A Prospective, Multicenter, Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Safety and Efficacy of Preoperative Antithrombin Supplementation in Patients Undergoing High-Risk Cardiac Surgery With Cardiopulmonary Bypass
Phase: PHASE2
Conditions: Cardiac Surgery, Cardiopulmonary Bypass
Sponsor: Grifols Therapeutics LLC



Protocol GTI1307     Version: 4.0
02 Apr 2015
CONFIDENTIAL
Page 2 of 83
Summary of Changes for Protocol Amendment 3
Protocol Version
Date of Finalization
4.0
including Amendment 3
02 Apr 2015
3.0
including Amendment 2
02 Sep 2014
2.0
including Amendment 1
27 Jan 2014
1.0
Original
29 Oct 2013
Version 4.0, 02 Apr 2015
A Prospective, Multicenter, Randomized, Double-Blind, Placebo-Controlled Study to 
Evaluate the Safety and Efficacy of Preoperative Antithrombin Supplementation in Patients 
Undergoing High-Risk Cardiac Surgery with Cardiopulmonary Bypass
The protocol for Study GTI1307 (Version 3.0 dated 02 Sep 2014) has been amended and 
reissued as Protocol Version 4.0, dated 02 Apr 2015.

Protocol GTI1307     Version: 4.0                                                                                      
02 Apr 2015
CONFIDENTIAL                                             
Page 3 of 83
AMENDMENT 3 – SUMMARY OF CHANGES
Sections
Change From (deletion – strikethrough): 
Change To (new text – underline):
Rationale:
Global 
changes  
Global changes:
1. Subjects undergoing complex/combined procedures will not be prescreened or screened for antithrombin (AT) levels. The inclusion requirement 
for AT level less than 80% has been removed for complex/combined procedures (coronary artery bypass graft [CABG+valve], double/triple valve 
repair/replacement, and ascending aorta/aortic arch surgeries).
2. Only subjects undergoing isolated CABG or single valve repair/replacements and not receiving preoperative heparin may be prescreened for AT 
levels (AT <80%). The inclusion criterion for isolated CABG or single valve repair replacement has been revised to allow inclusion based on 
either (a) AT level less than 80% OR (b) preoperative heparin administration (unfractionated heparin [UFH] for at least 12 hours; low-molecular-
weight heparin [LMWH] for more than 5 days).
3. To accommodate the above protocol modifications which no longer require local measurement of AT level for study entry for all subjects, the 
study drug dose calculation has been simplified  so that it is only based on the subject’s weight in order to achieve a potentially therapeutic dose of  
blinded Antithrombin III (Human) (AT-III [Human]).
Rationale:
The rationale to support these modifications in eligibility criteria is based on previous observational and published studies that report post heart 
surgery cardiopulmonary bypass decreases in mean AT levels of approximately 30-35% from baseline, which can be as high as 45-50%. These prior 
studies were almost exclusively performed with low-risk patients undergoing isolated procedures with relatively short bypass runs. Our present study 
aims to enroll high-risk cardiac surgery patients defined as either undergoing combined/complex surgery in which higher bypass times and AT 
consumption are expected or patients undergoing less complex procedures who present with intrinsically low baseline AT levels or have been treated 
with preoperative heparin and have a high-risk of arriving to the ICU with exceptionally low AT levels. Therefore, patients who will present baseline 
AT levels ≥80% may still be at risk of reaching the ICU with low AT levels, which could put them at risk for adverse clinical outcomes. Therefore, 
for complex/combined cardiac procedures (Inclusion #4) this amendment removes the requirement for AT level of less than 80%. However, for 
isolated CABG or single valve repair/replacements in order to qualify for entry, patients will be required to either have an AT level less than 80% or 
have received preoperative heparin (delineated above).
Detailed changes are described below including modification in study drug dose calculation which is now dependent solely on subject’s weight and 
targeted to achieve an absolute increase (Δ) of 20% (percentage points) above pretreatment AT levels.
Protocol 
Synopsis
Study Centers Planned
20
Study Centers Planned
35
To facilitate subject
enrollment.

Protocol GTI1307     Version: 4.0                                                                                      
02 Apr 2015
CONFIDENTIAL                                             
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Rationale:
Protocol 
Synopsis  
3.1            
Study 
Design and 
Plan
Overall Study Description
This study will be a prospective, multicenter, randomized, 
double-blind, placebo-controlled study. Participating 
subjects will be 404 adult subjects undergoing cardiac 
surgery with CPB who will be randomized into 2 treatment 
groups preoperatively in a 1:1 ratio: AT-III (Human) 
treatment group and Placebo control group. Subjects will be 
prescreened for AT activity levels (AT <80%) and stratified 
by their previous history of myocardial infarction (MI).
Subjects randomized to AT-III (Human) treatment group 
will receive preoperative supplementation with AT-III 
(Human) designed to achieve a 100% AT level. Subjects 
randomized to Placebo control group will receive 0.9% 
Sodium Chloride (NaCl) for Injection, USP (United States 
Pharmacopeia).
Overall Study Description
This study will be a prospective, multicenter, randomized, 
double-blind, placebo-controlled study. Participating 
subjects will be 404 adult subjects undergoing high-risk
cardiac surgery with CPB who will be randomized into 2 
treatment groups preoperatively in a 1:1 ratio: AT-III 
(Human) treatment group and Placebo control group. All 
subjects will be stratified by their previous history of 
myocardial infarction (MI). Subjects undergoing 
complex/combined procedures will not be prescreened or 
screened for AT levels using local lab values to assess 
eligibility. Only subjects undergoing isolated coronary 
artery bypass graft (CABG) or single valve 
repair/replacements and not receiving preoperative heparin 
may be prescreened locally for AT levels (AT <80%).
Subjects randomized to AT-III (Human) treatment group 
will receive preoperative supplementation with AT-III 
(Human) designed to achieve an absolute increase (Δ) of 
20% (percentage points) above pretreatment AT levels. 
Subjects randomized to Placebo control group will receive 
0.9% Sodium Chloride (NaCl) for Injection, USP (United 
States Pharmacopeia).
See the rationale for the
global changes.
Protocol 
Synopsis  
3.2.1          
Inclusion 
Criteria
Diagnosis and Main Eligibility Criteria:
A subject must meet all the following inclusion criteria to 
be eligible for participation in this study:
Inclusion Criteria:
4. Types of cardiac operations permitted: 
complex/combined procedures (coronary artery bypass 
graft [CABG+valve]), double/triple valve 
repair/replacement, ascending aorta/aortic arch 
surgeries. Isolated CABG or single valve 
repair/replacements are allowed only if subject has 
Diagnosis and Main Eligibility Criteria:
A subject must meet all the following inclusion criteria to 
be eligible for participation in this study:
Inclusion Criteria:
4. Types of cardiac operations permitted:
-Complex/combined procedures (CABG+valve), 
double/triple valve repair/replacement, ascending 
aorta/aortic arch surgeries (without baseline AT level 
restriction or preoperative heparin requirement). OR
-Isolated CABG or single valve repair/replacements are 
allowed only if either (a) AT level is less than 80% OR 
See the rationale for 
the global changes.

Protocol GTI1307     Version: 4.0                                                                                      
02 Apr 2015
CONFIDENTIAL                                             
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Rationale:
received preoperative heparin >2 days.
5.  Subject has a Prescreening/Screening and baseline local 
lab AT level of less than 80%.
(b) preoperative heparin is received (unfractionated 
heparin [UFH] for at least 12 hours; low-molecular-
weight heparin [LMWH] for more than 5 days).
5.  Not applicable – intentionally left blank for data 
management purposes (consistency in eCRF capture of
eligibility criteria historically)
Protocol 
Synopsis 
3.3.2.1   
Study Drug 
Doses
Investigational Product, Dose, and Mode of 
Administration:
Every subject randomized to the AT-III (Human) treatment 
group will receive, immediately after anesthesia induction, 
a single dose of AT-III (Human) sufficient to achieve an 
AT level of 100% according the following formula:
4.1
)
(
)
100
(
)
(
kg
in
weight
subject
subject
in
level
AT
actual
required
IU
dose
III
AT




Investigational Product, Dose, and Mode of 
Administration:
Every subject randomized to the AT-III (Human) treatment 
group will receive, immediately after anesthesia induction, 
a single dose of AT-III (Human) sufficient to achieve an 
absolute increase (Δ) of 20% (percentage points) above 
pretreatment AT levels according to the following formula:
4.1
)
(
)
20
(
)
(
kg
in
weight
subject
required
IU
dose
III
AT



The only variable in the equation is the subject’s body 
weight. For calculating AT-III (Human) dose, the subject’s 
weight obtained during the Screening visit will be used.
Since the aim is to 
increase plasma AT 
levels by an absolute 
amount of 20% 
(percentage points) 
above the pretreatment 
value for all subjects, 
the equation for dose 
calculation does not 
need to include the 
subject’s specific 
preoperative AT level 
because Target AT level 
– preoperative AT level 
is set at an absolute 
value of 20% 
(percentage points).
Therefore the dose 
calculation equation in 
the original protocol and 
previous amendments is 
simplified by replacing 
the first parenthetical 
term by a value of 20.

Protocol GTI1307     Version: 4.0                                                                                      
02 Apr 2015
CONFIDENTIAL                                             
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Rationale:
Protocol 
Synopsis  
3.6.2.1 
Prescreening 
Visit: (within 
Two Weeks 
Prior to 
Surgery)*
Study Procedures:
The following procedures will be performed during the 
study:
Prescreening Visit: (within Two Weeks Prior to Surgery)*
* Must be performed prior to Screening visit, unless a 
subject’s surgery is scheduled to occur in ≤ 24 hours. In 
the latter case, the Prescreening and Screening visit may 
be combined and the only assessments to be performed 
are those detailed for the Screening visit. All 
determinations for a separate Prescreening visit must be 
recorded on specific Prescreening sheets.
Study Procedures:
The following procedures will be performed during the 
study:
Prescreening Visit: (within Two Weeks Prior to Surgery)*
* Only applicable for subjects undergoing isolated CABG 
or single valve repair/replacements who will not be 
receiving preoperative heparin (see entry criteria) and 
whose eligibility will therefore be based on AT level 
<80%. If it is logistically feasible, Prescreening visit must 
be performed prior to Screening visit, unless a subject’s 
surgery is scheduled to occur in ≤72 hours. In the latter 
case, the Prescreening and Screening visit may be 
combined. All determinations for a separate Prescreening 
visit must be recorded on specific Prescreening sheets.
Note: The Prescreening visit is not required for subjects 
undergoing complex/combined procedures (CABG+valve, 
double/triple valve repair/replacements, ascending 
aorta/aortic arch surgeries).
See the rationale for the 
global changes.
Protocol 
Synopsis 
3.6.2.2 
Screening 
Visit: (within 
Two Weeks 
Prior to 
Surgery)*
Study Procedures:
Screening Visit: (within Two Weeks Prior to Surgery)*
• Medical case history and demographic data (age, gender, 
race, weight, height, body mass index [BMI], smoking 
habits, ejection fraction, previous MI, unstable angina, 
arrhythmia, cardiogenic shock, congestive heart failure, 
pre-existing renal failure or dialysis treatment, chronic 
obstructive pulmonary disease [COPD], previous stroke, 
percutaneous coronary interventions, previous pulmonary 
thromboembolism, previous IABP, diabetes mellitus 
requiring treatment, oral anticoagulation therapy, heparin 
therapy, peripheral vascular disease or systemic 
thromboembolism, hypertension, hypercholesterolemia, 
immunosuppressive treatment).
Study Procedures:
Screening Visit: (within Two Weeks Prior to Surgery)*
• All clinically relevant medical case history and 
demographic data (age, gender, race, weight, height, body 
mass index [BMI], smoking habits, ejection fraction, 
previous MI, unstable angina, arrhythmia, cardiogenic 
shock, congestive heart failure, pre-existing renal failure 
or dialysis treatment, chronic obstructive pulmonary 
disease [COPD], previous stroke, percutaneous coronary 
interventions, previous pulmonary thromboembolism, 
previous IABP, diabetes mellitus requiring treatment, oral 
anticoagulation therapy, heparin therapy, peripheral 
vascular disease or systemic thromboembolism, 
hypertension, hypercholesterolemia, immunosuppressive 
See the rationale for the
global changes.

Protocol GTI1307     Version: 4.0                                                                                      
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CONFIDENTIAL                                             
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Rationale:
• AT activity levels (local lab)
* The Screening visit may occur on the same day of the 
Prescreening visit. In this case, AT activity levels 
performed at the local lab will be assessed only once. If a 
subject’s surgery is scheduled to occur in ≤ 24 hours, the 
Prescreening and Screening visits may be combined. In 
this case, the only assessments to be performed are those 
detailed for the Screening visit.
treatment). Please include any relevant medical 
conditions as well as medical disorders requiring 
medication or that are currently active.
• AT activity levels (local lab) (Only for subjects 
undergoing isolated CABG or single valve 
repair/replacements not receiving preoperative heparin
[see entry criteria]).
* The Screening visit may occur on the same day of the 
Prescreening visit. If a subject’s surgery is scheduled to 
occur in ≤72 hours, the Prescreening and Screening visits 
may be combined.
Protocol 
Synopsis 
3.6.2.3
Preoperative 
Visit (Before 
Anesthesia 
Induction): 
Day 0§
Study Procedures:
Preoperative Visit (Before Anesthesia Induction): Day 0§
• AT activity levels (local lab)* 
• AT activity levels (central lab)
• Randomization†
• Confirmation of existing, and recording of any new 
events, or changes, in the medical and surgical history of 
the subject since the Screening visit. The combined 
Screening and Preoperative visit requires documentation 
of the medical and surgical history for the last 12 
months.
• Confirmation of existing and recording of any new 
medications, or changes in medications administered to 
the subject since the Screening visit. The combined 
Screening and Preoperative visit requires documentation 
of the lifetime history for the use of topical hemostats 
and bleeding abnormalities. In addition it requires 
documentation of medications that the subject is taking 
or has taken within the last month.
*Subject’s AT level will be measured locally at the 
Study Procedures:
Preoperative Visit (Before Anesthesia Induction): Day 0§
• AT activity levels (central lab)
• Randomization†
• Confirmation of existing, and recording of any new 
events, or changes, in the medical and surgical history of 
the subject since the Screening visit. 
• Confirmation of existing and recording of any new 
medications, or changes in medications administered to 
the subject since the Screening visit. The combined 
Screening and Preoperative visit requires documentation 
of the lifetime history of bleeding abnormalities. In 
addition it requires documentation of medications that 
the subject is taking or has taken within the last month.
§ The Preoperative visit (Before Anesthesia induction: Day 
See the rationale for the
global changes.

Protocol GTI1307     Version: 4.0                                                                                      
02 Apr 2015
CONFIDENTIAL                                             
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Rationale:
investigator site within 48 hours prior to the CPB. For 
those subjects treated with preoperative heparin, AT 
levels should be assessed within 24 hours before 
anesthesia induction. This AT determination will be used 
for AT dose calculation (Section 3.3.2.1) and 
reconfirmation of inclusion criteria # 5 before the 
subject’s randomization.
† Randomization on Preoperative visit (Day 0) may occur 
24 hours before the day of surgery (Day 0) once AT 
activity levels measured locally are made available and 
subject’s AT level is confirmed to be below 80%.
§ The Preoperative visit (Before Anesthesia induction: 
Day 0) may occur on the same day of the Screening 
visit. In this case, the only assessments to be performed 
are those detailed for the Screening visit AND the 
Randomization procedures detailed in Section 3.3.2.
0) may occur on the same day of the Screening visit if the 
latter is to be performed within 48 hours of the surgery. In 
this case, the only assessments to be performed are those 
detailed for the Screening visit AND the Randomization 
procedures detailed in Section 3.3.2.
† Randomization on Preoperative visit (Day 0) may occur 
24 hours before the day of surgery (Day 0) once all 
eligibility criteria are confirmed.

Protocol GTI1307     Version: 4.0                                                                                      
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CONFIDENTIAL                                             
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Rationale:
Protocol 
Synopsis 
3.5.1
Efficacy 
Variables
Clinical Outcome Measures:
Efficacy Variables
2. AT activity (levels) determinations: 
a. AT activity levels will be measured for both AT-III 
(Human) treatment and Placebo control groups at the 
following time points:
◦Prescreening visit (local lab)
◦Screening visit (local lab)
◦Screening visit (central lab)
◦Preoperatively (local lab)*
◦Preoperatively (central lab)
◦Immediately after study drug administration 
*Subject’s AT level will be measured locally at the 
investigator site within 48 hours prior to the CPB. For 
those subjects treated with preoperative heparin, AT 
levels should be assessed within 24 hours before 
anesthesia induction. This AT determination will be used 
for AT dose calculation (Section 3.3.2.1) and 
reconfirmation of inclusion criteria # 5 before 
randomization.
Clinical Outcome Measures:
Efficacy Variables
2. AT activity (levels) determinations: 
a.AT activity levels will be measured for both AT-III 
(Human) treatment and Placebo control groups at a 
central lab (unless specified at local lab) for the 
following time points:
◦Prescreening visit (local lab)*
◦Screening visit (local lab)*§
◦Screening visit
◦Preoperatively
◦Immediately before study drug administration
◦Immediately after study drug administration 
* Only applicable for subjects undergoing isolated CABG 
or single valve repair/replacements (will be needed for 
eligibility only if subject will not be receiving 
preoperative heparin [see entry criteria]).
§ This AT (local lab) determination will not be required if 
the Prescreening visit is conducted.
See the rationale for 
the global changes.
1.1
Background
…Moreover, given that this study was performed with less 
complex procedures such as isolated CABG or single valve, 
compared to more complex/combined procedures such as 
double/triple valve repair/replacement, ascending 
aorta/aortic arch surgeries, with normal baseline AT values, 
many subjects in the control group reached the ICU with
AT levels within the normal physiological range, 
suggesting that an AT supplementation may of more benefit 
in a higher risk patient population with lower baseline AT 
levels.
…Moreover, given that this study was performed with less 
complex procedures such as isolated CABG or single valve, 
compared to more complex/combined procedures such as 
double/triple valve repair/replacement, ascending 
aorta/aortic arch surgeries, with normal baseline AT values, 
many subjects in the control group reached the ICU with 
AT levels within the normal physiological range, 
suggesting that an AT supplementation may be of more 
benefit in a higher risk patient population (undergoing 
complex/combined cardiac surgeries with long bypass runs 
and/or high inflammatory response) prone to consume large 
amounts of AT or with lower baseline AT levels.
See the rationale for the 
global changes.

