Description of an In Vitro Platelet Function Analyzer (PFA-100/PFA-200) 30 Years in the Making

Description of an In Vitro Platelet Function Analyzer—PFA-100™

Welcome to another Commentary relating to our celebration of 50 years of publishing for Seminars in Thrombosis and Hemostasis (STH). As previously noted, 2024 marks the 50^th birthday of STH, which first published in 1974.[1] A half century of publishing is a landmark worthy of celebration. We started the celebrations in 2022, when we published our first 50^th Year Celebratory issue.[2] A second Celebratory issue was published in 2023,[3] and a third compilation was published as the first issue of 2024.[4] All issues were rich with content of a historical nature, as related to the fields of thrombosis and hemostasis. We plan to prepare a 4^th and final 50^th Year Celebratory compilation later in 2024. In the interim, we plan to publish a separate tribute to the rich history of STH in each issue of STH to publish within 2024. For the first issue of 2024, we republished the first paper ever published in STH, on the molecular structure of fibrinogen,[5] together with an accompanying Commentary from Neerman-Arbez and Casini.[6] The current Commentary accompanies the historical paper entitled “Description of an in vitro platelet function analyzer–PFA-100” republished in the current issue, from the authorship team of Kundu et al, and first published in a Supplementary issue of STH in 1995 ([Fig. 1]),[7] and which was identified as the 3^rd most highly cited STH paper of all time.[8]

Fig. 1 The front cover of the 1995 Supplement that published the historical paper[7] featured in the current issue of Seminars in Thrombosis and Hemostasis (Source: Reproduced with permission from Thieme Medical Publishers).

This historical paper[7] can be seen as a landmark paper, since it provided the first complete description of the PFA-100, an instrument that was in time to prove quite successful for its manufacturer, then Dade International Inc, which over time has transitioned into Siemens Healthineers. This paper does not mark the first “report” of the PFA-100, which occurred in a 1994 published conference paper,[9] with the affiliation then attributed to “Baxter Diagnostics.” The PFA-100 was based on an earlier (and larger) instrument called the Thrombostat-4000, which itself was often described as an in vitro bleeding time.[10] [11] The first publication mentioning the Thrombostat-4000 that I could identify from PubMed was from 1993.[10] Another four papers were published on the Thrombostat-4000 in 1993 and 1994.[12] [13] [14] [15] Then, in 1995, the prior noted Supplement of STH was published,[1] containing 16 papers that mentioned work using the Thrombostat-4000.[11] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] At the end of the Supplement issue appeared two papers related to the “updated” Thrombostat-4000, namely the PFA-100.[9] [31] Indeed, it was noted by the issue Guest Editors, in the Preface to the issue[32] that: “The Thrombostat 4000, which is no longer available, was modified and redesigned by scientists at Dade International, Inc. It is now referred to as the PFA 100 system, PFA meaning “platelet function analyzer for routine use, although at present, not yet available.””

As a Supplement of STH, this issue would have been sponsored by the manufacturer of the PFA-100. Indeed, Dade also took out an ad on the back cover to the issue ([Fig. 2]). The ad suggests that the instrument was launched at the International Society on Thrombosis and Haemostasis meeting held in Jerusalem in June of 1995 and perhaps the supplement was intended for major release at that meeting. I have no idea how much this “sponsorship” deal cost “Dade Diagnostics,” but I can conclude that this was money well spent. Given that the Thrombostat-4000 was no longer in production at that time, the publications related to this instrument[11] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] did not raise many citations. However, the two papers related to the PFA-100[9] [31] did, with both appearing in the top 100 most highly cited STH papers of all time.[8] Two other papers related to the PFA-100 also made this top 100 list.[33] [34] One of these, by Eberhard Mammen was the 4^th most highly cited STH paper of all time,[33] and the other paper[34] was written by me as a tribute to Eberhard Mammen in the year of his passing (2008).[35] [36]

Fig. 2 The back cover of the 1995 Supplement that published the historical paper[7] featured in the current issue of Seminars in Thrombosis and Hemostasis. This was an ad for the PFA-100 by the then manufacturer “Dade Diagnostics, Inc.” (Source: Reproduced with permission from Thieme Medical Publishers).

