Thrombogenic side-effects of recombinant factor VIIa after use in coronary artery bypass surgery

Recombinant activated factor VII (rFVIIa) has been used 'off licence' to successfully treat bleeding and reduce transfusion requirements in complex cardiac surgery. However; concerns over thrombogenic side-effects have limited but not excluded its use in patients undergoing coronary artery bypass surgery (CABG). We present two cases of CABG (one 'on pump' and one 'off pump') which were complicated by intraoperative aortic dissection and severe bleeding. In both cases the bleeding was successfully treated with rFVIIa. However the first case suffered from severe postoperative arrhythmias, myocardial infarction, cardiac arrest and worsening left ventricular dysfunction, suggesting graft patency may have been impaired, whereas the second case remained symptom-free suggesting graft patency was unaffected by the use of rFVIIa. If rFVIIa is needed to treat bleeding during CABG surgery, it may be more appropriate to administer smaller, repeated doses to minimize the risk of thrombosis and early graft failure.