PO02 - Reversal of anticoagulation in a patient with hemopericardium and cardiac tamponade treated with warfarin for recent placement of a mechanical valve prosthesis.

Wednesday, June 26, 2024

13:00 – 14:00 ICT

Co-Author(s)

PR

Paola Rufolo

resident
Federico II University of Naples
naples, Campania, Italy
PG

Paola Gargiulo

assistant professor
Department of Advanced Biomedical Sciences, Federico II University of Naples.
Naples, Campania, Italy
RR

Raffaele Russo

RESIDENT
DEPARTMENT OF CLINICAL MEDICINE AND SURGERY. Federico II University of Naples
Naples, Campania, Italy
FS

Federica Strano

RESIDENT
DEPARTMENT OF CLINICAL MEDICINE AND SURGERY. Federico II University of Naples
Naples, Campania, Italy
GC

Greta Chiarelli

RESIDENT
DEPARTMENT OF CLINICAL MEDICINE AND SURGERY. Federico II University of Naples
Naples, Campania, Italy
LV

Luigi junior Valletta

RESIDENT
DEPARTMENT OF CLINICAL MEDICINE AND SURGERY. Federico II University of Naples
Naples, Campania, Italy

Presenting Author(s)

Antonella Tufano, MD, PhD

ASSISTANT PROFESSOR
DEPARTMENT OF CLINICAL MEDICINE AND SURGERY , FEDERICO II UNIVERSITY OF NAPLES
Naples, Campania, Italy

Background: Life-threatening bleeding can complicate warfarin therapy. Rapid anticoagulant reversal via replacement of vitamin-K dependent factors is essential for hemostasis.

Aims: We describe a patient with hemopericardium/cardiac tamponade, treated with warfarin for a mechanical valve prosthesis.

Methods: A 33-year-old male with a recent placement of a mechanical valve prosthesis, on warfarin in the past 20 days, presented on November 3, 2023, to the ED for chest pain and dyspnea, with evidence of a large pericardial effusion. The patient underwent valve replacement surgery with a mechanical prosthesis on 27 October 2023, due to aortic bicuspid and severe aortic insufficiency. A pericardiocentesis was performed on November 3, with resolution of the pericardial effusion. Twelve days later the patient presented to the ED for syncope. The transthoracic echocardiogram evidenced hemopericardium with signs of cardiac tamponade. The laboratory evaluation showed an INR of 5.41, and severe anemia (hemoglobin 6.7 g/dl). Due to the rapid worsening of the hemodynamic conditions, the patient underwent a new pericardiocentesis, after reversal of the excessive anticoagulation with PCC 20 IU /kg body weight, and non-activated FVII concentrate 20 IU/Kg body weight, with rapid improvement of INR values (1.7). He was also given vitamin K, 10 mg intravenously, and two units of red blood cells.

Results: The pericardiocentesis was not complicated by new hemorrhages and the warfarin treatment was started soon after the procedure.

Conclusion(s): Acute reversal of anticoagulation may be necessary in patients undergoing surgery, or with severe bleedings. PCC, rFVIIa and non-activated FVII may be used for warfarin reversal and these agents have advantages over FFP for reducing the time required for the reversal, and the volume of transfusion. A 4F-PCC reversal strategy or the combination of 3F-PCC+non-activated FVII, is efficacious in INR reversal and provides lower thrombotic risk, as compared to 3F PCC+rFVIIa, in high risk patients, as the case described.