The history of the PFA-100 is now long and rich, and the PFA-100, subsequently morphing into the contemporary PFA-200, has been the subject of several reviews, including several recent “tributes” in this journal.[34] [37] [38] [39] A PubMed search of “(PFA-100) OR (PFA-200) OR (PFA100) OR (PFA200) OR (“platelet function analyser”) OR (“platelet function analyzer”)” yields over 1,200 hits ([Fig. 3]). Most of these papers are related to the PFA-100 or to the modern “updated” version (the PFA-200), but a handful are not (for example, PFA is also used as an abbreviation of “pulsed field ablation” and “phosphonoformic acid”). The first mention of the PFA-200 appears to be another of my own papers, as published in 2014, as also appearing in STH.[40] Indeed, the PFA-200 has been in operation in our laboratory since 2013, but interestingly is not yet available for sale in the United States. However, we still also operate our original PFA-100, acquired by us in 1996, and having the serial number 275! So, we were among the first pioneering group of users of this instrument; we published our first PFA related paper in 1999,[41] describing its utility as a screen for von Willebrand disease (VWD).

Fig. 3 The history of publications related to the PFA-100/PFA-200; data from PubMed.

We still, in 2024, use the PFA-100/-200 primarily to screen for VWD, with updated findings published in 2020,[42] or else to monitor desmopressin therapy in VWD.[43] The instruments may be used for a variety of different purposes in other laboratories, for example as a preoperative screen,[44] to evaluate platelet function in animals,[45] to evaluate effects of coronavirus disease 2019 spike protein on platelet function,[46] to evaluate drug effects on platelet function,[47] [48] to evaluate the effect of recombinant von Willebrand factor (VWF) on prolonged PFA closure times in extracorporeal membrane oxygenation patients with acquired von Willebrand syndrome,[49] to monitor antiplatelet therapy,[50] as a measure of platelet function in blood donors,[51] and as a potential marker of thrombosis risk,[52] just to name a few potential uses.

I do not know how many units of the PFA-100 that “Dade Diagnostics” sold following the inaugural announcements in STH,[7] [31] nor do I know how many units of the PFA-100 and PFA-200 that Siemens has sold since it acquired Dade, but I suspect that number to be quite sizable, and I also suspect that these sales have been aided greatly by publications related to these instruments, which essentially all began with the original publications in STH.[7] [31] However, the first mention of the PFA-100 appeared in a Conference paper in 1994, so it can also be noted that the PFA-100, like STH, also celebrates a milestone, with 30 years of service to the hemostasis community in 2024.[37] Happy birthday to the PFA-100!