Protocol GTI1307     Version: 4.0                                                                                      
02 Apr 2015
CONFIDENTIAL                                             
Page 10 of 83
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Figure 3-1
The figure is revised to 
reflect the relevant 
changes.
3.2 
Selection of 
Study 
Population
Subjects undergoing high risk, non-emergency cardiac 
surgery with CPB will be studied. Subjects will be 
prescreened according to baseline levels of AT activity 
measured locally which should be below 80% under all 
circumstances. Four hundred and four (404) subjects will be 
enrolled in this study.
Subjects undergoing high-risk, non-emergency cardiac 
surgery with CPB will be studied. Subjects undergoing 
isolated CABG or single valve repair/replacements may be 
prescreened for AT activity measured locally which should 
be below 80% unless treated with preoperative heparin
(details below). Four hundred and four (404) subjects will 
be enrolled in this study.
See the rationale for the
global changes.
3.3.2.2 
Rationale 
for 
Selection of 
Doses in the 
Study
…These AT levels were associated with an overall worse 
postoperative outcome. To build on this study, a 
preoperative AT target of 100% and inclusion of more 
severe subjects are intended to achieve better efficacy and 
safety.
… These AT levels were associated with an overall worse 
postoperative outcome. To build on this study, a more 
conservative dosing scheme and the inclusion of more 
severe subjects (i.e., undergoing complex/combined cardiac 
surgeries or subjects undergoing isolated procedures with 
low preoperative AT levels or treated with heparin 
preoperatively) are intended to achieve better efficacy and 
safety.
See the rationale for the 
global changes.
3.6.3.2 
Clinical 
Laboratory 
Tests
Laboratory panels include blood coagulation parameters 
and serum clinical chemistry as described below. 
Blood samples will be drawn at the following time points:
•
Prescreening visit (local lab)
•
Screening visit (local lab)
•
Screening visit (central lab)
•
Preoperatively (local lab)*  
Clinical chemistry panel: Creatinine, total bilirubin, ALT, 
AST, BUN, LDH, glucose, sodium, potassium, chloride, 
Laboratory panels include blood coagulation parameters 
and serum clinical chemistry as described below. 
Blood samples will be drawn at the following time points:
•
Screening visit (local lab)
•
Screening visit (central lab)
•
Preoperatively 
Clinical chemistry panel: Creatinine, total bilirubin, ALT, 
AST, BUN, LDH, glucose, sodium, potassium, chloride, 
See the rationale for the 
global changes.

Protocol GTI1307     Version: 4.0                                                                                      
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CONFIDENTIAL                                             
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and calcium
Blood samples will be drawn at the following time points:
•
Prescreening visit (local lab)
•
Screening visit (local lab)
•
Screening visit (central lab)
•
Preoperatively (local lab)*  
* Subject’s AT level will be measured locally at the 
investigator site within 48 hours prior to the CPB. For 
those subjects treated with preoperative heparin, AT 
levels should be assessed within 24 hours before 
anesthesia induction. This AT determination will be used 
for AT dose calculation (Section 3.3.2.1) and 
reconfirmation of inclusion criteria # 5 before 
randomization
The above listed laboratory panels will be performed by a 
central laboratory unless otherwise specified. Investigative 
site laboratories may also be used in some instances (e.g. in 
the case of Screening and Preoperative visit tests to 
determine subject's eligibility when testing results may be 
needed in a short timeframe). The Investigator will be 
required to classify laboratory results out of the normal 
range reported by the laboratory as clinically relevant or not 
according to his/her criteria. Results will be recorded in 
source documents and on the subject eCRF.
and calcium
Blood samples will be drawn at the following time points:
•
Screening visit (local lab)
•
Screening visit (central lab)
•
Preoperatively 
The above listed laboratory panels will be performed by a 
central laboratory unless otherwise specified. Investigative 
site laboratories may also be used in some instances (e.g. in 
the case of Screening and Preoperative visit tests to 
determine subject's eligibility when testing results may be 
needed in a short timeframe). The Investigator will be 
required to classify laboratory results out of the normal 
range reported by the laboratory as clinically relevant or not 
according to his/her criteria. Results will be recorded in 
source documents and on the subject eCRF when 
applicable.

Protocol GTI1307     Version: 4.0                                                                                      
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CONFIDENTIAL                                             
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3.7   
Screen 
Failures
Prescreening and screening evaluations will be used to 
determine the eligibility of each subject for enrollment.  
Subjects found to have a baseline AT activity level ≥80% 
(local lab) at the Prescreening visit will not continue any 
further subject eligibility evaluations and will not be 
considered as screening failures. Subjects who fail to meet 
eligibility criteria during screening evaluations (during 
Screening visit) will be considered screen failures and will 
not be randomized and participate in the study.
Prescreening and screening evaluations will be used to 
determine the eligibility of each subject for enrollment.  
Subjects undergoing isolated CABG or single valve 
repair/replacements and not receiving preoperative heparin
found to have a baseline AT activity level ≥80% (local lab) 
at the Prescreening visit will not continue any further 
subject eligibility evaluations and will not be considered as 
screening failures.
If a subject undergoing isolated CABG or single valve 
repair/replacements will receive preoperative heparin (see 
entry criteria), all Screening assessments will be performed 
because the subject may meet eligibility criteria without AT 
level as prerequisite. Subjects who fail to meet eligibility 
criteria during screening evaluations (during Screening 
visit) will be considered screen failures and will not be 
randomized and participate in the study.
See the rationale for the 
global changes.
Appendix 1 
Study Flow 
Chart and/or 
Schedule of 
Procedures
Study Flow Chart and/or Schedule of Procedures are 
revised to include all relevant changes described above.
See the rationale for the 
global changes.

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
CONFIDENTIAL                                                     Page 13 of 83
Investigator Signature Page
Protocol Title:
A Prospective, Multicenter, Randomized, Double-Blind, Placebo-Controlled Study To 
Evaluate The Safety And Efficacy Of Preoperative Antithrombin Supplementation In 
Patients Undergoing High-Risk Cardiac Surgery With Cardiopulmonary Bypass
Protocol Number: GTI1307
Version Number: 4.0
Version Date:   02 Apr 2015
The undersigned confirms that he/she agrees to conduct the study under the conditions 
described in this protocol and comply with International Conference on Harmonization 
Good Clinical Practice (ICH GCP) and all applicable regulatory requirements:
___________________________________
______________________
INVESTIGATOR NAME (Please Print)
LOCATION
___________________________________
______________________
INVESTIGATOR SIGNATURE
DATE

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
CONFIDENTIAL                                                     Page 14 of 83
PROTOCOL SYNOPSIS
Title of Study:
A Prospective, Multicenter, Randomized, Double-Blind, Placebo-Controlled Study to 
Evaluate the Safety and Efficacy of Preoperative Antithrombin Supplementation in Patients 
Undergoing High-Risk Cardiac Surgery with Cardiopulmonary Bypass
Sponsor:
Grifols Therapeutics Inc.
Study Number:
GTI1307
Phase:
2b
Number of Subjects Planned:
404
Study Centers Planned:
35
Target Population:
Patients that undergo high-risk cardiac surgery with cardiopulmonary bypass (CPB)
Duration of Treatment:
Subject participation (since enrollment): Approximately 30 to 48 days (7 weeks).
Study Objectives:
Primary Efficacy Objective:
The primary objective of this clinical study is to compare the percentage of subjects with any 
component of a major morbidity composite in two treatment groups randomly allocated to 
receive preoperative supplementation of AT-III (Human) or Placebo.  
Secondary Efficacy Objectives:
1. To compare postoperative antithrombin III (AT) levels at the Intensive Care Unit (ICU) 
admission between the AT-III (Human) treatment group and Placebo control group
2. To compare the following postoperative outcomes between the AT-III (Human) treatment 
group and Placebo control group:
-
Postoperative chest-drain blood loss in the first 12 and 24 hours after surgery
-
Transfusion requirements
-
Need for surgical reexploration

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
CONFIDENTIAL                                                     Page 15 of 83
-
Low cardiac output syndrome
-
Myocardial infarction
-
Stroke
-
Acute kidney injury
-
Arterial or venous thromboembolic events
-
Infections
-
Prolonged mechanical ventilation (>24 hours)
-
All-cause postoperative mortality
-
ICU stay duration
-
Prolonged ICU stay (>6 days)
-
Length of hospital stay
Safety Objectives:
Safety objectives include evaluation of AT-III (Human) for clinical safety including AEs and 
risks for bleeding, clinical laboratory testing, physical exam, and vital signs.
Overall Study Description:
This study will be a prospective, multicenter, randomized, double-blind, placebo-controlled 
study. Participating subjects will be 404 adult subjects undergoing high-risk cardiac surgery 
with CPB who will be randomized into 2 treatment groups preoperatively in a 1:1 ratio: AT-
III (Human) treatment group and Placebo control group. All subjects will be stratified by 
their previous history of myocardial infarction (MI). Subjects undergoing complex/combined 
procedures will not be prescreened or screened for AT levels (local lab) to assess eligibility. 
Only subjects undergoing isolated coronary artery bypass graft (CABG) or single valve 
repair/replacements and not receiving preoperative heparin may be prescreened locally for
AT levels (AT <80%).
Subjects randomized to AT-III (Human) treatment group will receive preoperative 
supplementation with AT-III (Human) designed to achieve an absolute increase () of 20% 
(percentage points) above pretreatment AT levels. Subjects randomized to Placebo control 
group will receive 0.9% Sodium Chloride (NaCl) for Injection, USP (United States 
Pharmacopeia).
The maximum study duration for a given subject will be approximately 7 weeks (48 days). 
There will be 2 weeks for prescreening, screening, and randomization into one of the 2 study 
groups (AT-III [Human] treatment or Placebo control). After the 2-week prescreening and 
screening period, the cardiac surgery procedure will take place with the preoperative 
administration of AT-III (Human) or Placebo supplementation. After surgery, the subject will 
be admitted to the ICU and be followed for approximately 1 month (30±4 days).
Both the primary efficacy endpoint (percentage of subjects with any component of the major 
morbidity composite) and the secondary endpoints will be evaluated for each subject after 

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
CONFIDENTIAL                                                     Page 16 of 83
each cardiac surgery procedure, at the ICU admission, ICU discharge, and during a follow-up 
period of approximately 1 month (30±4 days) (see protocol section 3.5.1).
Diagnosis and Main Eligibility Criteria:
A subject must meet all the following inclusion criteria to be eligible for participation in this 
study:
Inclusion Criteria:
1. Male or female.
2. At least 18 years of age.
3. Subject needs non-emergency cardiac surgery with cardiopulmonary bypass.
4. Types of cardiac operations permitted:
-
Complex/combined procedures (CABG+valve), double/triple valve 
repair/replacements, ascending aorta/aortic arch surgeries (without baseline AT level 
restriction or preoperative heparin requirement). OR
-
Isolated CABG or single valve repair/replacements are allowed only if either (a) AT 
level is less than 80% OR (b) preoperative heparin is received (unfractionated heparin 
[UFH] for at least 12 hours; low-molecular-weight heparin [LMWH] for more than 5 
days).
5. Not applicable – intentionally left blank for data management purposes (consistency in 
eCRF capture of eligibility criteria historically).
6. Subject has signed informed consent form.
7. Subject is willing to comply with all aspects of the protocol, including blood sampling, 
for the total duration of the study.

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Exclusion Criteria:
A subject meeting any of the following exclusion criteria is NOT eligible for participation in 
the study. All exclusion criteria involving hematology/coagulation and clinical chemistry 
determinations will be based on local lab results.
1. Subject needs emergency surgery.
2. Subject needs heart transplantation.
3. Use of minimally invasive surgery.
4. Previous cardiac operation.
5. Infective endocarditis.
6. Thromboembolic events, stroke, or ST-elevated myocardial infarction within 7 days of 
surgery.
7. Cardiogenic shock at the time of surgery.
8. Renal dysfunction: Creatinine levels >2 mg/dL or chronic dialysis.
9. Liver dysfunction: Aspartate transaminase (AST), alanine aminotransferase (ALT) 
increase ≥2-fold above the upper-limit of local lab normal ranges.
10. Treatment with Clopidogrel and Ticagrelor within 5 days before surgery, Prasugrel 
within 7 days before surgery, glycoprotein IIb/IIIa receptor blockers within 24 hours of 
surgery.
11. Treatment with new oral anticoagulants (Apixaban, Rivaroxaban, Dabigatran) within 
48 hours before surgery.
12. Vitamin K antagonist therapy and an international normalized ratio >1.3 on the day of 
surgery.
13. Platelet count <120,000/μL.
14. History or suspicion of a congenital or acquired coagulation disorder. 
15. History of anaphylactic reaction(s) to blood or blood components.
16. Allergies to excipients in study drug.
17. Refusal to receive allogenic transfusion of blood-derived products.
18. Received AT treatment within the last 3 months prior to Screening visit.
19. Subject is pregnant.
20. Subject has participated in any another investigational study within the last 3 months 
prior to Screening visit.
Investigational Product, Dose, and Mode of Administration:
This is a randomized, double-blind study.

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
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Antithrombin III (Human): AT-III (Human):
AT-III (Human) is a sterile, nonpyrogenic, stable lyophilized preparation of purified human 
antithrombin III obtained from human plasma by a continuous purification process.
Each vial will be labeled with the antithrombin potency expressed in international units (IU) 
as defined by the World Health Organization (WHO).
Every subject randomized to the AT-III (Human) treatment group will receive, immediately 
after anesthesia induction, a single dose of AT-III (Human) sufficient to achieve an absolute 
increase () of 20% (percentage points) above pretreatment AT levels according to the 
following formula:
4.1
)
(
)
20
(
)
(
kg
in
weight
subject
required
IU
dose
III
AT



The only variable in the equation is the subject’s body weight. For calculating AT-III 
(Human) dose, the subject’s weight obtained during the Screening visit will be used.
AT-III (Human) will be infused intravenously.
Placebo:
Placebo used in this study will be 0.9% Sodium Chloride (NaCl) for Injection, USP and will 
be infused intravenously.
Study Procedures:
The following procedures will be performed during the study:
Prescreening Visit: (within Two Weeks Prior to Surgery)*

Signed informed consent for Prescreening

AT activity levels (local lab)
* Only applicable for subjects undergoing isolated CABG or single valve 
repair/replacements who will not be receiving preoperative heparin (see entry criteria)
and whose eligibility will therefore be based on AT level <80%. If it is logistically 
feasible, Prescreening visit must be performed prior to Screening visit, unless a subject’s 
surgery is scheduled to occur in ≤72 hours. In the latter case, the Prescreening and 
Screening visit may be combined. All determinations for a separate Prescreening visit 
must be recorded on specific Prescreening sheets.
Note: The Prescreening visit is not required for subjects undergoing complex/combined 
procedures (CABG+valve, double/triple valve repair/replacements, ascending 
aorta/aortic arch surgeries).

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
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Screening Visit: (within Two Weeks Prior to Surgery)*

Signed informed consent

Allocation of Screening Number

Inclusion/Exclusion criteria 

Addition of subject’s data into Screening Log

All clinically relevant medical case history and demographic data (age, gender, race, 
weight, height, body mass index [BMI], smoking habits, ejection fraction, previous MI, 
unstable angina, arrhythmia, cardiogenic shock, congestive heart failure, pre-existing 
renal failure or dialysis treatment, chronic obstructive pulmonary disease [COPD], 
previous stroke, percutaneous coronary interventions, previous pulmonary 
thromboembolism, previous IABP, diabetes mellitus requiring treatment, oral 
anticoagulation therapy, heparin therapy, peripheral vascular disease or systemic 
thromboembolism, hypertension, hypercholesterolemia, immunosuppressive treatment).
Please include any relevant medical conditions as well as medical disorders requiring 
medication or that are currently active.

Physical examination

Vital signs (temperature [T], blood pressure [BP], heart rate [HR], respiratory rate [RR])

AT activity levels (local lab) (Only for subjects undergoing isolated CABG or single 
valve repair/replacements not receiving preoperative heparin [see entry criteria])

AT activity levels (central lab)

Hematology and coagulation (hemoglobin [Hb], hematocrit [Hct], red blood cell [RBC], 
white blood cell [WBC], platelets [PLT], activated partial thromboplastin time [aPTT], 
prothrombin time [PT], International Normalized Ratio [INR], fibrinogen, thrombin-
antithrombin complex [TAT], Prothrombin fragment 1+2 [F1+2])

Clinical chemistry (creatinine, total bilirubin, ALT, AST, blood urea nitrogen [BUN], 
lactate dehydrogenase [LDH], glucose, sodium, potassium, chloride, and calcium) 

Serum pregnancy test (for women of childbearing potential)

An appropriate volume of blood will be drawn in order to obtain a serum/plasma 
retention sample. The retention sample will be frozen and stored at -70ºC and stored in 
the event that additional testing is required in the future for purposes of this study only 
(i.e. repeat testing, or confirmation of virology results).

Documentation of medications that the subject is taking or has taken within the last 
month (including transfusions of blood or any blood-derived product)

Adverse events (AEs)
* The Screening visit may occur on the same day of the Prescreening visit. If a subject’s 
surgery is scheduled to occur in ≤72 hours, the Prescreening and Screening visits may 
be combined. 
Preoperative Visit (Before Anesthesia Induction): Day 0§

Review of inclusion/exclusion criteria to confirm subject eligibility

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
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
Physical examination

Vital signs (T, BP, HR, RR)

AT activity levels (central lab)

Randomization†

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium) 

An appropriate volume of blood will be drawn in order to obtain a serum/plasma 
retention sample. The retention sample will be frozen and stored at -70ºC and stored in 
the event that additional testing is required in the future for purposes of this study only 
(i.e. repeat testing, or confirmation of virology results).

Confirmation of existing, and recording of any new events, or changes, in the medical 
and surgical history of the subject since the Screening visit.

Confirmation of existing and recording of any new medications, or changes in 
medications administered to the subject since the Screening visit. The combined 
Screening and Preoperative visit requires documentation of the lifetime history of
bleeding abnormalities. In addition it requires documentation of medications that the 
subject is taking or has taken within the last month.

Adverse events
§ The Preoperative visit (Before Anesthesia induction: Day 0) may occur on the same day 
of the Screening visit if the latter is to be performed within 48 hours of the surgery. In 
this case, the only assessments to be performed are those detailed for the Screening visit 
AND the Randomization procedures detailed in Section 3.3.2.
† Randomization on Preoperative visit (Day 0) may occur 24 hours before the day of 
surgery (Day 0) once all eligibility criteria are confirmed.
Operative Visit (After Anesthesia Induction – Before ICU Admission): Day 0

Type of surgical procedure

Duration of CPB and aortic clamp

Preoperative heparin dose response*

Dose of heparin (initial, subsequent pre-CPB, during CPB), ACT, and dose of protamine* 
(* see protocol Section 3.6.2.4 for detail)

Study drug infusion

Minimum hematocrit during CBP (local lab)

Transfusion requirements

AT activity levels immediately before and after infusion of AT-III (Human) or Placebo

Concomitant medications

Adverse events

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ICU Admission: Day 0

Physical examination

Vital signs (T, BP, HR, RR)

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium)

Chest-drain blood loss in the first 12 and 24 hours postoperatively

Postoperative clinical outcomes (major morbidity composite, transfusion requirements, 
surgical reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney 
injury, arterial or venous thromboembolic events, infections, and postoperative mortality)

Concomitant medications

Adverse events

An appropriate volume of blood will be drawn in order to obtain a serum/plasma 
retention sample. The retention sample will be frozen and stored at -70ºC and stored in 
the event that additional testing is required in the future for purposes of this study only 
(i.e. repeat testing, or confirmation of virology results).
Postoperative Day 1, Day 2, Day 3, and Day 5

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium)

Chest-drain blood loss in the first 12 and 24 hours postoperatively

Postoperative clinical outcomes (major morbidity composite, transfusion requirements, 
surgical reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney 
injury, arterial or venous thromboembolic events, infections, prolonged mechanical 
ventilation, and postoperative mortality)

Concomitant medications

Adverse events
If this visit coincides in time with the ICU discharge, the only assessments to be performed 
are those detailed below in the ICU discharge visit. Regardless of when the ICU discharge 
takes place, AT activity levels should be measured on Postoperative days 1, 2, 3, and 5.

