasonable option in VAD these patients, with or without planned neurosurgical intervention.