Publication History

Article published online:
30 October 2023

• References

• 1 Advances in methods for platelet function analysis. Accessed August 30, 23 at: https://www.thieme-connect.com/products/ejournals/issue/10.1055/s-012-55744
• 2 Favaloro EJ. Celebrating 50 years of Seminars in Thrombosis and Hemostasis-part I. Semin Thromb Hemost 2022; 48 (08) 871-874
• 3 Favaloro EJ. Celebrating 50 years of Seminars in Thrombosis and Hemostasis-part II. Semin Thromb Hemost 2023; 49 (03) 212-216
• 4 Favaloro EJ. Celebrating 50 years of Seminars in Thrombosis and Hemostasis-part III. Semin Thromb Hemost 2024; 50 (01) 4-7
• 5 Murano G. The molecular structure of fibrinogen. Semin Thromb Hemost 1974; 1: 1-31
• 6 Neerman-Arbez M, Casini A. Fifty years of fibrinogen structure and function. Semin Thromb Hemost 2024; 50 (01) 148-150
• 7 Kundu SK, Heilmann EJ, Sio R, Garcia C, Davidson RM, Ostgaard RA. Description of an in vitro platelet function analyzer–PFA-100. Semin Thromb Hemost 1995; 21 (Suppl. 02) 106-112
• 8 Favaloro EJ. The most highly cited publications from Seminars in Thrombosis & Hemostasis: a data analysis 50 years in the making. Semin Thromb Hemost 2024; 50 (02) 157-168
• 9 Kundu S, Sio R, Mitu A, Ostgaard R. Conference paper - evaluation of platelet function by PFA-100(TM). Clin Chem 1994; 40 (09) 1827-1828
• 10 Högman CF, Eriksson L, Kristensen J. Leukocyte-depleted platelets prepared from pooled buffy coat post-transfusion increment and “in vitro bleeding time” using the Thrombostat 4000/2. Transfus Sci 1993; 14 (01) 35-39
• 11 Alshameeri RS, Mammen EF. Clinical experience with the Thrombostat 4000. Semin Thromb Hemost 1995; 21 (Suppl. 02) 1-10
• 12 Glaser A, Böck M, Rüschemeyer G. et al. Lagerung von Thrombozytenkonzentraten: Qualitätskontrolle durch In-vitro-Blutungstest. [Storage of thrombocyte concentrates: quality control by in vitro bleeding test] Infusionsther Transfusionsmed 1993; 20 (1–2): 14-16
• 13 Kristensen J, Eriksson L, Olsson K, Killander A, Högman C. Functional capacity of transfused platelets estimated by the Thrombostat 4000/2. Eur J Haematol 1993; 51 (03) 152-155
• 14 Kretschmer V, Huss B, Weber S. et al. Determination of bleeding risk in thrombocytopenic patients with platelet transfusion therapy. Beitr Infusionsther Transfusionsmed 1994; 32: 434-436
• 15 Kretschmer V, Huss B, Weber S. et al. A contribution to the indications for platelet transfusion and determination of its therapeutic efficacy. Transfus Sci 1994; 15 (04) 361-369
• 16 Dietrich GV, Kretschmer V, Weber D, Haupt W, Langen B, Huss B. Variables influencing the Thrombostat 4000: recommended standardization. Semin Thromb Hemost 1995; 21 (Suppl. 02) 11-19
• 17 Söhngen D, Hattstein E, Heyll A, Meckenstock G, Wienen S, Schneider W. Hematological parameters influencing the Thrombostat 4000. Semin Thromb Hemost 1995; 21 (Suppl. 02) 20-24
• 18 Kratzer MA, Negrescu EV, Hirai A, Yeo YK, Franke P, Siess W. The Thrombostat system. A useful method to test antiplatelet drugs and diets. Semin Thromb Hemost 1995; 21 (Suppl. 02) 25-31
• 19 Beck KH, Mohr P, Bleckmann U, Schweer H, Kretschmer V. Desmopressin effect on acetylsalicylic acid impaired platelet function. Semin Thromb Hemost 1995; 21 (Suppl. 02) 32-39
• 20 Beck KH, Bleckmann U, Mohr P, Kretschmer V. DDAVP's shortening of the bleeding time seems due to plasma von Willebrand factor. Semin Thromb Hemost 1995; 21 (Suppl. 02) 40-43
• 21 Weippert-Kretschmer M, Witte M, Budde U, Vigh T, Kretschmer V, Scharrer I. The Thrombostat 4000. A sensitive screening test for von Willebrand's disease. Semin Thromb Hemost 1995; 21 (Suppl. 02) 44-51
• 22 Ulshöfer B, Dorst V, Kretschmer V, Köhl H, Riedmiller H. Hemostaseological management of urological operations in patients taking aspirin using the Thrombostat 4000. Semin Thromb Hemost 1995; 21 (Suppl. 02) 52-58
• 23 Aleskog AE, Killander A, Olsson K, Eriksson L, Kristensen J. Preoperative evaluation of primary hemostasis in patients with thrombocytopenia using the Thrombostat 4000. Semin Thromb Hemost 1995; 21 (Suppl. 02) 59-65
• 24 Tabuchi N, Tigchelaar I, van Oeveren W. Shear-induced pathway of platelet function in cardiac surgery. Semin Thromb Hemost 1995; 21 (Suppl. 02) 66-70
• 25 Tigchelaar I, Monnink SH, Haan J, Tabuchi N, van Oeveren W. Platelet function analysis after in vitro treatment with hemostasis-affecting components. Semin Thromb Hemost 1995; 21 (Suppl. 02) 71-76
• 26 Dietrich GV, Söhngen D, Kretschmer V. Therapeutic use of phospholipids in thrombocytopenic or thrombocytopathic patients. Semin Thromb Hemost 1995; 21 (Suppl. 02) 77-78
