Warfarin Reversal With Four-Factor Prothrombin Complex Concentrate for Left Ventricular Assist Device Conversion Surgery Monitored by TEG6s: A Case Report

Figures

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  Figure 1. Test point of TEG and time changes in PT-INR during the operation. Blood tests showed prolonged prothrombin time and PT-INR 2.63 before 4F-PCC administration (test point A). 4F-PCC induced a rapid reduction of PT-INR to 1.22 at one hour after administration (test point B). PT-INR was 1.69 after administration of protamine following withdrawal from cardiopulmonary bypass (test point C). Platelets (20 U) and FFP (8 U) were transfused, and fibrinogen (3 g) was administered (test point D). Platelets (20 U) and FFP (8 U) were transfused, and fibrinogen (2 g) was administered additionally (test point E). PT-INR: prothrombin time-international normalized ratio; Vit. K: vitamin K; CPB: cardiopulmonary bypass; Plt: platelet; Fib: fibrinogen; FFP: fresh frozen plasma; U: units; ACT: activated clotting time; TEG: thromboelastogram

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  Figure 2. Overview of TEG6s data before 4F-PCC administration at test point A. The citrated kaolin (CK) assay containing the coagulation activator, kaolin, which mainly activates the intrinsic pathway, identifies hemostatic characteristics. The citrated rapid thromboelastogram (CRT) assay, containing tissue factor and kaolin, assesses hemostasis properties more rapidly. The citrated kaolin with heparinase (CKH) assay, containing kaolin and heparin-neutralizing enzyme, assesses hemostatic characteristics without the influence of heparin. Citrated functional fibrinogen (CFF) assay isolates fibrinogen function, which contributes to clot strength. R (minutes) is the time until thrombus amplitude reaches 2 mm. K (minutes) is the time from the thrombus amplitude reaching 2 mm until the amplitude reaches 20 mm. The angle is the slope of a tangent line from the tracing at the midpoint between the R and K times. A10 is the thrombus amplitude at 10 minutes, and MA is the absolute thrombus strength. LY30(%) represents the percentage of fibrinolysis at 30 minutes after max amplitude.

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  Figure 3. Overview of TEG6s data one hour after 4F-PCC administration (test point B).

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  Figure 4. Overview of TEG6s data after protamine administration following withdrawal from cardiopulmonary bypass (test point C).

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  Figure 5. Overview of TEG6s data after platelet (20 U) and FFP (8 U) transfusion, and fibrinogen (3 g) administration (test point D). FFP: fresh frozen plasma

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  Figure 6. Overview of TEG6s data after additional platelet (20 U) and FFP (8 U) transfusion, and fibrinogen (2g) administration (test point E). FFP: fresh frozen plasma