Low-Dose Prothrombin Complex Concentrate in Patients with Left Ventricular Assist Devices

Left ventricular assist devices (LVADs) have become an important advancement for patients with end-stage heart failure. Left ventricular assist devices come with the risk of stroke and pump thrombosis, and to mitigate these risks, anticoagulation is given to these patients. With anticoagulation comes increased bleeding risk, and urgent reversal may be necessary. Reports have shown that the risk of thrombosis with prothrombin complex concentrate (PCC) does exist, especially in patients with baseline risk factors for thrombosis. We describe two cases of warfarin reversal with low-dose 4-factor PCC (4F-PCC) in two different LVAD patient scenarios. Low-dose 4F-PCC was administered to one patient with a Heart Mate II (HM II) LVAD, international normalized ratio (INR) of 4.7 on admission and in need of an urgent procedure. He received approximately 16 units/kg of 4F-PCC with reversal of his INR to 2.3 within 45 minutes. The second patient also had a HM II LVAD and presented with a right occipital intraparenchymal hemorrhage and subdural hematoma with an INR of 3.7. He received approximately 11 units/kg of 4F-PCC with INR reversal to 1.6 within 1 hour. Both of these patients had no thrombotic complications and successful reversal of their INR with low-dose 4F-PCC. Further investigation into low-dose 4F-PCC dosing strategies is warranted.