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ICU Discharge Visit (Maximum One Month after Admission)

Physical examination

Vital signs (T, BP, HR, RR)

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium)

Concomitant medications

Adverse events

Postoperative clinical outcomes (major morbidity composite, transfusion requirements, 
surgical reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney 
injury, arterial or venous thromboembolic events, infections, prolonged mechanical 
ventilation, ICU stay duration, prolonged ICU stay, and postoperative mortality)
Follow-Up Visit (Day 30±4 Days after ICU Admission)*

Physical examination

Vital signs (T, BP, HR, RR)

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

An appropriate volume of blood will be drawn in order to obtain a serum/plasma 
retention sample. The retention sample will be frozen and stored at -70ºC and stored in 
the event that additional testing is required in the future for purposes of this study only 
(i.e. repeat testing, or confirmation of virology results).

Concomitant medications

Adverse events

Clinical outcomes (major morbidity composite, transfusion requirements, surgical 
reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney injury, 
arterial or venous thromboembolic events, infections, prolonged mechanical ventilation, 
postoperative mortality, and overall hospital stay duration)
* A phone call follow-up visit will be performed for those subjects unable to return to the 
investigational site during the scheduled time frame. The occurrence of any AEs since 
the last study visit and clinical outcomes will be investigated.
Clinical Outcome Measures:
Efficacy Variables
1. Percentage of subjects with any component of a major morbidity composite defined as 

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
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a composite of any one or more of the following events (up to Day 30±4 days):
a.
Postoperative mortality (defined as all deaths occurring within 30 days of the 
operation or occurring during the primary hospitalization)
b. Stroke (defined as a clinical diagnosis of focal or global neurological deficit of 
abrupt onset caused by a disturbance in cerebral blood supply)
c.
Acute kidney injury (defined as an increase of serum creatinine levels to >2.0 mg/dL 
and twice the baseline level or a new requirement for dialysis postoperatively)
d. Surgical reexploration (defined as having to return to the operating room because of 
bleeding, tamponade, graft occlusion or any other cardiac reason)
e.
Arterial or venous thromboembolic event (consisting of perioperative MI, 
mesenteric infarction, peripheral thromboembolism, acute coronary graft thrombosis, 
intracardiac thrombosis, deep vein thrombosis [DVT], and pulmonary embolism)
f.
Prolonged mechanical ventilation (defined as mechanical ventilation >24 hours) 
g. Infection (defined as presence of deep sternal-wound infection and/or bloodstream 
infections).
2. AT activity (levels) determinations:
a.
AT activity levels will be measured for both AT-III (Human) treatment and Placebo 
control groups at a central lab (unless specified at local lab) for the following time 
points:
◦
Prescreening visit (local lab)*
◦
Screening visit (local lab)* §
◦
Screening visit
◦
Preoperatively
◦
Immediately before study drug administration 
◦
Immediately after study drug administration 
◦
Postoperatively at ICU admission
◦
Postoperatively Day 1
◦
Postoperatively Day 2
◦
Postoperatively Day 3
◦
Postoperatively Day 5
◦
ICU discharge
◦
1-month follow-up visit
* Only applicable for subjects undergoing isolated CABG or single valve 
repair/replacements (will be needed for eligibility only if subject will not be 
receiving preoperative heparin [see entry criteria]).
§ This AT (local lab) determination will not be required if the Prescreening visit is 
conducted.

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b. Percentage of subjects with AT levels of 58% or higher at the ICU admission will be 
calculated for both treatment groups and compared.
All AT measurements will be performed on a central venous catheter blood sample if the 
central venous catheter is already in place, through a calibration curve prepared by serial 
dilution of the human normal plasma pool and expressed as a percentage of activity. If a 
central venous catheter is not already in place, peripheral blood sample will be used for 
measuring AT levels.
3. Chest-drain blood loss (mL) will be measured within the first 12 and 24 hours of chest 
closure.
Chest-drain blood loss in the first 12 and 24 hours is defined as the amount of blood 
collected in the cardiotomy reservoir from chest closure through the following 12 and 
24 hours measured.
4. Transfusion requirements will be measured as the number of units of Fresh frozen 
plasma (FFP), RBCs, PLTs, cryoprecipitate/fibrinogen, prothrombin complex 
concentrates (PCCs), from the day of ICU admission and throughout the follow-up 
period.
5. Percentage of subjects needing surgical reexploration defined as having to return to the 
operating room because of bleeding, tamponade, graft occlusion or any other cardiac 
reason will be considered from chest closure to the end of the follow-up period.
6. Percentage of subjects with low cardiac syndrome defined as the need for major 
inotropic support or intra-aortic balloon pump will be considered from the day of ICU 
admission and throughout the follow-up period.
7. Percentage of subjects with postoperative myocardial infarction defined through 
enzymatic criteria plus new Q-waves at the electrocardiogram (ECG) will be considered 
from the day of ICU admission and throughout the follow-up period.
8. Percentage of subjects with postoperative stroke defined as a clinical diagnosis of focal 
or global neurological deficit of abrupt onset caused by a disturbance in cerebral blood 
supply will be considered from the day of ICU admission and throughout the follow-up 
period.
9. Percentage of subjects with acute kidney injury defined as an increase of serum 
creatinine levels to >2.0 mg/dL and twice the baseline levels or new requirement for 
dialysis postoperatively, will be considered from the day of ICU admission and 
throughout the follow-up period. A new requirement for postoperative dialysis may 
include hemodialysis, peritoneal dialysis, and any form of ultrafiltration.
10. Percentage of subjects with arterial or venous thromboembolic events defined as 
perioperative MI, stroke, mesenteric infarction, peripheral thromboembolism, acute 
coronary graft thrombosis, intracardiac thrombosis, DVT, and pulmonary embolism, will 
be considered from the day of ICU admission and throughout the follow-up period.

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11. Percentage of subjects with infections defined as presence of deep sternal-wound 
infections involving muscle, bone or mediastinum or bloodstream infections from the day 
of ICU admission and throughout the follow-up period.
The diagnosis of infection must have at least one of the following conditions:
a.
Wound opened with excision of tissue or reexploration of the mediastinum
b. Positive culture
c.
Treatment with antibiotics
12. Percentage of subjects with prolonged mechanical ventilation defined as the need for 
mechanical ventilation >24 hours from the day of ICU admission and throughout the 
follow-up period.
13. Percentage of subjects with all-cause postoperative mortality defined as death during 
the same hospitalization as surgery or after discharge and throughout the follow-up 
period.
14. ICU stay duration (days) will be measured from the ICU admission. If duration is greater 
than the follow-up period, >1 month will be recorded.
15. Percentage of subjects with prolonged ICU stay defined as >6 days will be considered 
from ICU admission during a maximum of 34 days.
16. Length of hospital stay (days) in both groups defined as the discharge date minus the 
surgery date plus 1 day, during a maximum of 34 days after ICU admission. If this time 
interval is greater than the follow-up period, >1 month will be recorded.
Safety Variables:

Adverse events, serious adverse events (SAEs), suspected adverse drug reactions 
(ADRs), and discontinuations due to AEs.

Risk for bleeding (will be assessed by monitoring Hct levels, urine dipstick tests, and any 
clinical AEs for bleeding).

Physical examination and vital signs.

Clinical laboratory parameters: Hematology (red blood cell count, white blood cell count, 
hematocrit, hemoglobin, and platelets, etc.) and clinical chemistry (creatinine, total 
bilirubin, ALT, and AST, etc.).
Statistical and Analytical Methods:
Study Populations:

Intention-to-Treat population (ITT) will include all subjects who are randomized.

Per-protocol (PP) population will include all ITT subjects who have no major protocol 
deviations.

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
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
Safety population will include all subjects who receive any amount of study drug.
Demographics:
Demographic and baseline characteristics will be summarized by treatment group using ITT 
population. For quantitative variables, mean, standard deviation (SD), median, and 
minimum/maximum will be provided. For qualitative variables, the frequency and percentage 
will be provided.
Primary Efficacy Analyses:
The primary efficacy variable is the percentage of subjects with any component of the 
composite of major morbidity. The primary efficacy variable will be analyzed with Cochran 
Mantel Haenszel test adjusting for history of MI using ITT population. The sensitivity 
analyses using PP populations will also be provided.
Secondary Efficacy Analyses:
Postoperative AT levels at the ICU admission will be summarized by treatment group. The 
analysis of covariance (ANCOVA) will be used to compare the treatment difference. 
ANCOVA model will include the AT level as dependent variable, treatment as fixed effect 
and baseline AT level as covariate. The similar approach will also be used to analyze the AT 
levels in other time points.
Postoperative chest-drain blood loss in the first 12 and 24 hours after surgery will be 
summarized by treatment group and will be analyzed using group t-test.
For transfusion requirements, Number of units of RBC, Number of units of FFP, and Number 
of units of platelets will be summarized by treatment group and analyzed using group t-test.
The number and percentage of subjects with each following procedure or morbidity will be 
separately summarized by treatment group and will be analyzed using Chi-square test (or 
Fisher Exact test as appropriate)
-
Need for surgical reexploration
-
Low cardiac output syndrome
-
Myocardial infarction
-
Stroke
-
Acute kidney injury
-
Arterial or venous thromboembolic events
-
Infections
-
Prolonged mechanical ventilation (>24 hours)
-
All-cause postoperative mortality
-
Prolonged ICU stay (>6 days)

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
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Duration of ICU stay and the length of hospital stay will be summarized by treatment group. , 
Non-parametric will be used to compare the treatment differences and Hodges-Lehmann 
estimation will be provided.
Safety Analysis
The safety analysis will be based on safety population.
The incidence of AEs, SAEs, suspected ADRs, and AEs by severity will be summarized by 
treatment, system organ class and preferred term using descriptive statistics. Subjects with 
deaths, SAEs, and AEs leading to premature discontinuation from the study will be listed.
The Investigator verbatim term and the MedDRA coded term (system organ class and 
preferred term) will be shown simultaneously on the data listings of all AEs.
Clinical laboratory variables will be summarized by treatment using summary statistics at 
each time point and on the change from baseline. Shift tables will be provided to summarize 
values that fall outside the normal ranges.
Vital signs will be summarized by treatment using summary statistics at each time point and 
on the change from baseline.
Physical exam data will be provided in data listings.

Protocol GTI1307     Version: 4.0                                                                                                        02 Apr 2015
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TABLE OF CONTENTS
Investigator Signature Page ...............................................................................................13
PROTOCOL SYNOPSIS ........................................................................................................14
GLOSSARY AND ABBREVIATIONS..................................................................................31
1
INTRODUCTION ...........................................................................................................34
1.1
Background............................................................................................................34
1.2
Rationale for Conducting the Study.......................................................................36
2
STUDY OBJECTIVES....................................................................................................37
2.1
Primary Efficacy Objective....................................................................................37
2.2
Secondary Efficacy Objectives..............................................................................37
2.3
Safety Objectives ...................................................................................................38
3
INVESTIGATIONAL PLAN..........................................................................................38
3.1
Study Design and Plan...........................................................................................38
3.2
Selection of Study Population................................................................................41
3.2.1
Inclusion Criteria .........................................................................................41
3.2.2
Exclusion Criteria ........................................................................................41
3.3
Treatments..............................................................................................................42
3.3.1
Treatments to Be Administered ...................................................................42
3.3.1.1
AT-III (Human)..................................................................................42
3.3.1.2
Placebo................................................................................................43
3.3.1.3
Labeling of Investigational Products..................................................43
3.3.1.4
Storage of Investigational Products....................................................43
3.3.1.5
Accountability for Investigational Products.......................................43
3.3.2
Rationale for Selection of Doses/Timing of Investigational Products in 
the Study ......................................................................................................44
3.3.2.1
Study Drug Doses...............................................................................44
3.3.2.2
Rationale for Selection of Doses in the Study....................................44
3.3.3
Method of Assigning Subjects to Treatment Groups....................................45
3.3.3.1
Subject Numbering..............................................................................45
3.3.3.2
Randomization....................................................................................45
3.3.3.3
Blinding...............................................................................................45
3.3.3.4
Administration and Timing of Investigational Products for Each 
Subject.................................................................................................46
3.3.3.5
Treatment Compliance........................................................................46
3.4
Prior and Concomitant Therapy..............................................................................46
3.4.1
Prior to Study Treatment...............................................................................46
3.4.2
Concomitant Medications during the Study .................................................47
3.4.3
Prohibited Concomitant Medications during the Study................................47
3.5
Study Variables.......................................................................................................47

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3.5.1
Efficacy Variables........................................................................................47
3.5.2
Safety Variables...........................................................................................51
3.6
Assessments...........................................................................................................52
3.6.1
Assessment Periods......................................................................................52
3.6.2
Observations and Measurements .................................................................52
3.6.2.1
Prescreening Visit: (within Two Weeks Prior to Surgery)*...............52
3.6.2.2
Screening Visit: (within Two Weeks Prior to Surgery)*....................52
3.6.2.3
Preoperative Visit (Before Anesthesia Induction): Day 0§.................53
3.6.2.4
Operative Visit (After Anesthesia Induction – Before ICU 
Admission): Day 0..............................................................................54
3.6.2.5
ICU Admission: Day 0........................................................................55
3.6.2.6
Postoperative Day 1:...........................................................................55
3.6.2.7
Postoperative Day 2:...........................................................................56
3.6.2.8
Postoperative Day 3:...........................................................................56
3.6.2.9
Postoperative Day 5:...........................................................................57
3.6.2.10
ICU Discharge Visit (Maximum One Month after Admission).........57
3.6.2.11
Follow-Up Visit (Day 30±4 Days after ICU Admission)*................58
3.6.3
Description of Procedures and Laboratory Tests.........................................58
3.6.3.1
Surgical Procedures............................................................................58
3.6.3.2
Clinical Laboratory Tests...................................................................59
3.6.4
Drug Concentration Measurements .............................................................60
3.7
Screen Failures.......................................................................................................60
3.8
Removal of Subjects ..............................................................................................60
3.9
Subject Replacement..............................................................................................62
3.10
Follow-up of Subjects Withdrawn from Study......................................................62
3.11
Premature Termination of Study/Closure of Center..............................................62
4
ASSESSMENT OF SAFETY..........................................................................................63
4.1
Specification of Safety Parameters ........................................................................63
4.2
Methods and Timing for Assessing, Recording, and Analyzing Safety 
Parameters..............................................................................................................63
4.2.1
Adverse Events ............................................................................................63
4.2.2
Physical Examinations.................................................................................63
4.2.3
Vital Signs....................................................................................................64
4.2.4
Clinical Chemistry and Hematology............................................................64
4.3
Procedures for Eliciting Reports of and for Recording and Reporting Adverse 
Event and Intercurrent Illnesses.............................................................................64
4.3.1
Adverse Events ............................................................................................64
4.3.2
Causality of Adverse Event .........................................................................65
4.3.3
Suspected Adverse Drug Reaction and Adverse Reaction ..........................66
4.3.4
Severity (Grade) of the Adverse Event........................................................66
4.3.5
Serious Adverse Event.................................................................................66

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4.3.6
Expectedness of Adverse Event or Suspected Adverse Drug Reaction ......68
4.3.7
Adverse Event Documentation ....................................................................68
4.4
Reporting of Serious Adverse Events or Pregnancy..............................................69
4.4.1
Reporting Serious Adverse Event................................................................69
4.4.2
Reporting Pregnancy....................................................................................70
5
STATISTICAL METHODS AND DETERMINATION OF SAMPLE SIZE................70
5.1
Statistical and Analytical Plans..............................................................................70
5.1.1
Subject Population(s) for Analysis ..............................................................70
5.1.2
Demographic and Baseline Characteristics .................................................71
5.1.3
Efficacy Analysis.........................................................................................71
5.1.3.1
Primary Efficacy Analyses..................................................................71
5.1.3.2
Secondary Efficacy Analyses............................................................71
5.1.4
Safety Analysis ............................................................................................72
5.2
Determination of Sample Size ...............................................................................72
6
ADMINISTRATIVE .......................................................................................................72
6.1
Investigators, Other Study Personnel and External Committees...........................72
6.2
Data Quality...........................................................................................................73
6.3
Documentation.......................................................................................................73
6.3.1
Record Retention .........................................................................................73
6.3.2
Access to Information for Monitoring.........................................................74
6.3.3
Access to Information for Audits or Inspections.........................................74
7
ETHICAL AND LEGAL ASPECTS...............................................................................74
7.1
Institutional Review Board/Ethics Committee ......................................................74
7.2
Ethical Conduct of the Study.................................................................................74
7.3
Regulatory Authority Approvals/Authorizations...................................................75
7.4
Subject Information and Consent...........................................................................75
7.5
Insurance................................................................................................................75
7.6
Confidentiality .......................................................................................................75
8
USE OF DATA AND PUBLICATION ..........................................................................76
9
REFERENCES ................................................................................................................77
APPENDICES .........................................................................................................................81
LIST OF APPENDICES
Appendix 1
Study Flow Chart and/or Schedule of Procedures .............................82

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GLOSSARY AND ABBREVIATIONS
ACT
Activated clotting time
ADR
Adverse drug reaction
AE
Adverse event
AKI
Acute kidney injury
ALT
Alanine aminotransferase
ANCOVA
Analysis of covariance
aPTT
Activated partial thromboplastin time
AR
Adverse reaction
AST
Aspartate transaminase
AT
Antithrombin III
BMI
Body mass index
BP
Blood pressure
BUN
Blood urea nitrogen
CABG
Coronary artery bypass graft
CK
Creatine phosphokinase
CK-MB
Creatine phosphokinase MB isoenzyme
COPD
Chronic obstructive pulmonary disease
CPB
Cardiopulmonary bypass
CRO
Clinical research organization
CVP
Central venous pressure
DBP
Diastolic blood pressure
dL
Deciliters
DVT
Deep vein thrombosis
ECG
Electrocardiogram
eCRF
electronic case report form
F1+2
Prothrombin fragment 1+2
FFP
Fresh frozen plasma
GCP
Good Clinical Practice
Hb
Hemoglobin
Hct
hematocrit

