Bleeding Diathesis Due to Failed Antagonism of Heparin: Successful Treatment with Recombinant Factor VIIa

To the Editor: We here report on a patient whose protamine allergy was unknown to us, and who was admitted to the intensive care unit (ICU) after open heart surgery with a bleeding diathesis due to failed heparin antagonism. Despite transfusing red blood cells, fresh frozen plasma, and platelets, bleeding went on undiminished. Since treatment with recombinant factor VIIa (rFVIIa) has been described in intractable bleeding after redo coronary artery bypass graft surgery (1), we decided to treat this patient with rFVIIa. We infused 90 μg/kg rFVIIa. The following 30 min blood loss was about 100 mL, and cessation of bleeding could be observed during the next hour. Considering the mechanism of action of rFVIIa, which is described elsewhere (2), cessation of bleeding shortly after the application of rFVIIa suggests, however, a true procoagulant effect rather than a mere epiphenomenon. The patient recovered and no morbidity (i.e., myocardial infarction due to bypass-thrombosis) was observed. Long-term follow-up (3 mo) revealed complete recovery. With this case, we assume that application of rFVIIa is a therapeutic option when, due to protamine-allergy, antagonizing heparin fails. To our knowledge, this is the first case that reports on treatment with rFVIIa in this clinical scenario. Ulrich Jaschinski, MD Michael Ried, MD Michael Lichtwarck-Aschoff, Prof Helmuth Forst, Prof Department of Anesthesiology and Critical Care Medicine Klinikum Augsburg Augsburg, Germany [email protected]