Platelet-rich plasmapheresis in cardiac surgery: a meta-analysis of the effect on transfusion requirements

OBJECTIVE

Our purpose was to determine whether intraoperative platelet-rich plasmapheresis in cardiac surgery is effective in reducing the proportion of patients exposed to allogeneic red cell transfusions.

METHODS

A systematic search for prospective, randomized trials of platelet-rich plasmapheresis in cardiac surgery, using MEDLINE, HEALTHSTAR, Current Contents, "Biological Abstracts," and EMBASE/Excerpta Medica up to August 1997, was completed. Trials were included if they reported either the proportion of patients exposed to allogeneic red cells or the units of allogeneic red cells transfused. Trials were abstracted by 2 independent investigators and the quality of trial design was assessed with the use of a validated scale.

RESULTS

Seventeen references met the inclusion criteria (1369 patients [675 control: 694 platelet-rich plasmapheresis]). Platelet-rich plasmapheresis reduced the likelihood of exposure to allogeneic red cells in cardiac surgery (odds ratio 0.44; 95% confidence interval 0.27, 0.72, P = .001). Platelet-rich plasmapheresis had a small but statistically significant effect on both the volume of blood lost in the first 24 hours (weighted mean difference -102 mL; 95% confidence interval -148, -55 mL, P < .0001) and the mean units transfused (weighted mean difference -0.33 units; 95% confidence interval -0.43, -0.23, P < .0001). However, platelet-rich plasmapheresis was only marginally effective (odds ratio 0.83, 95% confidence interval 0.34, 2.01, P = .68) for "good" quality trials, whereas it appeared very effective in trials with poor methodologic quality (odds ratio 0.33, 95% confidence interval 0.17, 0.62, P = .0007).

CONCLUSIONS

Although platelet-rich plasmapheresis appeared effective in decreasing the proportion of patients receiving transfusions after cardiac operations, the quality of most of the supporting trials was low and the benefit was small in trials of good quality. Further clinical trials should be completed.

The importance of sampling site in the measurement of whole-blood platelet flow cytometry

PURPOSE

Flow cytometry is an emerging technology that may be of use in clarifying the defects of platelet function after cardiopulmonary bypass. However, the technique used for platelet sampling may affect results. The objective of this study was to evaluate the influence of the sampling site on the degree of expression of a variety of platelet-associated proteins.

METHODS

Whole-blood flow cytometric assays for the detection of platelet glycoprotein (GP) Ib, guanosine monophosphate (GMP)-140, thrombospondin, activated GPIIb/IIIa, and platelet-associated factor (FXIIIa) were developed. These markers were then measured in samples taken simultaneously from a peripheral vein, radial artery, and the side port of the central venous catheter, in eight patients about to undergo surgery.

RESULTS

When multiple samples from individual patients were assessed, the degree of activation with all of the activation assays (GMP-140, thrombospondin, activated GPIIb/IIIa, FXIIIa) was significantly greater in samples taken from the arterial catheter (p < 0.05) compared with the central venous catheter or the peripheral vein. The mean difference between sample sites was calculated in the study patients. Percent activation of FXIIIa from arterial blood was significantly greater than from the central vein and the peripheral vein (arterial-peripheral venous, 18.7 +/- 8.6; central venous-peripheral venous, 3.7 +/- 3.6; p = 0.005). There was no site-related difference in detected expression of platelet GPIb.

CONCLUSION

The site of platelet sampling significantly affects the degree of activation detected by flow cytometry. To approximate results that would be obtained from peripheral blood, samples should be taken from the side port of the central venous catheter and not from the arterial catheter in patients studied during surgery.

Papaverine solutions cause loss of viability of endothelial cells

OBJECTIVE

The optimal composition of the solution used for irrigation of saphenous veins used for cardiac surgery may influence ultimate graft patency due to potential injurious effects on the vein endothelium of some of the solution constituents.

EXPERIMENTAL DESIGN

The viability of cultured saphenous vein endothelial cells was assessed after incubation of saphenous vein endothelial cells with solutions containing saline, saline with papaverine (0.15 M NaCl, 32.5 mg/mL papaverine), culture medium and buffered saline solution (Plasma-Lyte-A).

RESULTS

Cell viability was significantly decreased after one hour incubation with solutions containing saline with papaverine (24.4+/-9.4%) as compared to culture medium and buffered saline solutions (medium 100%, Plasma-Lyte-A 86.8+/-6.90%). Loss of viability was directly related to the length of exposure of the cultured cells to papaverine. Morphologic changes of cells incubated with saline: papaverine were also seen including cell retraction and nuclear pyknosis. The cells exposed to medium recovered 100% viability whereas by 4 hours only 22% of the saline: papaverine cells were viable, and by 3 days this viability had fallen to 7.7%.