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HR
Heart rate
IABP
Intra-aortic balloon pump
IB
Investigator’s Brochure
ICF
Informed consent form
ICH
International Conference on Harmonization
ICU
Intensive care unit
LMWH
Low-molecular-weight heparin
IND
Investigational new drug
INR
International Normalized Ratio
IRB
Institutional Review Board
ITT
Intention to treat population
IU
International unit
IV
Intravenous
IVR
In vivo recovery
L
Liter
LBBB
Left bundle branch block
LMWH
Low-molecular weight heparin
MACE
Major adverse cardiac event
mg
Milligram
MI
Myocardial infarction
mL
Milliliter
mmol
millimole
mmHg
Millimeters of mercury
NaCl
Sodium chloride
NAT
Nucleic acid testing
PF
Prothrombin fragment
PLT
Platelets
PP
Per protocol population
PRN
Pro re nata
PT
Prothrombin time
RBC
Red blood cell

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rFVIIa
Recombinant activated factor VII
RR
Respiratory rate
SAE
Serious adverse event
SBP
Systolic blood pressure
SD
Standard deviation
SERPIN
SERine Protease Inhibitor
STS-SCA
Society of Thoracic Surgeons and Society of Cardiovascular Anesthesiologists 
SWFI
Sterile water for injection
T
Temperature
TAT
Thrombin-antithrombin complex
TRALI
Transfusion associated acute lung injury
UFH
Unfractionated heparin
USP
United States Pharmacopeia
USA
United States of America
WBC
White blood cell
WHO
World Health Organization

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1
INTRODUCTION
In addition to the information provided below, please also refer to the Investigator’s 
Brochure (IB) and any additional data supplied by the sponsor.
1.1
Background
Cardiac surgery interventions with cardiopulmonary bypass (CPB) lead to a systemic 
activation of the hemostatic and inflammatory systems compromising the equilibrium of pro-
and anticoagulant factors. Excessive hemostatic activation due to exposure of blood to non-
endothelial extracorporeal surfaces, re-transfusion of shed pericardial blood, enhanced 
fibrinolysis, and hemodilution often leads to a profound coagulopathological state 
predisposing patients to suffer both hemorrhagic and thrombotic complications during the 
perioperative and postoperative periods.
Despite the administration of large amounts of heparin and antifibrinolytics, systemic 
thrombin generation is still prominent throughout and after CPB. (1, 2, 3) Bursts of thrombin 
and fibrin formation are observed immediately after CPB initiation and after reperfusion of 
the heart and lungs. (4) Moreover, continuous thrombin generation can be detected several 
days after surgery. Overall, these findings have been postulated to be related with the 
occurrence of postoperative ischemic events such as myocardial infarctions, graft occlusions, 
ischemic stroke, and venous thromboembolism in addition to the procedure itself. (1)
Likewise, microvascular activation triggered by inflammatory mediators has also been 
suggested to contribute to organ function deterioration in the immediate postoperative period 
due to microvascular thrombosis. (5, 6)
Antithrombin (AT), an alpha 2-glycoprotein with a molecular weight of 58,000, is the major 
plasma inhibitor of thrombin. AT is produced by hepatocytes and belongs to the SERine 
Protease Inhibitor (SERPIN) superfamily and is composed by 432 amino acids. (7, 8) 
Inactivation of thrombin occurs by the formation of a covalent bond resulting in an inactive 
1:1 stoichiometric complex making the thrombin active site inaccessible to its usual 
substrates. This bond involves an active serine of thrombin and an arginine reactive site on 
AT. (9) In the absence of heparin, complex formation occurs at a relatively slow rate. 
However, when heparin or heparin sulfate on the endothelial wall is present, it binds to AT 
and dramatically accelerates the rate of complex formation. (10, 11) In addition to thrombin 
inhibition, AT is also capable of inactivating several other key coagulation proteases 
including factors IXa, Xa, XIa, and XIIa, and plasmin as well as displaying an array of anti-
inflammatory effects. (12, 13, 14, 15)
During cardiac operations with CPB the endogenous anticoagulant AT is diluted and 
extensively consumed, therefore AT activity at admission to the intensive care unit (ICU) has 
been reported to be significantly decreased. (16, 17, 18, 19, 20) Normal plasma AT 
concentrations range between 12.5-15 mg/dL, which translates to a normal range of the 
functional AT assay between 80% and 120%. (21) After cardiac surgery with CPB a decrease 
of AT activity of 40-60% is common and absolute values of AT activity at admission to the 

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ICU in the range of 50% are frequently encountered. (22) Such low AT levels are similar to 
those observed in patients with congenital AT deficiency in which spontaneous venous 
thromboembolic events are described. (23, 24) Moreover, a consistent rate of coronary 
y patients reach the operation theatre with sub-normal AT values (70%±15%, p<0.05) due to 
the preoperative use of unfractionated or low-molecular weight heparin (LMWH), advanced 
age or having suffered a recent myocardial infarction. (25, 26, 27, 28) Patients presenting 
ng with low preoperative AT levels often demonstrate reduced heparin responsiveness, 
sometimes leading to a heparin resistance pattern, defined as the inability to achieve a target 
clotting time result after a standard dose of unfractionated heparin. (25, 29, 30, 31, 32, 33)
The safety and efficacy of the administration of purified AT concentrates for the 
management of heparin resistance has been consistently demonstrated in both small studies 
and large phase III trials and is currently recommended by the Society of Thoracic Surgeons 
and Society of Cardiovascular Anesthesiologists (STS-SCA) Guidelines on Blood 
Conservation Clinical Practice over the use of fresh frozen plasma. (34, 35, 36) The rationale 
behind this preference is based on the safer profile of AT concentrates with respect to 
infectious disease transmission, avoidance of hemodilution and transfusion-related 
complications such as volume overload and transfusion-related acute lung injury (TRALI). 
(37)
The association of low AT levels and morbidity has been established in inherited AT 
deficiency and in certain situations of acquired AT deficiency such as sepsis. These 
observations triggered the hypothesis that lowered postoperative AT levels could influence 
the occurrence of postoperative complications after CPB. To this end, two large 
observational studies showed that patients with postoperative AT levels below 60% had 
greater risk of several negative outcomes during the ICU and postoperative period. (38, 39) 
Specifically, the retrospective observational study by Ranucci et al. demonstrated that low 
AT levels at the arrival to the ICU after cardiac operations was independently associated with 
prolonged ICU stay, surgical reexploration, adverse neurologic outcome, and 
thromboembolic events. Moreover, ICU-AT activity levels <58% was shown to be predictive 
for prolonged ICU stay (>5 days) with a sensitivity of 67% and a specificity of 83%. In this 
study, supplementary exogenous AT was not provided to any subjects to evaluate if the use 
of ICU-AT levels is a predictable marker for poor postoperative outcomes. (38) These 
findings were later confirmed by Paparella et al. which found that ICU-AT levels below 
63.7% was independently associated with prolonged mechanical ventilation, need of 
inotropic support, postoperative bleeding, and blood product transfusion. (39) However, 
another observational study failed to find a clear temporal correlation between baseline AT 
activity levels and the occurrence of postoperative major adverse cardiac events (MACE). 
(28)
In the light of these observations, a phase II randomized-controlled study was carried out to 
investigate the effects of preoperative AT supplementation in maintaining postoperative AT 
levels within normal physiologic range, avoidance of heparin resistance, and limiting 
postoperative morbidity. (40) Patients in the treatment group were supplemented with a 
single dose of a plasma-derived AT concentrate immediately after anesthesia induction 
aimed to achieve a target activity level of 120% whereas control patients were given the 

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same standard of care without the administration of AT. Preoperative supplementation of AT 
yielded significantly higher AT activity levels compared to untreated patients not only at the 
ICU admission, but throughout the entire postoperative stay until ICU discharge. Moreover, 
25 patients in the control group (26%) presented postoperative AT activity levels below 58% 
whereas no patients in the treatment group (0%) reached the ICU with AT levels below this 
threshold. In addition, patients in the AT arm had a significantly lower rate of heparin 
resistance and a trend towards fewer thromboembolic events. However, a higher 
postoperative bleeding rate (8 mL/hour) was observed in the treatment group, but was judged 
by the investigators not to be clinically significant. Conversely, due to the lack of statistical 
power, differences in postoperative outcomes were unattainable between study groups.
Post-hoc analysis of the abovementioned study confirmed previous observations that low 
postoperative AT levels (<58%) are a consistent predictor of prolonged ICU stay (>7 days) in 
untreated patients. Further, patients presenting ICU-AT levels below this threshold suffered 
overall worse postoperative outcome than patients that reached the ICU with AT levels above 
58% regardless of their treatment suggesting that prophylactic measures to avoid such low 
AT levels after CPB are warranted. On the other hand, a similar pattern was observed in 
patients reaching the ICU with unexpectedly high AT activity levels. The latter were more 
prone to suffer bleeding-related postoperative complications suggesting that AT 
overcorrection should also be avoided and that a preoperative AT target of 120% may be 
excessive. Moreover, given that this study was performed with less complex procedures such 
as isolated CABG or single valve, compared to more complex/combined procedures such as 
double/triple valve repair/replacement, ascending aorta/aortic arch surgeries, with normal 
baseline AT values, many subjects in the control group reached the ICU with AT levels 
within the normal physiological range, suggesting that an AT supplementation may be of 
more benefit in a higher risk patient population (undergoing complex/combined cardiac 
surgeries with long bypass runs and/or high inflammatory response) prone to consume large 
amounts of AT or with lower baseline AT levels.
Overall these findings still do not clarify if a pharmacological supplementation of AT aimed 
to avoid excessively low and excessively high postoperative AT levels is an effective 
therapeutic strategy for the prevention of negative postoperative outcomes in patients 
undergoing cardiac surgery with cardiopulmonary bypass.
1.2
Rationale for Conducting the Study
Cardiac surgery with CPB causes a massive consumptive coagulopathy and thrombotic 
complications in a similar way that disseminated intravascular coagulation does. Therefore, 
suppressing excessive hemostatic activation is a plausible therapeutic strategy that may 
impact postoperative morbidity.
Several studies have consistently reported the association of low postoperative AT levels 
with poor clinical outcomes (28, 38, 39) and that preoperative AT supplementation is able to 
o maintain AT levels within a normal range throughout the postoperative period. (40, 41) 
Conversely, past studies have also highlighted the potential anticoagulant action of purified 
AT. (31, 34) Likewise, a dose dependent trend towards higher bleeding rates and a trend 

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towards an increased incidence of postoperative complications (namely bleeding related) in 
AT treated patients reaching the ICU with exceptionally high AT levels has been reported. 
(40, 41) The latter observations generate the hypothesis that an AT supplementation strategy 
aimed to avoid both excessively low (<58%) and excessively high (>100%) postoperative 
AT levels may represent an effective therapeutic goal to ameliorate the occurrence of 
bleeding and thrombotic events, respectively. However, these assumptions have been derived 
from post-hoc analysis and small studies performed with a limited number of patients. (40, 
41)
Thus, this clinical study has been designed to evaluate the safety and efficacy of a 
preoperative treatment with AT supplementation (Antithrombin III [Human]) in subjects who 
undergo high-risk cardiac surgery with CPB targeting AT levels in such a way to avoid both 
excessively low and excessively high postoperative AT activity levels and to assess if 
management of AT levels in this range may decrease negative clinical outcomes during the 
ICU and hospital stay. The present clinical trial is intended to assess if directed preoperative 
AT supplementation will show favorable trends in decreasing the incidence of a composite of 
major morbidity when compared to placebo.
Antithrombin III (Human) with the trade name of THROMBATE III® is marketed in several 
countries for replacement therapy in subjects with hereditary deficiency of AT during 
pregnancy or surgery, or if at risk of thromboembolism. For simplicity, Antithrombin 
(Human) is abbreviated as AT-III (Human) in this protocol. Please refer to AT-III (Human) 
IB for additional detail.
2
STUDY OBJECTIVES
2.1
Primary Efficacy Objective
The primary objective of this clinical study is to compare the percentage of subjects with any 
component of a major morbidity composite between 2 groups of subjects randomly allocated 
to receive preoperative supplementation of AT-III (Human) or Placebo.
2.2
Secondary Efficacy Objectives
The secondary objectives of this clinical study are the following:
1. To compare postoperative AT levels at the ICU admission between the AT-III (Human) 
treatment group and Placebo control group
2. To compare the following postoperative outcomes between the AT-III (Human) treatment 
group and Placebo control group:
-
Postoperative chest-drain blood loss in the first 12 and 24 hours after surgery
-
Transfusion requirements
-
Need for surgical reexploration
-
Low cardiac output syndrome

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-
Myocardial infarction
-
Stroke
-
Acute kidney injury
-
Arterial or venous thromboembolic events
-
Infections
-
Prolonged mechanical ventilation (>24 hours)
-
All-cause postoperative mortality
-
ICU stay duration
-
Prolonged ICU stay (>6 days)
-
Length of hospital stay
2.3
Safety Objectives
Safety objectives include evaluation of AT-III (Human) for clinical safety including adverse 
events (AEs), risks for bleeding, clinical laboratory testing, physical exam, and vital signs.
3
INVESTIGATIONAL PLAN
3.1
Study Design and Plan
This study will be a prospective, multicenter, randomized, double-blind, placebo-controlled 
study. Participating subjects will be 404 adult subjects undergoing cardiac surgery with CPB 
who will be randomized into two treatment groups preoperatively in a 1:1 ratio: AT-III 
(Human) treatment group and Placebo control group. All subjects will be stratified by their 
previous history of MI. Subjects undergoing complex/combined procedures will not be 
prescreened or screened for AT levels using local lab values to assess eligibility. Only 
subjects undergoing isolated CABG or single valve repair/replacements and not receiving 
preoperative heparin may be prescreened locally for AT levels (must be AT <80%).
Subjects randomized to AT-III (Human) treatment group will receive preoperative 
supplementation with AT-III (Human) designed to achieve an absolute increase () of 20%
(percentage points) above pretreatment AT levels. Subjects randomized to Placebo control 
group will receive 0.9% Sodium Chloride (NaCl) for Injection, USP (United States 
Pharmacopeia).
The maximum study duration for a given subject will be approximately 7 weeks (48 days). 
There will be 2 weeks for prescreening and screening, and randomization into one of the two 
study groups (AT-III [Human] treatment or Placebo control). After the 2-week prescreening
and screening period, the cardiac surgery procedure will take place with the preoperative 
administration of AT-III (Human) or Placebo supplementation. After surgery, the subject will 
be admitted to the ICU and be followed for approximately 1 month (30±4 days).

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Both the primary efficacy endpoint (percentage of subjects with any component of the major 
morbidity composite) and the secondary endpoints will be evaluated for each subject after 
each cardiac surgery procedure, at the ICU admission, ICU discharge, and during a follow-up 
period of approximately 1 month (30±4 days) (see Section 3.5.1).
The overall study schema is shown in Figure 3-1.

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Figure 3-1 Overall Study Schema

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3.2
Selection of Study Population
Subjects undergoing high-risk, non-emergency cardiac surgery with CPB will be studied. 
Subjects undergoing isolated CABG or single valve repair/replacements maybe prescreened 
for AT activity measured locally which should be below 80% unless treated with 
preoperative heparin (details below). Four hundred and four (404) subjects will be enrolled in 
this study.
3.2.1
Inclusion Criteria
A subject must meet all the following inclusion criteria to be eligible for participation in this 
study:
1. Male or female.
2. At least 18 years of age.
3. Subject needs non-emergency cardiac surgery with cardiopulmonary bypass.
4. Types of cardiac operations permitted:
-
Complex/combined procedures (CABG+valve), double/triple valve 
repair/replacements, ascending aorta/aortic arch surgeries (without baseline AT level 
restriction or preoperative heparin requirement). OR
-
Isolated CABG or single valve repair/replacements are allowed only if either (a) AT 
level is less than 80% OR (b) preoperative heparin is received (unfractionated heparin 
[UFH] for at least 12 hours; low-molecular-weight heparin [LMWH] for more than 
5 days).
5. Not applicable – intentionally left blank for data management purposes (consistency in 
eCRF capture of eligibility criteria historically).
6. Subject has signed informed consent form.
7. Subject is willing to comply with all aspects of the protocol, including blood sampling, 
for the total duration of the study.
3.2.2
Exclusion Criteria
A subject meeting any of the following exclusion criteria is NOT eligible for participation in 
the study. All exclusion criteria involving hematology/coagulation and clinical chemistry 
determinations will be based on local lab results.
1. Subject needs emergency surgery.
2. Subject needs heart transplantation.
3. Use of minimally invasive surgery.
4. Previous cardiac operation.
5. Infective endocarditis.

