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This case series describes the use of four factor prothrombin complex concentrate (4FPCC) to reverse warfarin anticoagulation without the need for pre-procedure bridging with a parenteral agent or the use of FFP or vitamin K in patients with ventricular assist devices (VAD) who require invasive procedures. Patients were included if they had a history of recent warfarin use and documentation of temporary warfarin reversal for the procedure. Patients were excluded if their first dose of 4FPCC was for active bleeding. INR was assessed prior to 4FPCC administration, and trended for at least 90 h afterwards. Charts were reviewed for adverse events. In patients who received only 4FPCC for INR correction, the mean INR before 4FPCC was given was 2.7 (SD 0.64), which dropped an average of 35.4% after administration to a mean INR of 1.6 (SD 0.30). In the two patients who also received vitamin K, the average INR before reversal was 2.0 (SD 0.49), and was reduced by 35.9% to 1.3 (SD 0.21). The average number of days until patients re-established a therapeutic INR with 4FPCC alone was 3.2 days post procedure compared to 8.5 days for patients who received concomitant vitamin K. No bleeding or thrombotic events were observed. Using 4FPCC without vitamin K may provide VAD patients and clinicians with safe, effective, and rapid reversal of warfarin with faster recovery to the target INR following the procedure.

Lowering INR using four factor prothrombin complex concentrate for procedures in patients with ventricular assist devices: A case series