RiaSTAP vs. Conventional Transfusion in Patients Having Heart Valve Surgery

• Status: Terminated
• Trial end date: 2013-05-01
• Target enrollment: 0
• Participant gender: All

Summary

Heart surgery involving valve replacement often involves the use of the heart-lung machine for over 90 minutes, and bleeding tendency is frequently seen. Conventionally, platelet transfusion has been the primary therapy to treat bleeding after this type of procedure. More recently, perioperative supplementation of purified fibrinogen (RiaSTAP, CSL Behring) was shown to reduce bleeding and blood product use (plasma or platelets) after heart surgery. The objective of this trial is to demonstrate the clinical equivalency and economic utility of using fibrinogen concentrate, RiaSTAP for the mitigation of post-operative bleeding in patients in lieu of platelet transfusion.

Purified fibrinogen concentrate has been approved by FDA, and it has been used for the treatment of acute bleeding episodes in patients with low fibrinogen due to hereditary causes (e.g., afibrinogenemia). Compared to the transfusion of platelets which may be associated with volume overload, bacterial/viral infection, immunological effects and excess blood clotting, purified fibrinogen has several advantages. First, it contains no liquid plasma allowing for low volume infusion. Several viral inactivation/reduction steps are used to prepare the fibrinogen concentrate, increasing its viral safety. No antibodies or white blood cells are contained in the fibrinogen concentrate; therefore transfusion reactions are rare. Although platelet transfusion is widely used after heart surgery, there has been no randomized study to endorse this practice. In this study, patients undergoing heart valve replacement will be randomized to receive either platelet (1 unit) transfusion or fibrinogen concentrate (4g) after heparin anticoagulation is reversed. Subjects will be treated only if there is evidence of significant microvascular bleeding. Fifteen minutes after the initial treatment, subjects will be reevaluated for bleeding. If bleeding continues, subjects will be treated with blood transfusion per institutional standard of care.

The primary endpoints for this study are the hemostatic condition of the surgical field and 24-hour total of blood product transfusion.

• Phase: Phase 2
• Accepts Healthy Volunteers?: No

Details

• Lead Sponsor: Emory University
• Collaborator: CSL Behring

Criteria

Inclusion Criteria:

• Willing and able to provide written informed consent

• Age >17 and < 86 years

• Patients undergoing planned cardiopulmonary bypass (CPB) for:

1. combined coronary artery bypass grafting and valve replacement/repair surgery

2. single valve replacement surgery

3. mitral valve repair surgery

3. or double valve surgery (aortic and mitral)

• Presence of clinically relevant microvascular bleeding after protamine administration (hemostasis assessment score of 2-3)

• Patients should fulfill the following parameters prior to the study intervention:

• Body temperature > 35.0°C

• Blood pH > 7.2

• Hb > 7.0 mg/dL

• Activated clotting time (ACT) < 155 seconds

• CPB time > 60 minutes

Exclusion Criteria:

• Replacement of aorta

• Planned valve replacement without median sternotomy

• Previous valve replacement surgery (previous coronary artery bypass graft (CABG) acceptable)

• History or suspicion of a congenital or acquired coagulation disorder such as hemophilia, von Willebrand disease, and liver disease

• Hemodialysis dependent renal failure

• Liver dysfunction (aspartate aminotransferase (AST) or alanine aminotransferase (ALT) increased ≥ 2-fold above the upper limit of local laboratory normal ranges)

• Known allergy/anaphylaxis to fibrinogen concentrate or apheresis platelet units

• Clopidogrel administration within 5 days of surgery

• Coumadin (warfarin) administration within 5 days of surgery

• Participation in another clinical study in the 4 weeks preceding surgery

• Any indication that a potential subject did not comprehend the study restrictions, procedures, or consequences therein an informed consent cannot be convincingly given

• Life expectancy less than 48 hours