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6. Thromboembolic events, stroke, or ST-elevated myocardial infarction within 7 days of 
surgery.
7. Cardiogenic shock at the time of surgery.
8. Renal dysfunction: Creatinine levels >2 mg/dL or chronic dialysis.
9. Liver dysfunction: AST, ALT increase ≥2-fold above the upper-limit of local lab normal 
ranges.
10. Treatment with Clopidogrel and Ticagrelor within 5 days before surgery, Prasugrel 
within 7 days before surgery, glycoprotein IIb/IIIa receptor blockers within 24 hours of 
surgery.
11. Treatment with new oral anticoagulants (Apixaban, Rivaroxaban, Dabigatran) within 
48 hours before surgery.
12. Vitamin K antagonist therapy and an international normalized ratio >1.3 on the day of 
surgery.
13. Platelet count <120,000/μL.
14. History or suspicion of a congenital or acquired coagulation disorder.
15. History of anaphylactic reaction(s) to blood or blood components.
16. Allergies to excipients in the study drug.
17. Refusal to receive allogenic transfusion of blood-derived products.
18. Received AT treatment within the last 3 months prior to Screening visit.
19. Subject is pregnant.
20. Subject has participated in any another investigational study within the last 3 months 
prior to Screening visit.
3.3
Treatments
3.3.1
Treatments to Be Administered
3.3.1.1
AT-III (Human)
Detailed information of AT-III (Human) is also available in the IB.
AT-III (Human), a freeze-dried preparation for intravenous (IV) administration, has AT as 
the active ingredient. It is obtained from human plasma by a continuous purification process, 
which is performed in an authority-regulated plant in Clayton, North Carolina. Antithrombin 
is the main inhibitor of blood coagulation.
AT-III (Human) is prepared from pooled units of human plasma from normal donors by 
modifications and refinements of the cold ethanol method of Cohn. When reconstituted with 
sterile water for injection (SWFI), USP, AT-III (Human) has a pH of 6.0–7.5, a sodium 
content of 110–210 mEq/L, a chloride content of 110–210 mEq/L, an alanine content of 

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0.075–0.125 M, and a heparin content of not more than 0.1 IU heparin/IU ATIII. AT-III 
(Human) contains no preservative and must be administered by the IV route.
AT-III (Human) preparation will be reconstituted in 10 mL SWFI, which will be transferred 
into the vial containing the concentrate.
Usually the solution is clear or slightly opalescent. Do not use solutions that are cloudy or 
have deposits. Infusion of AT-III (Human) should be started within 3 hours of study drug 
reconstitution. It should be kept at room temperature not to exceed and precautions must be 
taken to avoid microbiological contamination. It should not be stored in the refrigerator or 
mixed with other drugs. Leftover product must never be kept for later use.
3.3.1.2
Placebo
Placebo used in this study will be 0.9% Sodium Chloride (NaCl) for Injection, USP.
3.3.1.3
Labeling of Investigational Products
Investigational products will be labeled according to the requirements of local law and 
legislation. Label text will be approved according to agreed Grifols procedures, and a copy of 
the labels will be made available to the study site.
Each vial of AT-III (Human) will be labeled with the antithrombin potency expressed in 
international units (IU) as defined by the World Health Organization (WHO).
3.3.1.4
Storage of Investigational Products
The investigational product should be stored at temperatures not to exceed 25°C (77°F). Do 
not freeze. The investigational product must be stored in a secure area accessible only to the 
unblinded pharmacist, or designee, until dispensed for the study subject.
3.3.1.5
Accountability for Investigational Products
Investigational product is to be used only for the study in accordance with the directions 
given in this protocol. The Investigator, or designee such as the study pharmacist, is 
responsible for the distribution of the investigational product in accordance with directions 
given in the protocol and pharmacy manual.
The Investigator is responsible for maintaining accurate records of the investigational 
product for his/her site. Investigational product inventory/dispensing documentation 
verifying the receipt, dispensing, destruction, or return must be maintained and kept current 
by the unblinded pharmacist. The inventory must be made available for inspection by the 
monitor. Investigational product supplies (including placebo) must be accounted for by the 
monitor and inventory/dispensing logs must be verified by the monitor prior to 
Investigational product return or destruction. Written documentation of any used and unused 

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inventory is required. At the end of the study, a copy of the inventory/dispensing log(s) will 
be retrieved by the monitor and returned to Grifols Therapeutics Inc.
Any unused investigational product will be accounted for and returned to the Sponsor’s 
distributor. When required by local policies, unused supplies may be destroyed at the study 
site. The Investigator will ensure that such disposition does not expose subjects to risks from 
the investigational product. The Investigator and the Sponsor’s representative will maintain 
records of any such alternate disposition to permit accurate drug accountability.
3.3.2
Rationale for Selection of Doses/Timing of Investigational Products in the 
Study
3.3.2.1
Study Drug Doses
Every subject allocated in the AT-III (Human) treatment group will receive, immediately 
after anesthesia induction, a single dose of AT-III (Human) sufficient to achieve an absolute 
increase (Δ) of 20% (percentage points)above pretreatment AT levels according to the 
formula:
4.1
)
(
)
20
(
)
(
kg
in
weight
subject
required
IU
dose
III
AT



The only variable in the equation is the subject’s body weight. For calculating AT-III 
(Human) dose, subject’s weight obtained during the Screening visit will be used. 
AT-III (Human) or Placebo (0.9% NaCl) will be prepared according to the volume calculated 
by unblinded pharmacist or designee and will be infused intravenously.
AT-III (Human) will not be administered postoperatively unless the Investigator decides 
otherwise for clinical reasons (if this is the case, the subject will be excluded from the 
efficacy analysis).
After the operation, all subjects will be admitted to the ICU and will be followed for 
approximately 1 month regardless of when the ICU discharge takes place (see Section 3.6.2).
3.3.2.2
Rationale for Selection of Doses in the Study
The goal for dose selection is to avoid both low and high postoperative AT levels in treated 
subjects. In a previous study using another AT product for the same indication (40), the 
preoperative AT target of 120% was explored. The results suggested that dosing of subjects 
with a preoperative AT target of 120% resulted in a large number of AT treated subjects 
reaching the ICU with high postoperative AT levels (>100%). These AT levels were 
associated with an overall worse postoperative outcome. To build on this study, a more 
conservative dosing scheme and the inclusion of more severe subjects (i.e., undergoing 
complex/combined cardiac surgeries or subjects undergoing isolated procedures with low 

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preoperative AT levels or treated with heparin preoperatively) are intended to achieve better 
efficacy and safety.
3.3.3
Method of Assigning Subjects to Treatment Groups
3.3.3.1
Subject Numbering
Within each study site, subjects in the study will receive a consecutive subject number. 
Subject numbers are generated beginning with the study center number (3 digits, assigned by 
the sponsor) followed consecutively with a unique number for each subject (4 digits, 
including leading zeros). For example, if the Investigator’s center number is 301, subject 
number will be 3010001, 3010002, 3010003, etc., in consecutive order. Subject numbers, 
once assigned, will not be reused at any center.
3.3.3.2
Randomization
Subjects will be randomized into one of two treatment groups: AT-III (Human) treatment 
group and Placebo control group. Subjects will be stratified by their previous history of 
myocardial infarction (MI). Unblinded pharmacist or designee will obtain the treatment 
assignment based on a computer-generated randomization schedule. The randomization 
number will be assigned at Preoperative visit (Day 0) after all enrollment criteria are met.
3.3.3.3
Blinding
To minimize the risk of unblinding, all subjects will receive the same total volume for all 
treatments with no visible differences in the external appearance of treatments, infusion bags 
will be covered with a non-transparent sleeve, and opaque IV tubing will be utilized.
The unblinded study pharmacist, or designee, will prepare investigational product (i.e., 
AT-III [Human] and placebo) at each site. Monitoring of activated clotting time (ACT) for 
subject safety can potentially unblind an investigator if performed immediately before AND 
immediately after IP administration. Thus, to avoid potential unblinding, investigators should 
restrain from monitoring ACT values immediately before AND immediately after IP 
administration. Individual ACT determinations before OR after IP administration is not 
considered as potentially unblinding and is therefore permitted. However, if ACT monitoring 
is done prior to IP administration care must be taken to ensure blinded study personnel are 
not unblinded. Grifols Clinical Trial Materials personnel and Grifols Pharmacovigilance 
personnel will have access or be privy to treatment assignments.
Emergency unblinding instructions will be located in the Pharmacy Manual (to be used only 
if required).
Investigators must not draw any blood samples for AT levels outside the requirements of the 
protocol. Results from protocol-specified AT, TAT, and F1+2 measurements will not be 
provided to the Investigator or blinded sponsor personnel in order to ensure maintenance of 
the treatment blind.

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3.3.3.4
Administration and Timing of Investigational Products for Each Subject
The dose of AT-III (Human) will be slowly administered, at a maximum rate of 
0.1 mL/kg/min (minute), intravenously. The initial rate will be 0.05 mL/kg/min during the 
first 5 minutes, accelerating to 0.1 mL/kg/min if tolerated. Intolerance (the inability to 
provide the subject one full dose) of an infusion due to allergic reactions and anaphylactic 
symptoms may require decreasing or stopping the infusion rate of the product. In these 
instances, the following algorithm will be employed:
Severe reaction:  Stop infusion. If symptoms subside, it will be at the physician’s discretion 
whether to restart the infusion. The infusion may be restarted under careful nursing 
monitoring at one-half the previous rate. Appropriate concomitant medication may be given 
as directed by the physician based on the clinical evaluation.
Moderate reaction:  Stop the infusion until all symptoms resolve.  If resolution occurs in less 
than 30 minutes, the infusion may be restarted under careful nursing monitoring at one-half 
the previous infusion rate. Appropriate concomitant medication may be given as directed by 
the physician based on the clinical evaluation.
3.3.3.5
Treatment Compliance
Treatment compliance will be measured only in terms of the subject receiving an infusion of 
AT-III (Human) from the study personnel. No other measure of treatment compliance will be 
employed.
Reasons for any deviation from the administration of less than 100% of the investigational 
product dose as prepared by the pharmacist, or designee, must be recorded in the electronic 
case report form (eCRF) and in the subject’s medical records.
3.4
Prior and Concomitant Therapy
Concomitant medications and those taken within the last month (including transfusions of 
blood or any blood-derived product) prior to the Screening visit must be recorded in the 
eCRF, including the trade or generic names of the medication, the dose, the route of 
administration, and the duration of the medication (frequency).
3.4.1
Prior to Study Treatment
Subjects may be on heparin or low-molecular weight heparin, and vitamin K antagonists if 
international normalized ratio (INR) <1.3 on the day of surgery. Prior treatment with 
Clopidogrel and Ticagrelor must be discontinued at least 5 days before surgery. Prior 
treatment with Prasugrel must be discontinued at least 7 days before surgery. Glycoprotein 
IIb/IIIa receptor blockers must be discontinued at least 24 hours before surgery.

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3.4.2
Concomitant Medications during the Study
Concomitant administration of heparin, low-molecular weight heparin, coumadin, tranexamic 
acid, aminocaproic acid, desmopressin, and recombinant activated factor VII (rFVIIa) may 
be used in order to avoid thrombotic risk.
Details of any concomitant medication must be recorded on the eCRF except for anesthesia 
related products, fluid replacement therapies, and electrolyte supplementation.
In addition, products given at different doses on the same day to manage and maintain vital 
functions (e.g. insulin, furosemide) will only be recorded once on the eCRF and dosage will 
be reported as PRN (pro re nata).
In the event that an AE or suspected adverse drug reaction (ADR) should occur, complete 
details of all concomitant medication will be reported to the sponsor.
3.4.3
Prohibited Concomitant Medications during the Study
Tirofiban, abciximab, and eptifibatide may not be used during this clinical trial.
3.5
Study Variables
3.5.1
Efficacy Variables
1. Percentage of subjects with any component of a major morbidity composite defined as 
a composite of any one or more of the following events (up to Day 30±4 days):
a.
Postoperative mortality (defined as all deaths occurring within 30 days of the 
operation or occurring during the primary hospitalization).
b. Stroke (defined as a clinical diagnosis of focal or global neurological deficit of 
abrupt onset caused by a disturbance in cerebral blood supply).
c.
Acute kidney injury (defined as an increase of serum creatinine levels to >2.0 mg/dL 
and twice the baseline level or a new requirement for dialysis postoperatively).
d. Surgical reexploration (defined as having to return to the operating room because of 
bleeding, tamponade, graft occlusion or any other cardiac reason).
e.
Arterial or venous thromboembolic event (consisting of perioperative MI, 
mesenteric infarction, peripheral thromboembolism, acute coronary graft thrombosis, 
intracardiac thrombosis, deep vein thrombosis [DVT], and pulmonary embolism).
f.
Prolonged mechanical ventilation (defined as mechanical ventilation >24 hours).
g. Infection (defined as presence of deep sternal-wound infection and/or bloodstream 
infections).

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2. AT activity (levels) determinations:
a.
AT activity levels will be measured for both AT-III (Human) treatment and Placebo 
control groups at a central lab (unless specified at local lab) for the following time 
points:
◦
Prescreening visit (local lab)*
◦
Screening visit (local lab)* §
◦
Screening visit
◦
Preoperatively
◦
Immediately before study drug administration
◦
Immediately after study drug administration
◦
Postoperatively at ICU admission
◦
Postoperatively Day 1
◦
Postoperatively Day 2
◦
Postoperatively Day 3
◦
Postoperatively Day 5
◦
ICU discharge
◦
1-month follow-up visit
* Only applicable for subjects undergoing isolated CABG or single valve 
repair/replacements (will be needed for eligibility only if subject not receiving 
preoperative heparin [see entry criteria]).
§ This AT (local lab) determination will not be required if the Prescreening visit is 
conducted.
b. Percentage of subjects with AT levels of 58% or higher at the ICU admission will be 
calculated for both treatment groups and compared.
All AT measurements will be performed on a central venous catheter blood sample, if the 
central venous catheter is already in place, through a calibration curve prepared by serial 
dilution of the human normal plasma pool and expressed as a percentage of activity. If a 
central venous catheter is not already in place, peripheral blood sample will be used for 
measuring AT levels.
3. Chest-drain blood loss (mL) will be measured within the first 12 and 24 hours of chest 
closure.
Chest-drain blood loss in the first 12 and 24 hours is defined as the amount of blood 
collected in the cardiotomy reservoir from chest closure through the following 12 and 
24 hours measured.

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4. Transfusion requirements will be measured as the number of units of Fresh frozen 
plasma (FFP), red blood cells (RBCs), platelets (PLTs), cryoprecipitate/fibrinogen, 
prothrombin complex concentrates (PCCs), from the day of ICU admission and 
throughout the follow-up period.
A specific perioperative transfusion algorithm will be applied:
Standardized Transfusion Algorithm
Red blood cells:
Administration of RBCs should be performed one unit at a time after which the hemoglobin 
(Hb) levels should be reanalyzed to check the suitability for the next unit.
- Hb <6.0 g/dL (≤3.72 mmol/L [millimoles/liter]): Transfusion is mandatory
- Hb = 6.0-8.0 g/dL (3.72-4.96 mmol/L): Transfusion is optional
- Hb = (8.0-10.0 g/dL). Transfusion is acceptable only if clinically justified*
- Hb >10.0 g/dL: Transfusion is not permitted.
* One or more of the following clinical justifications must be provided:

Central venous saturation (Swan Ganz / Central Venous Pressure (CVP) <60% with an 
arterial oxygen saturation of at least 90%.

Cardiac Index (CI) <2.0 unresponsive to inotropic or mechanical support (catecholamine, 
intra-aortic balloon pump [IABP], etc.).

Signs / symptoms of organ ischemia, such as: change in ST-segment or left ventricular 
wall motion abnormalities (LV).
Coagulation products:
Only if subject is bleeding 4 mL/kg/hour or more over at least 30 minutes or 1.5 mL/kg/hour 
or more over 2 consecutive hours.

Fresh frozen plasma (10-15 mL/kg) / Prothrombin complex concentrates: If subject is 
actively bleeding and presents an INR ≥1.5.

Platelets: 1 apheresis unit or 4-6 pooled units if the PLT count is <100,000/μL.

Cryoprecipitate / Fibrinogen concentrates:  Administration of 8-10 units of 
cryoprecipitate or 2 grams of fibrinogen concentrate if the concentration of fibrinogen 
≤1.5 g/L.
Shed blood collected during surgery can be retransfused according to institutional practice. 
Retransfusion of chest-drain collected blood is not permitted.

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5. Percentage of subjects needing surgical reexploration defined as having to return to the 
operating room because of bleeding, tamponade, graft occlusion or any other cardiac 
reason will be considered from chest closure to the end of the follow-up period.
6. Percentage of subjects with low cardiac syndrome defined as the need for major 
inotropic support or intra-aortic balloon pump will be considered from the day of ICU 
admission and throughout the follow-up period.
7. Percentage of subjects with postoperative myocardial infarction defined through 
enzymatic criteria plus new Q-waves at the electrocardiogram (ECG) will be considered 
from the day of ICU admission and throughout the follow-up period.
A perioperative  MI is diagnosed by the following criteria:
(0-24 hours postoperation):
The CK-MB (or CK if MB not available) must be greater than or equal to 5 times the upper 
limit of normal with or without new Q waves present in two or more contiguous ECG leads. 
No symptoms required.
(>24 hours postoperation): Documented by at least one of the following criteria:
a.
Evolutionary ST-segment elevations
b. Development of new Q-waves in two or more contiguous ECG leads
c.
New or presumably new left bundle branch block (LBBB) pattern on the ECG
d. Creatine phosphokinase-MB isoenzyme (CK-MB) (or CK if MB not available) ≥3 times 
the upper limit of normal
8. Percentage of subjects with postoperative stroke defined as a clinical diagnosis of focal 
or global neurological deficit of abrupt onset caused by a disturbance in cerebral blood 
supply will be considered from the day of ICU admission and throughout the follow-up 
period.
9. Percentage of subjects with acute kidney injury defined as an increase of serum 
creatinine levels to >2.0 mg/dL and twice the baseline levels or new requirement for 
dialysis postoperatively, will be considered from the day of ICU admission and 
throughout the follow-up period. A new requirement for postoperative dialysis may 
include hemodialysis, peritoneal dialysis, and any form of ultrafiltration.
10. Percentage of subjects with arterial or venous thromboembolic events defined as 
perioperative MI, stroke, mesenteric infarction, peripheral thromboembolism, acute 
coronary graft thrombosis, intracardiac thrombosis, deep vein thrombosis [DVT], and 
pulmonary embolism, will be considered from the day of ICU admission and throughout 
the follow-up period.

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11. Percentage of subjects with infections defined as presence of deep sternal-wound 
infections involving muscle, bone or mediastinum or bloodstream infections from the day 
of ICU admission and throughout the follow-up period.
The diagnosis of infection must have at least one of the following conditions:
a.
Wound opened with excision of tissue or reexploration of the mediastinum
b. Positive culture
c.
Treatment with antibiotics
12. Percentage of subjects with prolonged mechanical ventilation defined as the need for 
mechanical ventilation >24 hours from the day of ICU admission and throughout the 
follow-up period.
13. Percentage of subjects with all-cause postoperative mortality defined as death during 
the same hospitalization as surgery or after discharge and throughout the follow-up 
period.
14. ICU stay duration (days) will be measured from the ICU admission. If duration is greater 
than the follow-up period, >1 month will be recorded.
15. Percentage of subjects with prolonged ICU stay defined as >6 days will be considered 
from ICU admission during a maximum of 34 days.
16. Length of hospital stay (days) in both groups defined as the discharge date minus the 
surgery date plus 1 day, during a maximum of 34 days after ICU admission. If this time 
interval is greater than the follow-up period, >1 month will be recorded.
3.5.2
Safety Variables
The following safety variables will be assessed in this study:

Adverse events, serious adverse events (SAEs), and discontinuations due to AEs.

Risk for bleeding (will be assessed by monitoring hematocrit levels, urine dipstick tests, 
and any clinical adverse events for bleeding).

Physical examination and vital signs.

Clinical laboratory parameters: Hematology (red blood cell count, white blood cell count, 
hematocrit, hemoglobin, and platelets, etc.) and clinical chemistry (creatinine, total 
bilirubin, ALT, and AST, etc.).

Viral retention samples:
Blood samples for viral nucleic acid testing (NAT) and viral serology testing will be 
collected throughout the 30-day follow-up but will be tested only if the subject exhibits 
clinical signs and symptoms of viral infection during the one-month follow-up period.

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3.6
Assessments
3.6.1
Assessment Periods
The expected duration of a study subject’s participation will be approximately 7 weeks (30 to 
48 days).
The study will consist of the following periods:

Prescreening and Screening period: within 2 weeks prior to surgery.

Preoperative period: from the Screening visit to the day of surgery, before anesthesia 
induction.

Operative period: from the anesthesia induction to ICU admission.

ICU admission.