• 27 Kretschmer V, Huss B, Bonacker G. et al. Thrombocytopenia-adapted in vitro bleeding test assesses platelet function in thrombocytopenic patients. Semin Thromb Hemost 1995; 21 (Suppl. 02) 79-90
• 28 Böck M, Groh J, Glaser A, Storck K, Kratzer MA, Heim MU. Quality control of platelet concentrates by the Thrombostat 4000. Semin Thromb Hemost 1995; 21 (Suppl. 02) 91-95
• 29 Kretschmer V, Huss B, Feller K, Ponath N, Kiefel V. Influence of HPA-1a and HLA antibodies on primary hemostasis. Semin Thromb Hemost 1995; 21 (Suppl. 02) 96-102
• 30 Suzuki S, Matsuno K, Kondoh M. Primary hemostasis during women's life cycle measured by Thrombostat 4000. Semin Thromb Hemost 1995; 21 (Suppl. 02) 103-105
• 31 Mammen EF, Alshameeri RS, Comp PC. Preliminary data from a field trial of the PFA-100 system. Semin Thromb Hemost 1995; 21 (Suppl. 02) 113-121
• 32 Kratzer MAA, Kretschmer V, Mammen EF. Advances in methods for platelet function analysis. Semin Thromb Hemost 1995
• 33 Mammen EF, Comp PC, Gosselin R. et al. PFA-100 system: a new method for assessment of platelet dysfunction. Semin Thromb Hemost 1998; 24 (02) 195-202
• 34 Favaloro EJ. Clinical utility of the PFA-100. Semin Thromb Hemost 2008; 34 (08) 709-733
• 35 Favaloro EJ, Kessler C, Levi M. Editorial. Eberhard Mammen 1930–2008. Semin Thromb Hemost 2008; 34: 307
• 36 Favaloro EJ. A tribute to Eberhard F. Mammen, M.D. (1930-2008). Semin Thromb Hemost 2008; 34 (08) 703-707
• 37 Favaloro EJ, Pasalic L, Lippi G. Towards 50 years of platelet function analyser (PFA) testing. Clin Chem Lab Med 2022; 61 (05) 851-860
• 38 Gosselin RC. From ink pens to computers: a personal look back at landmark changes during 5 decades as a clinical laboratory scientist in U.S. hemostasis laboratories. Semin Thromb Hemost 2023; 49 (03) 225-233
• 39 Favaloro EJ. Evolution of hemostasis testing: a personal reflection covering over 40 years of history. Semin Thromb Hemost 2023; DOI: 10.1055/s-0043-1761487.
• 40 Favaloro EJ, Bonar R. External quality assessment/proficiency testing and internal quality control for the PFA-100 and PFA-200: an update. Semin Thromb Hemost 2014; 40 (02) 239-253
• 41 Favaloro EJ, Facey D, Henniker A. Use of a novel platelet function analyzer (PFA-100) with high sensitivity to disturbances in von Willebrand factor to screen for von Willebrand's disease and other disorders. Am J Hematol 1999; 62 (03) 165-174
• 42 Favaloro EJ. Utility of the platelet function analyser (PFA-100/200) for exclusion or detection of von Willebrand disease: a study 22 years in the making. Thromb Res 2020; 188: 17-24
• 43 Favaloro EJ, Kershaw G, Bukuya M, Hertzberg M, Koutts J. Laboratory diagnosis of von Willebrand disorder (vWD) and monitoring of DDAVP therapy: efficacy of the PFA-100 and vWF:CBA as combined diagnostic strategies. Haemophilia 2001; 7 (02) 180-189
• 44 Leal-Noval SR, Casado M, Palomares C. et al. Prospective assessment of platelet function in patients undergoing elective resection of glioblastoma multiforme. Platelets 2023; 34 (01) 2216802
• 45 Kennerly R, Coleman AE, Jasper SL, Arnold RD, Brainard BM. Effects of orally administered pimobendan on platelet function in healthy adult cats. Am J Vet Res 2023; 84 (09) ajvr.23.05.0103
• 46 Vettori M, Carpenè G, Salvagno GL. et al. Effects of recombinant SARS-CoV-2 spike protein variants on platelet morphology and activation. Semin Thromb Hemost 2024; 50 (02) 275-283
• 47 Eckart F, Tauer JT, Suttorp M, Knöfler R. Impact of tyrosine kinase inhibitors applied for first-line chronic myeloid leukemia treatment on platelet function in whole blood of healthy volunteers in vitro. Hamostaseologie 2023; 43 (03) 179-187
• 48 Sukun A, Tekeli F. Comparison of clopidogrel, prasugrel and ticagrelor response of patients by PFA-100-innovance test results. Indian J Hematol Blood Transfus 2023; 39 (02) 294-299
• 49 Büchsel M, Geisen U, Beckenkamp C. et al. The effect of recombinant versus plasma-derived von Willebrand factor on prolonged PFA closure times in ECMO patients with acquired von Willebrand syndrome - an observational study. Thromb J 2023; 21 (01) 4
• 50 Davidson S. Monitoring of antiplatelet therapy. Methods Mol Biol 2023; 2663: 381-402
• 51 Belkacemi M, Berber A. Platelet dysfunction in blood donors detected by platelet function analyzer PFA-100™. Cureus 2022; 14 (05) e25497
• 52 Llobet D, Vallvé C, Tirado I. et al. Platelet hyperaggregability and venous thrombosis risk: results from the RETROVE project. Blood Coagul Fibrinolysis 2021; 32 (02) 122-131