CONCLUSIONS

Loss of viability was shown in cultured saphenous vein endothelial cells exposed to saline solutions containing papaverine, whereas no difference was found between culture medium, saline and balanced salt solutions. Cell death was directly related to the length of exposure of the cells to papaverine. Further, after short- and long-term recovery periods, there was little recovery of cell viability. Although papaverine is a potent vasodilator, exposure to this compound may compromise long-term viability of graft endothelial cells.

Tissue factor expression by cells used for sodding of prosthetic vascular grafts

Sodding of vascular grafts involves coating the biomaterial with cells prepared from collagenase-digested fat tissue after removal of the adipocytes by centrifugation. The goal of this study was to investigate the staining characteristics of the sodding cells as well as their ability to express the procoagulant protein tissue factor, and to compare these findings to those found with extensively purified microvascular endothelial cells (MEC) prepared from similar tissue. Sodding cells and MEC, isolated using immunomagnetic separation with anti-PECAM antibodies, were prepared from liposuction material and endothelial-specific staining was compared. The expression of tissue factor on these cells was examined using both an ELISA and a chromogenic assay to assess the rate of generation of factor Xa. Sodding cells expressed significantly more tissue factor than the unstimulated MEC in which the expression was undetectable (sodding cells 2466 +/- 830 pg/mL, P < 0.05). There was no further increase in tissue factor expression in the sodding cells with stimulation with lipopolysaccharide (LPS); however, purified MEC expressed significantly more tissue factor after exposure to LPS (1247 +/- 356 pg/mL, P < 0.05). These results were confirmed by the determination of procoagulant activity of the cells whereby the procoagulant activity on unstimulated MEC was significantly less than that found after stimulation of these cells, and it was also less than stimulated and unstimulated sodding cells (absorbance at 405 nm: 0.423 +/- 0.125, unstimulated MEC; 1.000 +/- 0.438, stimulated MEC; 1.129 +/- 0.396, unstimulated sodding cells; 1.171 +/- 0.254, stimulated sodding cells, P < 0.05). Staining of these two cells types also demonstrated significant uptake of acetylated LDL (Ac-LDL) in the purified MEC which was essentially absent in the sodding cells. Further, vWf staining was found to a greater degree in the purified MEC than in the sodding cells. These experiments demonstrated that the cells prepared for cell sodding express large amounts of tissue factor. The sodding cells do not stain for antigens known to be specific for endothelial cells, whereas MEC do and therefore the concentration of endothelial cells in the sodding cells is small. The significance of the tissue factor expression on the surface of sodded grafts is not yet known.

A cone-and-plate device for the investigation of platelet biomaterial interactions

A device based on the cone-and-plate flow geometry commonly employed for viscometry was developed for the investigation of cell-surface interactions. The cone-and-plate geometry is capable of generating uniform, constant shear-rate flow fields, and control of cone rotational speed allows for easy variation of fluid shear rate. The current design is adapted for use with any material that is available in the form of a flat plate (film or coating). It also allows for replicate samples (the same or different surfaces) to be evaluated simultaneously. The device was tested under varying flow conditions for its ability to measure platelet adhesion from suspensions of washed platelets containing red cells. Collagen- and albumin-coated polymer materials were used as "standard" surfaces of known platelet reactivity (high and low, respectively). Adhesion to the collagen-coated surface was measured over a range of shear rate from 0 to 300 s(-1) and times up to 15 min. Platelet adhesion was observed to increase with increasing shear rate and time. Adhesion was significantly higher in the presence of red cells as has been observed by others. Effective platelet diffusion coefficients, calculated from the data on adhesion to the collagen surface, increased with increasing shear rate. Very little platelet adhesion to the albumin-coated surface, known to be unreactive to platelets, was observed when measured over a 15 min time period at 300 s(-1) shear rate, indicating that the device itself does not stimulate the platelets in the flow field. The data generated provide validation for this device as a simple means of measuring cell adhesion under controlled flow conditions to any smooth surface available in flat plate form.

Platelet accumulation on fibrin-coated polyethylene: role of platelet activation and factor XIII

Platelet accumulation on small- and medium-calibre vascular grafts plays a significant role in graft occlusion. We examined platelet accumulation on the surface of fibrin-coated polyethylene tubing (internal diameter 0.17 cm) during 10 min flow (10 ml/min) at high wall shear rate (764 s-1). Washed platelets labelled with 51Cr were resuspended in Tyrode solution containing albumin, apyrase and red blood cells (hematocrit 40%). When the thrombin that was used to form the fibrin-coated surface was inactivated with FPRCH2Cl before perfusion of the tubes with the platelet: red blood cell suspension, the accumulation of platelets was 59,840 +/- 27,960 platelets per mm2, whereas accumulation on fibrin with residual active thrombin was 316,750 +/- 32,560 platelets per mm2 (n = 4). When the fibrin on the surface was cross-linked by including recombinant factor XIII (rFXIII) in the fibrinogen solution used to prepare the fibrin-coated surface, platelet accumulation, after thrombin neutralization, was reduced by the cross-linking from 46,974 +/- 9702 to 36,818 +/- 7964 platelets per mm2 (n = 12, p < 0.01). Platelet accumulation on tubes coated with D-dimer was ten times less than on tubes coated with D-domain; this finding also supports the observation that cross-linking of fibrin with the formation gamma-gamma dimers reduces platelet accumulation on the fibrin-coated surface. Thrombin-activated platelets themselves were shown to cross-link fibrin when they had adhered to it during perfusion, or in a static system in which thrombin was used to form clots from FXIII-free fibrinogen in the presence of platelets.(ABSTRACT TRUNCATED AT 250 WORDS)