Postoperative follow-up period: from ICU admission to approximately 1 month (30 ± 
4 days) regardless of when the ICU discharge takes place.
3.6.2
Observations and Measurements
The following is a description of the procedures/assessments to take place at each study visit. 
See the Study Flow Chart and/or Schedule Procedure in Appendix 1.
3.6.2.1
Prescreening Visit: (within Two Weeks Prior to Surgery)*

Signed informed consent for Prescreening

AT activity levels (local lab)
* Only applicable for subjects undergoing isolated CABG or single valve 
repair/replacements who will not be receiving preoperative heparin (see entry criteria)
and whose eligibility will therefore be based on AT level <80%. If it is logistically 
feasible, Prescreening visit must be performed prior to Screening visit, unless a 
subject’s surgery is scheduled to occur in ≤72 hours. In the latter case, the Prescreening 
and Screening visit may be combined. All determinations for a separate Prescreening 
visit must be recorded on specific Prescreening sheets.
Note: The Prescreening visit is not required for subjects undergoing complex/combined 
procedures (CABG+valve, double/triple valve repair/replacements, ascending aorta/aortic 
arch surgeries).
3.6.2.2
Screening Visit: (within Two Weeks Prior to Surgery)*

Signed informed consent

Allocation of Screening Number

Inclusion/Exclusion criteria

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
Addition of subject’s data into Screening Log

All clinically relevant medical case history and demographic data (age, gender, race, 
weight, height, body mass index [BMI], smoking habits, ejection fraction, previous MI, 
unstable angina, arrhythmia, cardiogenic shock, congestive heart failure, pre-existing 
renal failure or dialysis treatment, chronic obstructive pulmonary disease [COPD], 
previous stroke, percutaneous coronary interventions, previous pulmonary 
thromboembolism, previous IABP, diabetes mellitus requiring treatment, oral 
anticoagulation therapy, heparin therapy, peripheral vascular disease or systemic 
thromboembolism, hypertension, hypercholesterolemia, immunosuppressive treatment).
Please include any relevant medical conditions as well as medical disorders requiring 
medication or that are currently active.

Physical examination

Vital signs (temperature [T], blood pressure [BP], heart rate [HR], respiratory rate [RR])

AT activity levels (local lab) (Only for subjects undergoing isolated CABG or single 
valve repair/replacements and not receiving preoperative heparin [see entry criteria])

AT activity levels (central lab)

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, lactate dehydrogenase 
[LDH], glucose, sodium, potassium, chloride and calcium)

Serum pregnancy test (for women of childbearing potential)

An appropriate volume of blood will be drawn in order to obtain a serum/plasma 
retention sample. The retention sample will be frozen and stored at -70ºC and stored in 
the event that additional testing is required in the future for purposes of this study only 
(i.e. repeat testing, or confirmation of virology results).

Documentation of medications that the subject is taking or has taken within the last 
month (including transfusions of blood or any blood-derived product)

Adverse events
* The Screening visit may occur on the same day of the Prescreening visit. If a subject’s 
surgery is scheduled to occur in ≤72 hours, the Prescreening and Screening visits may 
be combined.
3.6.2.3
Preoperative Visit (Before Anesthesia Induction): Day 0§

Review of inclusion/exclusion criteria to confirm subject eligibility

Physical examination

Vital signs (T, BP, HR, RR)

AT activity levels (central lab)

Randomization†

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

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
Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium)

An appropriate volume of blood will be drawn in order to obtain a serum/plasma 
retention sample. The retention sample will be frozen and stored at -70°C and stored in 
the event that additional testing is required in the future for purposes of this study only 
(i.e. repeat testing, or confirmation of virology results).

Confirmation of existing, and recording of any new events, or changes, in the medical 
and surgical history of the subject since the Screening visit.

Confirmation of existing and recording of any new medications, or changes in 
medications administered to the subject since the Screening visit. The combined 
Screening and Preoperative visit requires documentation of the lifetime history of
bleeding abnormalities. In addition, it requires documentation of medications that the 
subject is taking or has taken within the last month.

Adverse events
§ The Preoperative visit (Before Anesthesia induction: Day 0) may occur on the same day 
of the Screening visit if the latter is to be performed within 48 hours of the surgery. In 
this case, the only assessments to be performed are those detailed for the Screening visit 
AND the Randomization procedures detailed in Section 3.3.2.
† Randomization on Preoperative visit (Day 0) may occur 24 hours before the day of 
surgery (Day 0) once all eligibility criteria are confirmed.
3.6.2.4
Operative Visit (After Anesthesia Induction – Before ICU Admission): Day 0

Type of surgical procedure 

Duration of CPB and aortic clamp

Preoperative heparin dose response*

Dose of heparin (initial, subsequent pre-CPB, during CPB), ACT, and dose of protamine*

Study drug infusion

Minimum hematocrit during CBP (local lab)

Transfusion requirements

AT activity levels immediately before and after infusion of AT-III (Human) or Placebo

Concomitant medications

Adverse events
* A specific perioperative anticoagulation management protocol below will be applied to 
all participating subjects:

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Anticoagulation management protocol:
- An initial heparin loading dose of 400 IU/kg will be administered aimed to achieve a pre-
CPB ACT value of 480 seconds. Heparin responsiveness will be determined according to 
institutional practice (i.e., use of heparin dose response method).    
- Failure to achieve the desired ACT after an IV administration of 400 IU/kg of heparin will 
be managed by a maximum of three (3) separate heparin administrations of 100 IU/kg 
each. If the target ACT is still not obtained additional measures will be performed 
according to institutional practice (e.g. additional heparin, FFP, AT). If AT is administered 
the subject will be excluded from the final analysis.
- At the end of CPB, heparin will be reversed with protamine at a 0.5:1 ratio of the total 
heparin dose. Additional protamine may be infused according to local standards.  
- Postoperatively, 15 mg of protamine will be administered as an infusion every hour (± 15 
minutes) during the first 5 hours postoperation.
3.6.2.5
ICU Admission: Day 0

Physical examination

Vital signs (T, BP, HR, RR)

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium)

Chest-drain blood loss in the first 12 and 24 hours postoperatively

Postoperative clinical outcomes (major morbidity composite, transfusion requirements, 
surgical reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney 
injury, arterial or venous thromboembolic events, infections, and postoperative mortality)

Concomitant medications

Adverse events

An appropriate volume of blood will be drawn in order to obtain a serum/plasma 
retention sample. The retention sample will be frozen and stored at -70ºC and stored in 
the event that additional testing is required in the future for purposes of this study only 
(i.e. repeat testing, or confirmation of virology results).
3.6.2.6
Postoperative Day 1:

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

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
Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium)

Chest-drain blood loss in the first 12 and 24 hours postoperatively

Postoperative clinical outcomes (major morbidity composite, transfusion requirements, 
surgical reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney 
injury, arterial or venous thromboembolic events, infections, prolonged mechanical 
ventilation, and postoperative mortality)

Concomitant medications

Adverse events
If this visit coincides in time with the ICU discharge, the only assessments to be performed 
are those detailed below in the ICU discharge visit. Regardless of when the ICU discharge 
takes place AT activity levels should be measured on Postoperative days 1, 2, 3, and 5.
3.6.2.7
Postoperative Day 2:

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium)

Postoperative clinical outcomes (major morbidity composite, transfusion requirements, 
surgical reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney 
injury, arterial or venous thromboembolic events, infections, prolonged mechanical 
ventilation, and postoperative mortality)

Concomitant medications

Adverse events
If this visit coincides in time with the ICU discharge, the only assessments to be performed 
are those detailed below in the ICU discharge visit. Regardless of when the ICU discharge 
takes place AT activity levels should be measured on Postoperative days 1, 2, 3, and 5.
3.6.2.8
Postoperative Day 3:

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium)

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
Postoperative clinical outcomes (major morbidity composite, transfusion requirements, 
surgical reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney 
injury, arterial or venous thromboembolic events, infections, prolonged mechanical 
ventilation, and postoperative mortality)

Concomitant medications

Adverse events
If this visit coincides in time with the ICU discharge, the only assessments to be performed 
are those detailed below in the ICU discharge visit. Regardless of when the ICU discharge 
takes place AT activity levels should be measured on Postoperative days 1, 2, 3 and 5.
3.6.2.9
Postoperative Day 5:

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium)

Postoperative clinical outcomes (major morbidity composite, transfusion requirements, 
surgical reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney 
injury, arterial or venous thromboembolic events, infections, prolonged mechanical 
ventilation, and postoperative mortality)

Concomitant medications

Adverse events
If this visit coincides in time with the ICU discharge, the only assessments to be performed 
are those detailed below in the ICU discharge visit. Regardless of when the ICU discharge 
takes place AT activity levels should be measured on Postoperative days 1, 2, 3 and 5.
3.6.2.10
ICU Discharge Visit (Maximum One Month after Admission)

Physical examination

Vital signs (T, BP, HR, RR)

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

Clinical chemistry (creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, 
potassium, chloride, and calcium)

Postoperative clinical outcomes (major morbidity composite, transfusion requirements, 
surgical reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney 
injury, arterial or venous thromboembolic events, infections, prolonged mechanical 
ventilation, ICU stay duration, prolonged ICU stay, and postoperative mortality)

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
Concomitant medications

Adverse events
If the ICU stay is longer than 1 month, the assessments for both ICU Discharge visit and 
Follow-up Day 30±4 days visit will be performed at Day 30±4 days. There will be no 
additional ICU Discharge visit and follow-up visits.
3.6.2.11
Follow-Up Visit (Day 30±4 Days after ICU Admission)*

Physical examination

Vital signs (T, BP, HR, RR)

AT activity levels

Hematology and coagulation (Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, fibrinogen, 
TAT, F1+2)

An appropriate volume of blood will be drawn in order to obtain a serum/plasma 
retention sample. The retention sample will be frozen and stored at -70ºC and stored in 
the event that additional testing is required in the future for purposes of this study only 
(i.e. repeat testing, or confirmation of virology results)

Clinical outcomes (major morbidity composite, transfusion requirements, surgical 
reexploration, low cardiac syndrome, myocardial infarction, stroke, acute kidney injury, 
arterial or venous thromboembolic events, infections, prolonged mechanical ventilation, 
postoperative mortality, and overall hospital stay duration)

Concomitant medications

Adverse events
*A phone call follow-up visit will be performed for those subjects unable to return to the 
investigational site during the scheduled time frame. The occurrence of any adverse
events since the last study visit and clinical outcomes will be investigated.
3.6.3
Description of Procedures and Laboratory Tests
3.6.3.1
Surgical Procedures
During the operative period and in addition to the routine monitoring of the subject, the 
following data will be recorded on the eCRF:
- Type of surgical procedure: Isolated CABG, isolated aortic valve replacement, aortic valve 
replacement + CABG, isolated mitral valve replacement, mitral valve replacement + 
CABG, isolated mitral valve repair, mitral valve repair + CABG, ascending aorta/aortic 
arch surgeries, etc.)
- Duration of CPB and aortic clamp
- Preoperative heparin dose response

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- Dose of heparin (initial, subsequent pre-CPB, during CPB), ACT, and dose of protamine
- Minimum hematocrit during CPB (local lab)
- Adverse events
3.6.3.2
Clinical Laboratory Tests
Laboratory panels include blood coagulation parameters and serum clinical chemistry as 
described below.
Hematological and coagulation parameters: Hb, Hct, RBC, WBC, PLT, aPTT, PT, INR, 
Fibrinogen, TAT, F1+2.
Blood samples will be drawn at the following time points:

Screening visit (local lab)

Screening visit (central lab)

Preoperatively

ICU admission (Day 0) 

Postoperative Day 1

Postoperative Day 2

Postoperative Day 3

Postoperative Day 5

ICU discharge

End of the follow-up period (Day 30±4 days)
Clinical chemistry panel: Creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, 
sodium, potassium, chloride and calcium
Blood samples will be drawn at the following time points:

Screening visit (local lab)

Screening visit (central lab)

Preoperatively

ICU admission (Day 0)

Postoperative Day 1

Postoperative Day 2

Postoperative Day 3

Postoperative Day 5

ICU discharge

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The above listed laboratory panels will be performed by a central laboratory unless otherwise 
specified. Investigative site laboratories may also be used in some instances (e.g. in the case 
of Screening and Preoperative visit tests to determine subject's eligibility when testing results 
may be needed in a short timeframe). The Investigator will be required to classify laboratory 
results out of the normal range reported by the laboratory as clinically relevant or not 
according to his/her criteria. Results will be recorded in source documents and on the subject 
eCRF when applicable.
Laboratory results out of the normal range judged by the Investigator as clinically relevant 
will be considered AEs.
3.6.4
Drug Concentration Measurements
All subjects will have blood samples collected for measurement of serum AT concentration 
at select study visits as specified in Section 3.6.2 and Appendix 1. However, it should be 
pointed out that AT levels reflect both endogenous AT and infused AT-III (Human) 
exogenously.
All samples for measurement of serum AT concentration will be analyzed using an antigenic 
content assay that is validated according to current regulatory and industry guidelines and 
expectations. To maintain the study blind, no unblinded AT concentration result will be 
reported to the study sites or to blinded Grifols personnel until after closure of the study 
database.
3.7
Screen Failures
Prescreening and screening evaluations will be used to determine the eligibility of each 
subject for enrollment. Subjects undergoing isolated CABG or single valve 
repair/replacements and not receiving preoperative heparin found to have a baseline AT 
activity level ≥80% (local lab) at the Prescreening visit will not continue any further subject 
eligibility evaluations and will not be considered as screening failures.
If a subject undergoing isolated CABG or single valve repair/replacements will receive 
preoperative heparin (see entry criteria), all Screening assessments will be performed because 
the subject may meet eligibility criteria without AT level as prerequisite. Subjects who fail to 
meet eligibility criteria during screening evaluations (during Screening visit) will be 
considered screen failures and will not be randomized and participate in the study.
3.8
Removal of Subjects
Subjects may withdraw or be withdrawn from the study for the following reasons:
1. At their own request or at the request of their legally acceptable representative.
2. If, in the Investigator's opinion, continuation in the study would be detrimental to the 
subject's well-being.

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3. At the specific request of the sponsor.
Subject participation in the study may be terminated early under the following circumstances:
1. The subject withdraws his/her informed consent to participate in the clinical trial.
2. The subject does not meet all inclusion criteria and is deemed a screen failure.
3. The subject meets any of the exclusion criteria and is deemed a screen failure.
4. The subject is not able to adhere to the main protocol requirements (major protocol 
violations).
5. The occurrence of an AE, which in the Investigator’s opinion requires the withdrawal of 
the subject from the clinical trial.
6. The subject is lost to follow-up.
7. Subject’s death.
8. Subjects with an occurrence of a concomitant disease, or any medical condition which, 
either because of its severity or duration or necessary change in treatment, contravenes 
the condition of the study or puts the subject at unnecessary risk or harm per Investigator 
discretion.
9. Subjects who develop an infection with HAV, HBV, HCV, B19V, or HIV during the 
study. A subject should be withdrawn if, in the opinion of his/her physician, he/she 
develops any of these viral infections.
10. Any event, which in the opinion of the Investigator impedes the subject’s participation in 
the study.
If the reason for early discontinuation is an AE, in so far as is possible, the subject will be 
followed-up until the event resolves, or has been stabilized, and no further change is 
expected.
In all cases, the reason for withdrawal must be recorded in the eCRF and in the subject's 
records.
A subject may leave the study at any time for any reason and will be permitted to do so 
without penalty. Grifols Therapeutics, Inc. will be notified by the Investigator if a subject 
terminates or is terminated from the study early. The reason for early termination will be 
clearly documented in the eCRF and reasonable efforts to perform study completion 
procedures will be made when appropriate. The Investigator can withdraw a subject from the 
clinical trial at any time.
For subjects who are considered screen failures because they do not meet all inclusion 
criteria or they meet any of the exclusion criteria, it is not necessary to perform additional 
study completion procedures other than recording all the study data gathered until the 

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moment when the subjects is deemed to be a screen failure, including the reasons for the 
screen failure.
For subjects who are not screen failures and withdraw from the clinical trial before the 
beginning of the surgical procedure, study completion procedures consisting of a physical 
assessment, recording of vital signs (heart rate, respiration rate, systolic and diastolic blood 
pressure and temperature) and concomitant medications, and assessment of AEs will be 
performed during their last visit at the site, if possible.
For enrolled subjects who early discontinue the clinical trial, study procedures and 
assessments scheduled for the Follow-up visit will be performed.
For subjects who withdraw their informed consent to participate in the clinical trial, it is not 
necessary to perform additional study completion procedures other than recording all the 
study data gathered until the moment when the subjects withdraw their informed consent.
3.9
Subject Replacement
Subjects withdrawn from the study because of safety reasons will not be replaced.  Enrolled 
subjects (i.e. randomized subjects) who early discontinue the clinical trial cannot be replaced.
3.10
Follow-up of Subjects Withdrawn from Study
Subjects who receive any amount of investigational product and discontinue early from the 
study will be requested to return for the follow-up visit (Day 30±4 days) procedures as close 
as practical to 30 days after their last administration of the investigational product.
3.11
Premature Termination of Study/Closure of Center
The sponsor, Institutional Review Board/Ethics Committee (IRB/EC), and/or regulatory 
authorities have the right to close this study or a study center, and the Investigator/Sponsor 
has the right to close a center, at any time, although this should occur only after consultation 
between involved parties. The IRB/EC must be informed. Should the study/center be closed 
prematurely, all study materials (except documentation that has to remain stored at site) must 
be returned to the sponsor. The Investigator will retain all other documents until notification 
given by the sponsor for destruction.
A study center can be closed for the following reasons:

Lack of enrollment

Non-compliance with the requirements of the study protocol

Non-compliance with ICH GCP

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4
ASSESSMENT OF SAFETY
4.1
Specification of Safety Parameters
Safety of AT-III (Human) will be evaluated in this study. Safety endpoints will include:
1. Adverse events including serious adverse events (SAEs), suspected ADRs, and 
discontinuations due to AEs.
2. Risk for bleeding (will be assessed by monitoring Hct levels, urine dipstick tests, and any 
clinical AEs for bleeding).
3. Clinical laboratory panels.
4. Physical examination.
5. Vital signs.
Also see Section 3.5.2.
4.2
Methods and Timing for Assessing, Recording, and Analyzing 
Safety Parameters
Safety will be assessed throughout the clinical trial to all subjects who has received any 
amount of the investigational product (AT-III [Human] or Placebo). See Section 5.1.4.
4.2.1
Adverse Events
Adverse events (includes adverse reactions [AR]) occurring at any time between signing of 
the subject’s ICF and the last day of the subject’s participation in the clinical trial will be 
reported and recorded on the appropriate subject’s eCRF entry.
It is the Investigator’s responsibility to ensure that all AEs are appropriately recorded.
Adverse events will be elicited by spontaneous reporting by the study individual or by a 
non-leading inquiry or direct observation by the study staff.
4.2.2
Physical Examinations
A medically certified individual will conduct a physical examination at the screening visit, 
within 48 hours prior to the first AT-III (Human) infusion, at ICU admission, at ICU 
discharge, and at the follow-up visits. The findings of each examination will be recorded on 
the eCRF. Abnormal findings judged as clinically relevant by the Investigator will be 
considered AEs.

