Successful control of massive coumarol-induced acute upper gastrointestinal bleeding and correction of prothrombin time by recombinant active factor VII (Eptacog-alpha, NovoSeven) in a patient with a prosthetic aortic valve and two malignancies (chronic lymphoid leukaemia and lung cancer).
Severe, life-threatening acute upper gastrointestinal bleeding may occasionally occur in patients receiving coumarol prophylaxis for prosthetic heart valves. These patients are exposed to two potential, serious risks: bleeding due to the severe blood loss induced by excessive anticoagulant effect or as a consequence of the cessation of anticoagulation subsequent thrombotic occlusion of the valve and loss of patency. Herein a short case report is presented. The elderly male patient had a prosthetic valve in the aortic position and also suffered from two malignant diseases: chronic lymphocytic leukaemia and a more recently developed lung cancer with metastatic spread into both lungs. The patient had a major gastrointestinal bleed, leading to a sudden fall of haematocrit (0.09), and to a collapse of peripheral circulation due to too excessive a coumarol effect (International Normalized Ratio > 8). An acute left ventricular failure developed during the early period of the emergency blood transfusion, so the correction of prothrombin time by fresh-frozen plasma (due to the large volume requirement) was not feasible. The patient received 50 microg/kg intravenous bolus of NovoSeven (recombinant active factor VII) in an almost desperate situation. The International Normalized Ratio changed to 2.1 in 30 min; bleeding had stopped immediately. There was neither evidence of disseminated intravascular coagulation (in spite of the age and underlying diseases) nor loss of valve patency or infective endocarditis during follow-up. This modest report may call attention to the potential use of recombinant active factor VII in the coumarol-induced severe bleeding episodes of prosthetic heart valve patients.
Udvardy
Miklos
M
2nd Department of Medicine, University Health and Medical Science Centre, Debrecen University, Hungary. mudvardy@jaguar.dote.hu
Telek
Bela
B
Mezey
Gabriella
G
Batar
Peter
P
Altorjay
Istvan
I
D000208:Acute Disease; D000368:Aged; D001021:Aortic Valve; D003374:Coumarins / Q000009:adverse effects*; D005167:Factor VII / Q000627:therapeutic use*; D015942:Factor VIIa; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced* / Q000188:drug therapy; D006350:Heart Valve Prosthesis / Q000009:adverse effects*; D006801:Humans; D019934:International Normalized Ratio; D015451:Leukemia, Lymphocytic, Chronic, B-Cell / Q000150:complications*; D008175:Lung Neoplasms / Q000150:complications*; D008297:Male; D011292:Premedication; D011517:Prothrombin Time; D011994:Recombinant Proteins / Q000627:therapeutic use*; D041742:Upper Gastrointestinal Tract; D018487:Ventricular Dysfunction, Left
D003374:Coumarins; D011994:Recombinant Proteins; D005167:Factor VII; C103587:recombinant FVIIa; D015942:Factor VIIa