RiaSTAP vs. Conventional Transfusion in Patients Having Heart Valve Surgery
RiaSTAP vs. Conventional Transfusion in Patients Having Heart Valve Surgery
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.
Platelet and plasma transfusion remain in the mainstay hemostatic therapy for perioperative
 bleeding. Several studies indicate that acquired fibrinogen deficiency can be the primary
 cause of bleeding after cardiac surgery. The aim of the study is to compare hematologica and
 transfusion profiles between the first-line fibrinogen replacement and platelet transfusion
 in post-cardiac surgical bleeding. In this prospective randomized, open-lable study, 20 adult
 patients undergoing valve replacement or repair, and fulfilling preset visual bleeding scale
 (0=excellent hemostasis; 1=oozing; 2=moderate bleeding; 3=severe bleeding from multiple
 bleeding sites) are randomized to 4 g of fibrinogen or 1 unit of apheresis platelet
 transfusion. After the initial randomized intervention, additional transfusions are given in
 the presence of bleeding (>200 ml/hour) according to the institutional practie as follows; 1
 apheresis platelet unit if platelet count is less than 100 x 10^9 /L, 2 units of plasma if
 international normalized ratio is >1.6, or 10 units of cryoprecipitate if fibrinogen level is
 <200 mg/dL. Primary endpoints include hemostatic condition in the surgical field and 24-hour
 hemostatic product usage. Hematologica data, clinical outcome, and safety date are collected
 up to the 28th day postoperative visit.
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