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4.2.3
Vital Signs
Vital signs will be measured by a medically certified individual or a nurse according to 
his/her standard clinical practice. Vital signs will be measured at the Screening visit, 
preoperatively, at ICU admission, and during the follow-up period.
The following vital signs will be assessed:
-
T
-
BP (systolic blood pressure [SBP]) and diastolic blood pressure [DBP]),
-
HR
-
RR
Vital signs will be routinely monitored by the study staff as detailed in Section 3.6.2 and 
Appendix 1. The Investigator will be required to classify vital signs abnormalities as 
clinically relevant or not according to his/her criteria. Results will be recorded in source 
documents and on the subject eCRF. Vital signs abnormalities judged by the Investigator as 
clinically relevant will be considered AEs.
4.2.4
Clinical Chemistry and Hematology
All clinical laboratory data for renal (creatinine, BUN), hepatic (ALT, AST, AP and TB) and 
haematological parameters (CBC including differential leukocyte count) will be listed for 
each clinical trial subjects.
The Investigator will be required to classify laboratory results out of the normal range 
reported by the laboratory as clinically relevant or not according to his/her criteria.
Laboratory results out of the normal range judged by the Investigator as clinically relevant 
will be considered AEs.
4.3
Procedures for Eliciting Reports of and for Recording and 
Reporting Adverse Event and Intercurrent Illnesses
4.3.1
Adverse Events
An AE is defined as any untoward medical occurrence in a patient or clinical investigation 
subject administered a medicinal product or study treatment and which does not necessarily 
have a causal relationship with this administration. An AE can therefore be any unfavorable 
and unintended sign (including any abnormal laboratory findings, for instance), symptoms, or 
disease temporally associated with the use of a medicinal product or study treatment, whether 
or not considered related to the medicinal product or study treatment.

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Any AE that occurs at any time between signature of the informed consent and last day of the 
subject’s participation in the clinical safety period of the study (Follow-up visit Day 30 ± 
4 days) must be reported on the AE eCRF entry.
4.3.2
Causality of Adverse Event
The investigator will be asked to assess the causal relationship of the AE to the study 
treatments according to the following classification based on Karch FE et al (42):
-
Definite: An event that follows a reasonable temporal sequence from administration 
of the treatment or in which the treatment level has been established in body fluids or 
tissues; that follows a known response pattern to the suspected treatment; and that is 
confirmed by improvement on stopping the treatment (dechallenge), and 
reappearance of the event on repeated exposure (rechallenge).
-
Probable: An event that follows a reasonable temporal sequence from administration 
of the treatment; that follows a known response pattern to the suspected treatment; 
that is confirmed by dechallenge; and that could not be reasonably explained by the 
known characteristics of the subject’s clinical state.
-
Possible: An event that follows a reasonable temporal sequence from administration 
of the treatment; that follows a known response pattern to the suspected treatment; 
but that could have been produced by the subject’s clinical state or other modes of 
therapy administered to the subject.
-
Doubtful/Unlikely: An event that follows a reasonable temporal sequence from 
administration of the treatment; that does not follow a known response pattern to the 
suspected treatment; but that could not be reasonably explained by the known 
characteristics of the subject’s clinical state.
-
Unrelated: Any event that does not meet the criteria above.
The operational tool to decide the AE causal relationship is based on algorithms by 
Karch-Lasagna and Naranjo (43, 44).
When an AE is classified, assessing casual relationship by the investigator, as definitive, 
probable, possible, or doubtful/unlikely, the event will be defined as suspected ADR. When 
the causal relationship is labeled “Unrelated”, then it will be considered that the AE is not 
imputable to the study treatment and it is not a suspected ADR. For definition of AR, see 
Section 4.3.3.
Any AE experienced by the subject prior to the first blinded investigational product infusion 
on Day 0 will be labeled as Unrelated to the study drug.
In addition, when a causal relationship between the study treatment and the AE cannot be 
ruled out by the Investigator, it means that the AE cannot be labeled “Unrelated”; then, the 
Investigator will be asked to evaluate whether the AE is attributable only to the study 

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treatment or also to the surgical technique employed. Potential causal relationships between 
an AE and the surgical technique will be evaluated.
4.3.3
Suspected Adverse Drug Reaction and Adverse Reaction
All noxious and unintended responses to a medicinal product or device related to any dose 
should be considered suspected ADRs. The phrase “responses to a medicinal product or 
device” means that a causal relationship between a medicinal product or device and an AE is 
at least a reasonable possibility, that is, the relationship cannot be ruled out. In the framework 
of this study, a suspected ADR with a causal relationship of “definite” will be named as AR. 
Adverse reactions are a subset of suspected ADR.
The sponsor is responsible for assessing the suspected ADR expectedness during the clinical 
trial.
4.3.4
Severity (Grade) of the Adverse Event
For any AE or SAE, the severity (grade) of an event must be assessed. The following 
guidance should be used to determine event severity:

Mild: usually transient in nature and generally not interfering with normal activities. 
Subjects have transient symptoms; no treatment required other than non-prescription 
drugs.

Moderate: sufficiently discomforting to interfere with (but may not overtly prevent) 
normal activities. Subject was symptomatic and required treatment, but had no sequela.

Severe: prevents normal activities. Subject was incapable of work or usual activity; 
treatment with prescription medication was required and/or sequela were produced
Adverse event and suspected ADR severity (intensity) gradation must be distinguished from 
AE and suspected ADR seriousness gradation, which is defined according to event 
consequence. For example, a headache could be mild, moderate, or severe but unusually is 
serious in all these cases.
The investigator will be responsible for assessing the AE or suspected ADR severity 
(intensity) during the clinical trial, taking into account currently criteria detailed in this 
section.
4.3.5
Serious Adverse Event
An SAE is an AE or a suspected ADR, occurring at any dose that fulfils one or more of the 
following:

results in death

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
is immediately life-threatening (life-threatening in the definition of SAE refers to an 
event in which the subject was at immediate risk of death at the time of the event; it does 
not refer to an event which hypothetically might have caused death if it were more 
severe).

requires in-subject hospitalization or prolongation of existing hospitalization*

results in persistent or significant disability or incapacity

is a congenital anomaly or birth defect

is an important medical event: important medical event in the definition of “serious” 
refers to those events which may not be immediately life-threatening, or result in death, 
or hospitalization, but from medical and scientific judgment may jeopardize the subject 
and/or may require medical or surgical intervention to prevent one of the other outcomes 
listed above. Examples of such events are intensive treatment in an emergency room or at 
home for allergic bronchospasm, blood dyscrasias or convulsions that do not result in 
hospitalization. Development of cancer or drug dependency or drug abuse will normally 
be considered serious by this criterion.
*Hospitalization is to be considered only hospital stay for equal or more than 24 hours. 
The following hospitalizations should not be reported as SAEs:
-
Hospitalization or prolongation of hospitalization needed for procedures required by 
the clinical trial protocol.
-
Hospitalization or prolongation of hospitalization as part of a routine procedure 
followed by the center.
-
Hospitalization for a survey visit, annual physicals, or social reasons.
-
Elective (pre-planned) hospitalizations for a pre-existing condition that had not 
worsened from Baseline (e.g. elective or scheduled surgery arranged prior to start of 
the study).
-
Admissions not associated with an AE (e.g. social hospitalization for purposes of 
respite care).
A distinction should be drawn between serious and severe AEs. The term “severe” is used to 
describe the severity of a specific event; the event itself, however, may be of relative minor 
medical significance (such as severe headache). This is not the same as “serious”, which is 
defined on subject/event outcome or action criteria usually associated with events that pose a 
threat to a subject’s life or functioning. Seriousness (not severity) is a medical term while
severity is a subjective term.
According to the medical criteria, an AE, or a suspected ADR, can be classified as serious, 
although it does not fulfill the conditions fixed in this section, if it is considered important 
from a medical point of view. The investigator is responsible for assessing the AE, or 
suspected ADR, seriousness during the clinical trial, taking into account currently criteria 
fixed in this section.

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4.3.6
Expectedness of Adverse Event or Suspected Adverse Drug Reaction
An AE or suspected ADR is considered “unexpected” if the nature, seriousness, severity, or 
outcome of the reaction(s) is not consistent with the reference information. The expectedness 
of an AR shall be determined by the sponsor according to the reference document (ie, IB).
Events not listed for the particular drug under investigation in the IB are considered 
“unexpected” and those listed are considered “expected.” When new AE information is 
received, it is the sponsor’s responsibility to determine whether the event is “unexpected” for 
investigational new drug (IND) safety reporting purposes.
4.3.7
Adverse Event Documentation
All AEs and SAEs occurring after the subject has signed the informed consent form (ICF)
must be fully recorded in the subject’s eCRF or SAE form. For example, a laboratory test 
abnormality considered clinically relevant, eg, causing the subject to withdraw from the 
study, requiring treatment, causing apparent clinical manifestations, or judged relevant by the 
investigator, should be reported as an AE. Each event must be adequately supported by 
documentation as it appears in the subject’s medical or case file.
At each visit, AEs will be elicited by asking the individual a non-leading question such as 
“Do you feel different in way since the last visit?”. Moreover, AE will also be collected 
through directly observed events or spontaneously volunteered by the subject. Clearly related 
signs, symptoms, and abnormal diagnostic procedures should preferably be grouped together 
and recorded as a single diagnosis or syndrome wherever possible. It is responsibility of the 
Investigator to ensure that AEs are appropriately recorded.
The following variables must to be recorded on the AE eCRF entry:
1. the verbatim term (a diagnosis is preferred)
2. date/time of onset
3. date/time of resolution
4. intensity (mild, moderate, severe)
5. causality (unrelated, doubtful/unlikely, possible, probable, definite)*
6. seriousness (yes, no)
7. action taken (with regard to study drug)
8. other action (to treat the event)
9. outcome and sequel (follow-up on AE)
*Causality assessment will be only made when the AE occurs after the subject has 
received one or another study treatment. AE occurring before subject's exposure to 
study treatments will be always labeled as "Unrelated".

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For AEs that occur during infusions, the infusion rate in effect at the time of onset of the AE, 
the time of onset of the AE and the time of AE change materially in intensity and/or resolve 
will be captured the eCRF entry.
In addition to the Investigator’s own description of the AEs, each AE will be encoded by the 
sponsor (or designee, eg, CRO) according to the MedDRA® dictionary of medical codes.
A pregnancy not verified before randomization but occurring during the course of the study 
will be not considered an AE, unless a relation to the study drug is suspected. In any case, 
must be completed a Pregnancy Report Form and send as soon as possible to the Sponsor, 
and the study treatment must be discontinued. A copy of the form should be filled at the 
study site for follow-up until the end of the pregnancy.
4.4
Reporting of Serious Adverse Events or Pregnancy
4.4.1
Reporting Serious Adverse Event
All SAEs must be expeditiously reported, whether or not considered attributable to the study 
drugs. A SAE Report Form should be used to expeditiously report the SAE to the receiver 
appointed.
When the Investigator becomes aware of an SAE, she/he must submit by email a complete, 
signed, and dated SAE Report Form within 24 hours to the Sponsor.
After the initial report, all relevant follow-up information for the SAE including the outcome, 
must be also supplied to the Sponsor in a timely manner (within 3 days from its identification 
or within 24 hours for relevant new information) by means of the SAE Report Form or by 
other appropriate means, such as data clarification form issued by the Sponsor or CRO. In 
addition, the Sponsor or CRO may request additional information and/or reports.
All SAE Report Forms must be reported to:
Grifols Global Drug Safety
Serious adverse events will be assessed by the Sponsor or designee for expectedness 
assuming that all subjects have been treated with AT-III. If the event is considered serious, 
suspected potentially related to the study drug and unexpected (SUSAR), then the treatment 
allocation will be unblinded. The following possibilities resulting from the unblinding will be 
considered:

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1. If the study drug administered to the subject is AT-III, the case will be reported in 
accordance to local regulations.
2. If the study drug administered to the subject is Placebo, the suspected ADR will be 
reassessed for expectedness according to the reference safety information and:
a.
If the suspected ADR is still considered unexpected, it will be reported in accordance 
with applicable requirements and guidelines.
b. If the suspected ADR is considered expected, it will not be reportable on an expedited 
basis, unless specifically requested by local regulations.
4.4.2
Reporting Pregnancy
While pregnancy itself is not a true “AE,” pregnancy occurring in a clinical study must be 
followed, to collect information regarding the experiences of gestation and pregnancy with 
investigational product exposure. The Investigator must report any pregnancy that occurs in a 
study subject subsequent to informed consent until 28 days after the last dose of 
investigational product. Any female subject who becomes pregnant during the study will be 
discontinued from investigational product treatment and will be followed for pregnancy 
outcome.
For any pregnancy with an outcome of live birth, the newborn infant will be followed until 
one month of age. Any anomalies, complications, abnormal outcomes, or birth defect 
observed in the child must be reported as an SAE within 24 hours of the Investigator or study 
personnel’s first knowledge.
5
STATISTICAL METHODS AND DETERMINATION OF SAMPLE 
SIZE
5.1
Statistical and Analytical Plans
Unless otherwise specified, descriptive statistics will include the number of observations, 
mean, standard deviation (SD), median, minimum and maximum values for the 
continuous/quantitative data, or frequency counts and percentages for categorical/qualitative
data.
Data handling and evaluation procedures will be described in the Statistical Analysis Plan.
5.1.1
Subject Population(s) for Analysis
Intention-to-Treat population (ITT) will include all subjects who are randomized.
Per-protocol (PP) population will include all ITT subjects who have no major protocol 
deviations.

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Safety population will include all subjects who receive any amount of study drug.
5.1.2
Demographic and Baseline Characteristics
Demographic and baseline characteristics will be summarized by treatment group using ITT 
population. For quantitative variables, mean, SD, median, and minimum/maximum will be 
provided. For qualitative variables, the frequency and percentage will be provided.
5.1.3
Efficacy Analysis
5.1.3.1
Primary Efficacy Analyses
The primary efficacy variable is the percentage of subjects with any component of the 
composite of major morbidity. The primary efficacy variable will be analyzed with Cochran 
Mantel Haenszel test adjusting for history of MI using ITT population. The sensitivity 
analyses using PP populations will also be provided.
5.1.3.2
Secondary Efficacy Analyses
Postoperative AT levels at the ICU admission will be summarized by treatment group. The 
analysis of covariance (ANCOVA) will be used to compare the treatment difference. 
ANCOVA model will include the AT level as dependent variable, treatment as fixed effect 
and baseline AT level as covariate. The similar approach will also be used to analyze the AT 
levels in other time points.
Postoperative chest-drain blood loss in the first 12 and 24 hours after surgery will be 
summarized by treatment group and will be analyzed using group t-test.
For transfusion requirements, Number of units of RBC, Number of units of FFP, and Number 
of units of platelets will be summarized by treatment group and analyzed using group t-test.
The number and percentage of subjects with each following procedure or morbidity will be 
separately summarized by treatment group and will be analyzed using Chi-square test (or 
Fisher Exact test as appropriate)
-
Need for surgical reexploration
-
Low cardiac output syndrome
-
Myocardial infarction
-
Stroke
-
Acute kidney injury
-
Arterial or venous thromboembolic events
-
Infections
-
Prolonged mechanical ventilation (>24 hours)

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-
All-cause postoperative mortality
-
Prolonged ICU stay (>6 days)
Duration of ICU stay and the length of hospital stay will be summarized by treatment group. 
Non-parametric will be used to compare the treatment differences and Hodges-Lehmann 
estimation will be provided.
5.1.4
Safety Analysis
The safety analysis will be based on safety population.
The incidence of AEs, SAEs, suspected ADRs, and AEs by severity will be summarized by 
treatment, system organ class and preferred term using descriptive statistics. Subjects with 
deaths, SAEs, and AEs leading to premature discontinuation from the study will be listed.
The Investigator verbatim term and the MedDRA coded term (system organ class and 
preferred term) will be shown simultaneously on the data listings of all AEs.
Clinical laboratory variables will be summarized by treatment using summary statistics at 
each time point and on the change from baseline. Shift tables will be provided to summarize 
values that fall outside the normal ranges.
Vital signs will be summarized by treatment using summary statistics at each time point and 
on the change from baseline.
Physical exam data will be provided in data listings.
5.2
Determination of Sample Size
Assuming that percentage of subjects with major morbidity composite is 22.0% in Placebo 
group and 14.3% in AT-III treatment group (ie, AT-III treatment group has a 35% relative 
reduction comparing to the Placebo control group), 192 subjects per treatment arm (total 
384 subjects) are needed to have 70% power to detect a trend at alpha = 0.15. Considering 
5% dropout rate, it is estimated that 404 subjects (202 subjects per treatment arm) need to be 
randomized.
6
ADMINISTRATIVE
6.1
Investigators, Other Study Personnel and External Committees
Information regarding additional key personnel involved in the conduct of the study, 
including names and contact details of participating investigators, monitors, clinical 
laboratories, technical departments and/or institutions, as well as information on members of 

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additional study committees, will be found in the study files of the sponsor and at the 
Investigator sites within the study reference manual/file.
6.2
Data Quality
Monitoring and auditing procedures defined/agreed by the sponsor will be followed, in order 
to comply with ICH GCP guidelines. Each center will be visited at regular intervals by a 
monitor to ensure compliance with the study protocol, ICH GCP and legal aspects. The 
on-site verification of the eCRF for completeness and clarity will include cross checking with 
source documents, and clarification of administrative matters. Query verification of data will 
be described in the Data Management Plan.
6.3
Documentation
The study data will be recorded and kept current in the eCRF by the site study personnel 
directly responsible for the information. Entries made in the eCRF must be verifiable against 
source documents, or have been directly entered into the eCRF, in which case the entry in the 
eCRF will be considered the source data.
The data in the eCRF will be monitored at the site by Grifols Therapeutics Inc. 
representatives at regular intervals and reviewed for completeness and compared with the 
source documents. Examples of source documents include individual subject medical 
records, which are separate from the eCRFs.
All AEs and SAEs must be recorded. All SAEs must be recorded on the SAE form. The SAE 
form must be kept in site records with a copy provided to the designated person as detailed in 
the study file.
6.3.1
Record Retention
At study completion, all study data will be transferred to Grifols Therapeutics Inc. according 
to ICH GCP guidelines, local laws, regulations, and Grifols Therapeutics Inc. requirements. 
The study file and all source data should be retained until notification is given by the sponsor 
for destruction.
An Investigator is required by ICH GCP guidelines to retain the study files. If an Investigator 
moves, withdraws from an investigation, or retires, the responsibility for maintaining the 
records may be transferred to another person (eg, other Investigator). Grifols Therapeutics 
Inc. must be notified in writing of the person responsible for record retention and the 
notification will be retained in the sponsor study file and the Investigator site file.