Displacement of fibrin-bound thrombin by r-hirudin precludes the use of 131I-r-hirudin for detecting pulmonary emboli in the rabbit

Pulmonary emboli are detectable by filling defects in the pulmonary vasculature upon pulmonary angiography. Emboli derived from venous thrombi are rich in fibrin to which thrombin remains bound. Hirudin, a specific thrombin inhibitor, binds to thrombin to yield a 1:1 stoichiometric complex. We examined whether 131I-recombinant hirudin (r-hirudin) could be used to detect pulmonary emboli in rabbits. Clots were formed by re-calcifying rabbit plasma in vitro, and then injected (0.034 ml) into a femoral vein to lodge in the lungs. 131I-r-hirudin (29 +/- 4 microCi/kg) was injected intravenously but emboli could not be detected by gamma camera in real time. Post-mortem analysis of lung tissue showed that 131I-r-hirudin did not associate with emboli prepared with 125I-fibrin. Because of these findings, we used different techniques to look at the binding of hirudin to plasma clots. Clots formed in vitro were incubated with 131I-r-hirudin in the presence of equimolar amounts of 125I-albumin; specific binding of 131I-r-hirudin was not observed. Experiments with immobilized fibrin(ogen) showed that 125I-r-hirudin did not bind to and remain with fibrin-bound 131I-thrombin but did lead to the inactivation and displacement of up to 70% of bound thrombin as r-hirudin-thrombin complex; residual thrombin bound to fibrin remained active. Thus, released r-hirudin-thrombin complex is probably cleared rapidly from the region of the embolus in vivo; radioiodinated r-hirudin may not, therefore, be useful as a marker for detecting emboli.

The effect of antithrombin III-independent thrombin inhibitors and heparin on fibrin accretion onto fibrin-coated polyethylene

Prosthetic vascular grafts become coated with a layer of fibrin that contributes to graft thrombosis and occlusion. We compared the effect of antithrombin III-independent inhibitors of thrombin with heparin for their ability to prevent fibrin accretion onto a model of a vascular graft formed in vitro by coating polyethylene tubing with thrombin bound to a layer of polymerized fibrin. Equivalent antithrombin concentrations of heparin, D-Phe-Pro-Arg CH2Cl (PPACK), recombinant hirudin (r-hirudin), and Hirulog-1 were added to barium chloride-absorbed plasma containing radiolabelled fibrinogen. Whereas, PPACK and r-hirudin persistently inhibited fibrin accretion, the inhibition by heparin was transient. Hirulog-1 had no effect on early fibrin accretion and was actually associated with enhanced accretion at 30 min (control 11.7 +/- 2.0 micrograms fibrin/cm2; Hirulog-1, 18.4 +/- 3.5 micrograms fibrin/cm2, p < 0.001). Both Hirulog-1 and r-hirudin displaced radiolabelled thrombin from the fibrin surface. Whereas hirudin-thrombin complexes are stable, Hirulog-1 produces only transient inhibition of the displaced thrombin thereby accounting for the enhanced fibrin accretion with this anticoagulant. These studies show that the antithrombin III-independent inhibitors, r-hirudin and PPACK, are more effective inhibitors of fibrin accretion onto fibrin-coated polyethylene than heparin or Hirulog-1. In addition, they emphasize the importance of determining the ability of anticoagulants to displace thrombin from fibrin and to form stable thrombin-inhibitor complexes; lack of stability of thrombin-inhibitor complexes must be countered by levels of anticoagulant that are adequate to maintain its effectiveness.

Patterns of failure in Hancock pericardial bioprostheses

A series of Hancock pericardial valve bioprostheses was reviewed for cases of primary valve failure. Thirteen mitral and 10 aortic valve explants were recovered from 21 adult patients. Mitral valves had been in place for a mean of 56.4 months, and aortic valves for 53.8 months. All valves failed with cusp tears from stents (with a mean of 1.7 for mitral valves and 2.6 for aortic valves) in a predictable pattern, suggesting that wear and stress at cusp stitch sites are important in their pathogenesis. The topography of these tears is illustrated as are the less common associates of primary failure, such as calcification, fibrosis, and thrombosis. Similarities and differences of this valve's failure compared with that of the Ionescu-Shiley pericardial valve are discussed.

Right coronary artery injury during tricuspid valve annuloplasty

An unusual complication after tricuspid valve annuloplasty is described where a ring suture ligated right coronary artery and precipitated myocardial infarct and patient death. The need for caution to prevent this complication with such surgery is emphasized.