Recombinant Factor VIIa for Life-Threatening Bleeding in High-Risk Cardiac Surgery Despite Full-Dose Aprotinin

In Brief We report the case of an orthotopic heart transplant in a patient with multiple previous cardiac surgeries. The case was prolonged and complicated by severe coagulopathy and bleeding despite the use of full-dose aprotinin throughout. Bleeding was not controlled after 30 U of platelets, 20 U of fresh frozen plasma, and 10 U of cryoprecipitate. However, after the administration of recombinant factor VIIa 90 μg/kg, the rate of bleeding slowed dramatically and no further factor replacement was required. There was no evidence of unwanted clot formation within the newly transplanted heart or around the intraaortic balloon pump that remained in situ for 72 h postoperatively. With the combined risks of coagulopathy and bleeding as well as acute right ventricular failure with increases in pulmonary vascular resistance, the re-do sternotomy for heart transplant seems to be an ideal situation in which to consider the use of recombinant factor VIIa. IMPLICATIONS: Despite full-dose prophylactic aprotinin and aggressive treatment of coagulopathy in a high-risk cardiac surgical case, life-threatening microvascular bleeding was controlled only after the administration of recombinant factor VIIa. There was no evidence of prothrombotic complications.