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6.3.2
Access to Information for Monitoring
The data will be recorded and kept current in CRF/eCRFs by the study site personnel directly 
responsible for the information and reviewed for completeness by the monitor. Grifols 
Therapeutics Inc. personnel or designee can review the records.
In accordance with ICH GCP guidelines, the monitor must have direct access to the 
Investigator’s source documentation in order to verify the data recorded in the eCRFs for 
consistency and to verify adherence to the protocol, and the completeness, consistency, and 
accuracy of data entered. “Source documentation” includes individual subject files, separate 
from the eCRFs, which should be maintained and include visit dates, laboratory results, 
concomitant treatment, vital signs, medical history, examinations, AEs, investigational 
product dispensing logs, and other notes as appropriate. The Investigator agrees to cooperate 
with the monitor to ensure that any problems noted during the course of these monitoring 
visits are resolved.
6.3.3
Access to Information for Audits or Inspections
Representatives of regulatory authorities or of Grifols Therapeutics Inc. or designee may 
conduct audits or inspections or audits of the Investigator study site. If the Investigator is 
notified of an audit or inspection by a regulatory authority, the Investigator agrees to notify 
the Grifols Therapeutics Inc. Medical Monitor immediately. The Investigator agrees to 
provide to representatives of a Regulatory Agency or Grifols Therapeutics Inc. access to 
records, facilities, and personnel for the effective conduct of an audit or inspection.
7
ETHICAL AND LEGAL ASPECTS
7.1
Institutional Review Board/Ethics Committee
Documented approval from appropriate IRBs/ECs will be obtained for all participating 
centers/countries prior to study start, according to ICH GCP guidelines, local laws, 
regulations, and organizations. When necessary, an extension, amendment or renewal of the 
IRBs/ECs approval must be obtained and also forwarded to the sponsor. The IRBs/ECs must 
supply to the sponsor, upon request, a list of the IRBs/ECs members involved in the vote and 
a statement to confirm that the IRBs/ECs is organized and operates according to ICH GCP 
guidelines and applicable laws and regulations.
7.2
Ethical Conduct of the Study
The procedures set out in this protocol, pertaining to the conduct, evaluation, and 
documentation of this study, are designed to ensure that the sponsor and Investigator abide 
by ICH GCP guidelines. The study will also be carried out in keeping with applicable local 
law(s) and regulation(s). This may include an audit by the sponsor representatives and/or an 
inspection by Regulatory Authority representatives at any time. The Investigator must agree 
to the audit or inspection of study-related records by the sponsor representatives and/or 

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Regulatory Authority representatives, and must allow direct access to source documents to 
the sponsor and/or Regulatory Authority representatives.
Modifications to the study protocol will not be implemented by either the sponsor or the 
Investigator without agreement by both parties. However, the Investigator may implement a 
deviation from, or a change to, the protocol to eliminate an immediate hazard(s) to the study 
subjects without prior IRB/EC/Sponsor approval/favorable opinion. As soon as possible, the 
implemented deviation or change, the reasons for it and if appropriate the proposed protocol 
amendment should be submitted to the IRB/EC/Sponsor. Any deviations from the protocol 
must be fully explained and documented by the Investigator.
7.3
Regulatory Authority Approvals/Authorizations
Regulatory Authority approvals/authorizations/ notifications, where required, must be in 
place and fully documented prior to study start. Study information including contact 
information for Investigator sites responsible for conducting the study will be posted on a 
publicly accessible clinical registry(ies) as required by local law.
7.4
Subject Information and Consent
Subject information and ICF will be provided to Investigator sites. Prior to the beginning of 
the study, the Investigator must have the IRB/EC written approval/favorable opinion of the 
written ICF and any other written information to be provided to subjects. The written 
approval of the IRB/EC together with the approved subject information/ICF must be filed in 
the study files and a copy of the documents must also be provided to Sponsor by the 
Investigator site.
Written ICF must be obtained before any study specific procedure takes place. Subjects must 
provide written approval to specific ICFs prior to any Prescreening and Screening activities, 
respectfully. Participation in the study and date of ICF given by the subject should be 
documented appropriately in the subject’s files. A signed copy of the subject ICF will be 
provided to the subject or subject’s authorized representative.
7.5
Insurance
All subjects participating in the study will have insurance coverage by the sponsor, which is 
in line with applicable laws and/or regulations.
7.6
Confidentiality
All records identifying the subject will be kept confidential and, to the extent permitted by 
the applicable laws and/or regulations, will not be made publicly available.
Subject names will not be supplied to the sponsor. Only the subject number and subject 
initials will be recorded in the eCRF, and if the subject’s name appears on any other 

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document (eg, pathologist report), it must be obliterated before a copy of the document is 
supplied to the sponsor. Study findings stored on a computer will be stored in accordance 
with local data protection laws. Subjects will be informed in writing that representatives of 
the sponsor, IRB/EC, or Regulatory Authorities may inspect their medical records to verify 
the information collected, and that all personal information made available for an audit or 
inspection will be handled in strictest confidence and in accordance with local data protection 
laws.
If the results of the study are published, the subject’s identity will remain confidential.
The Investigator will maintain a list to enable subjects’ records to be identified.
8
USE OF DATA AND PUBLICATION
Institution and the Investigator agree that the first publication shall be made in conjunction 
with the presentation of a joint, multi-center publication of the study results from all 
appropriates sites. If such a multi-center publication is not submitted within twelve (12) 
months after conclusion of the study at all sites or after Grifols confirms there will be no 
joint, multi-center publication, then institution and/or Investigator shall have the right, at 
their discretion, to publish, either in writing or orally, the results of the study performed 
under the protocol, subject to the conditions outlined below:

The results of the study will be reported in the publicly accessible registry(ies).

Institution and/or Investigator shall furnish Grifols with a copy of any proposed 
publication at least thirty (30) days in advance of the date of submission for publication.

Within said thirty (30) day period, Grifols shall:
-
Review such proposed publication for Confidential Information (other than Study 
results) and for subject information subject to the Health Insurance Portability and 
Accountability Act of 1996 (“HIPAA”) and other applicable privacy laws;
-
Review such proposed publication for the unauthorized use of the name, symbols 
and/or trademarks of Grifols;
-
By written notice to the Investigator, identify with specificity the text or graphics in 
such proposed publication that Grifols contends contains Confidential Information, 
protected subject information, or the unauthorized use of Grifols’ name, symbols 
and/or trademarks so that the proposed publication may be edited appropriately to 
remove such text or graphics before publication; and
-
By written request, Grifols may delay proposed publications up to sixty (60) days to 
allow Grifols to protect its interests in Grifols Inventions described in such 
publications.

Institution and/or Investigator shall give Grifols the option of receiving an 
acknowledgment for its sponsorship of the study in all such publications or presentation.

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9
REFERENCES
1. Lison S, Dietrich W, Braun S, et al. Enhanced thrombin generation after cardiopulmonary 
bypass surgery. Anesth Analg 2011; 112:37-45.
2. Edmunds LH Jr, Coleman RW. Thrombin during cardiopulmonary bypass. Ann Thorac 
Surg 2006; 82:2315-22.
3. Slaughter TF, LeBleu TH, Douglas JM, et al. Characterization of prothrombin activation 
during cardiac surgery by hemostatic molecular markers. Anesthesiology 1994; 80:520-6.
4. Chandler WL, Velan T. Estimating the rate of thrombin and fibrin generation in vivo 
during cardiopulmonary bypass. Blood. 2003 1;101:4355-62.
5. Dixon B, Santamaria J, Cambell D. Coagulation activation and organ dysfunction 
following cardiac surgery. Chest 2005; 128:229-36.
6. Rinder C. Cellular inflammatory response and clinical outcome in cardiac surgery. Curr 
Opin Anaesththesiol 2006; 19: 65-68.
7. Rosenberg RD, Bauer KA, Marcum JA: Protease inhibitors of human plasma. 
Antithrombin III “the heparin-antithrombin system” J Med 1985; 16; 351-416.
8. Murano G, Williams L, Miller-Andersson M, Aronson DL, King C: Some properties of 
antithrombin-III and its concentration in human plasma. Thromb Res 1980; 18; 259-262.
9. Rosenberg RD: Action and interactions of antithrombin and heparin. N Engl J Med 1975; 
292; 146-151.
10. Olson ST, Björk I,Sheffer R, et al. Role of the antithrombin-binding pentasaccharide in 
heparin acceleration of antithrombin-proteinase reactions. Resolution of the antithrombin 
conformational change contribution to heparin rate enhancement. Journal of Biological 
Chemistry 1992; 267:12528-12538.
11. Johnson DJ, Huntington JA. Crystal structure of antithrombin in a heparin-bound 
intermediate state. Biochemistry 2003; 42:8712-19.
12. Okajima, Uchiba. The anti-inflammatory properties of antithrombin III: new therapeutic 
implications. Semin Thromb Hemost. 1998; 24(1):27-32.
13. Ostrovsky L, Woodman RC, Payne D, Teoh D, Kubes P. Antithrombin III prevents and 
rapidly reverses leukocyte recruitment in ischemia/reperfusion. Circulation. 1997 Oct 
7;96(7):2302-10.

Protocol GTI1307     Version: 4.0
02 Apr 2015
CONFIDENTIAL
Page 78 of 83
14. Dunzendorfer S, Kaneider N. Cell-surface heparin sulfate proteoglycan-mediated 
regulation of human neutrophil migration by the serpin ATIII. Blood 2001; 
15;97(4):1079-85.
15. Oelschläger C, Römisch J, Staubitz A, Stauss H, Leithäuser B, Tillmanns H, 
Hölschermann H. Antithrombin III inhibits nuclear factor kappaB activation in human 
monocytes and vascular endothelial cells. Blood. 2002 Jun 1;99(11):4015-20.
16. Zaidan JR, Johnson S, Brynes R, et al. Rate of protamine administration: its effect on 
heparin reversal and antithrombin recovery after coronary artery surgery. Anesth Analg 
1986; 65: 377-380.
17. Hashimoto K, Yamagishi M, Sasaki T, Nakano M, Kurosawa H. Heparin and 
antithrombin III levels during cardiopulmonary bypass: correlation with subclinical 
plasma coagulation. Ann Thorac Surg 1994; 58:799-805.
18. Despotis GJ, Levine V, Joist JH, Joiner-Maier D, Spitznagel E. Antithrombin III during 
cardiac surgery: effect on response of activated clotting time to heparin and relationship 
to markers of hemostatic activation. Anesth Analg 1997; 85: 498-506.
19. Ranucci M, Cazzaniga A, Soro G, Isgrò G, Frigiola A, Menicanti L. The antithrombin 
III-saving effect of reduced systemic heparinization and heparin-coated circuits. J 
Cardiothorac Vasc Anesth 2002; 16: 316-320.
20. Despotis GJ, Joist JH, Hogue CW, et al. More effective suppression of hemostatic system 
activation in patients undergoing cardiac surgery by heparin dosing based on heparin 
blood concentrations rather than ACT. Thromb Haemost 1996; 76: 902-908.
21. Lane DA, Mannucci PM, Bauer KA, Bertina RM, Bochkov NP, Boulyjenkov V et al. 
Inherited thrombophilia: part 1. Thromb Haemost 1996;76:651-662.
22. Despotis GJ, Joist JH. Anticoagulation and anticoagulation reversal with cardiac surgery 
involving cardiopulmonary bypass: an update. J Cardiothorac Vasc Anesth 1999; 13: 18-
29.
23. Bucur SZ, Levy JH, Despotis GJ, Spiess BD, Hillyer CD. Uses of antithrombin III 
concentrate in congenital and acquired deficiency states. Transfusion 1998;38:481-498.
24. Demers C, Ginsberg JS, Hirsh J, Henderson P and Blajchman MA. Thrombosis in 
antithrombin-III-deficient persons. Report of a large kindred and literature review. Ann 
Int Med 1992;116:754-61.
25. Staples MH, Dunton RF, Karlson KJ, et al. Heparin resistance after preoperative heparin 
therapy or intraaortic ballon pumping. Ann Thorac Surg 1994;57: 1211-6.

Protocol GTI1307     Version: 4.0
02 Apr 2015
CONFIDENTIAL
Page 79 of 83
26. Cloyd GM, D'Ambra MN, Akins CW. Diminished anticoagulant response to heparin in 
patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 1987; 
94:535-8.
27. Dietrich W, Spannagl M, Schramm W, et al. the influence of preoperative anticoagulation 
on heparin response during cardiopulmonary bypass. J Thorac Cardiovasc Surg 1991; 
102:505-14.
28. Garvin S, Muehlschlegel JD, Perry TE, et al. Postoperative activity, but not preoperative 
activity, of antithrombin is associated with major adverse cardiac events after coronary 
artery bypass graft surgery. Anesth Analg 2010;111:862-69.
29. Ranucci M, Ditta A, Boncilli A, et al. Determinants of antithrombin consumption in 
cardiac operations requiring cardiopulmonary bypass. Perfusion 2004;19:47–52.
30. Ranucci M, Isgro G, Cazzaniga A, et al. Different patterns of heparin resistance: 
therapeutic implications. Perfusion 2002; 17:199-204.
31. Avidan MS, Levy JH, Scholz, et al. A phase III, double-blind, placebo-controlled, 
multicenter study on the efficacy of recombinant human antithrombin in heparin-resistant 
patients scheduled to undergo cardiac surgery necessitating cardiopulmonary bypass. 
Anesthesiology 2005; 102:276-84.
32. Rodríıguez-López JM, del Barrio E, Lozano FS, Muriel C. Does preoperative level of 
antithrombin III predict heparin resistance during extracorporeal circulation? Anesth 
Analg. 2008;107:1444-5.
33. Muedra V, Bonanad S, Gomez M, wt al. Relationships between antithrombin activity, 
anticoagulant efficacy of heparin therapy and perioperative variables in patients 
undergoing cardiac surgery requiring cardiopulmonary bypass. Perfusion. 2011;26:487-
95.
34. Avidan MS, Levy JH, van Aken H, et al. Recombinant human antithrombin III restores 
heparin responsiveness and decreases activation of coagulation in heparin-resistant 
patients during cardiopulmonary bypass. J Thorac Cardiovasc Surg. 2005; 130:107-13.
35. Lemmer JH Jr, Despotis GJ. Antithrombin III concentrate to treat heparin resistance in 
patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2002;123:213-7.
36. Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, 
Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, et al. 2011 Update to The 
Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood 
conservation clinical practice guidelines. Ann Thorac Surg. 2011;91:944-82.
37. Spiess B. Treating heparin resistance with antithrombin or fresh frozen plasma. Ann 
Thorac Surg. 2008; 85:2153-60.

Protocol GTI1307     Version: 4.0
02 Apr 2015
CONFIDENTIAL
Page 80 of 83
38. Ranucci M, Frigiola A, Menicanti L, Ditta A, Boncilli A, Brozzi S. Postoperative 
antithrombin levels and outcome in cardiac operations. Crit Care Med 2005; 33: 335-61.
39. Paparella D, Cappabianca G, Scrascia G, et al.  Antithrombin after cardiac surgery: 
implications on short and mid-term outcome. J Thromb Thrombolysis 2009 Jan; 27(1): 
105–114.
40. Ranucci M, Baryshnikova E, Crapelli GB, et al. Preoperative antithrombin 
supplementation in cardiac surgery: A randomized controlled trial. J Thorac Cardiovasc 
Surg 2013;145:1393-9.
41. Dietrich W, Busley R, Spannagl M, et al. The influence of antithrombin substitution on 
heparin sensitivity and activation of hemostasis during coronary artery bypass graft 
surgery: A dose-finding study. Anesth Analg. 2013; 116(6): 1223-30.
42. Karch FE, Lasagna L. Adverse drug reactions. JAMA 1975; 234 (12): 1236-1241.
43. Karch FE, Lasagna L. Towards the operational identification of adverse drug reactions. 
Clin Pharmacol Ther 1977; 21: 247-254.
44. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of 
adverse drug reactions. Clin Pharmacol Ther 1981; 30: 239-245.

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APPENDICES

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Appendix 1
Study Flow Chart and/or Schedule of Procedures
Visits
Procedures/Assessments
Pre-
screening 
Visit
(-14 days)a
Screening 
Visit
(-14 days)
Pre-
Operative 
Visit
(Day 0)
Operative 
Visit
(Day 0)
ICU 
Admission
(Day 0)
Post-
Operative
(Day 1)
Post-
Operative 
(Day 2)
Post-
Operative 
(Day 3)
Post-
Operative 
(Day 5)
ICU 
Discharge
Follow-up 
Visit
(Day 30±4 
days)
Informed consent
X
X
Inclusion/Exclusion criteria
X
X
Medical history/demographics
X
Randomizationb
Xb
Concomitant medications
X
X
X
X
X
X
X
X
X
X
Vital signs
X
X
X
X
X
Physical examination
X
X
X
X
X
AT levels for isolated 
CABG/valve repair/replacements 
without preop heparin (local lab)c
X
X
AT Levels (central lab)c
X
X
X
X
X
X
X
X
X
X
Adverse events
X
X
X
X
X
X
X
X
X
X
Hematology and coagulationd
X
X
X
X
X
X
X
X
X
Hematocrit
Xe
Clinical chemistryf
X
X
X
X
X
X
X
X
Pregnancy test (serum)
X
Retention sampleg
X
X
X
X
Heparin dose
X
ACT
X
Protamine dose
X
Study drug infusion
X
Operative assessmentsh
X
Chest-drain blood lossi
X
Clinical outcomesj
X
X
X
X
X
X
X
X

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a
Subjects undergoing complex/combined procedures will not be prescreened or screened for AT levels. Only applicable for subjects undergoing isolated 
CABG or single valve repair/replacements who will not be receiving preoperative heparin (see entry criteria) and whose eligibility will therefore be based on 
AT level < 80%. If it is logistically feasible, Prescreening visit must be performed prior to Screening visit, unless a subject’s surgery is scheduled to occur in 
≤ 72 hours. In the latter case, the Prescreening and Screening visit may be combined. All determinations for a separate Prescreening visit must be recorded 
on specific Prescreening sheets.
b
Randomization may occur 24 hours before the day of surgery (Day 0).
c
Baseline AT activity levels (hematology lab): Prescreening and Screening visits (-14 days).. Subjects undergoing isolated CABG or single valve 
repair/replacements will be prescreened for AT levels (AT <80%) if they are not receiving preoperative heparin (see entry criteria). These AT activity levels
will be measured locally at the investigator site. The AT (local lab) determination at the Screening visits will not be required if the Prescreening visit is 
conducted. All further AT determinations will be assessed at a central lab. AT activity levels will be measured immediately before and after infusion of AT-
III (Human) or Placebo at Operative visit (Day 0).
d
Hemoglobin, hematocrit, red blood cells, white blood cells, platelets, aPTT, PT, INR, fibrinogen, TAT, and F1+2.
e
Hematocrit only (local lab).
f
Creatinine, total bilirubin, ALT, AST, BUN, LDH, glucose, sodium, potassium, chloride, and calcium.
g
An appropriate volume of blood will be drawn in order to obtain a serum/plasma retention sample. The retention sample will be frozen and stored at -70ºC 
and stored in the event that additional testing is required in the future for purposes of this study only (i.e. repeat testing, or confirmation of virology results). 
Viral nucleic acid testing (NAT) and viral serology testing will be performed only if the subject exhibits clinical signs and symptoms of viral infection 
during the one month follow-up period.
h
Type of surgical procedure, duration of CPB and aortic clamp, and transfusion requirements.
i
Chest-drain blood loss in the first 12 and 24 hours postoperatively.
j
Postoperative clinical outcomes (major morbidity composite, transfusion requirements, surgical reexploration, low cardiac syndrome, myocardial infarction, 
stroke, acute kidney injury, arterial or venous thromboembolic events, infections, and postoperative mortality) and chest-drain blood loss in the first 12 and 
24 hours postoperatively.