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Thrombin generation and bleeding in cardiac surgery: a clinical narrative review. Can J Anaesth 2020; 67:746-753. [PMID: 32133581 DOI: 10.1007/s12630-020-01609-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 12/27/2022] Open
Abstract
This narrative review discusses the role of thrombin generation in coagulation and bleeding in cardiac surgery, the laboratory methods for clinical detection of impaired thrombin generation, and the available hemostatic interventions that can be used to improve thrombin generation. Coagulopathy after cardiopulmonary bypass (CPB) is associated with excessive blood loss and adverse patient outcomes. Thrombin plays a crucial role in primary hemostasis, and impaired thrombin generation can be an important cause of post-CPB coagulopathy. Existing coagulation assays have significant limitations in assessing thrombin generation, but whole-blood assays designed to measure thrombin generation at the bed-side are under development. Until then, clinicians may need to institute therapy empirically for non-surgical bleeding in the setting of normal coagulation measures. Available therapies for impaired thrombin generation include administration of plasma, prothrombin complex concentrate, and bypassing agents (recombinant activated factor VII and factor eight inhibitor bypassing activity). In vitro experiments have explored the relative potency of these therapies, but clinical studies are lacking. The potential incorporation of thrombin generation assays into clinical practice and treatment algorithms for impaired thrombin generation must await further clinical development.
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52
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Platelet dysfunction during pediatric cardiac ECMO. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2019.101187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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53
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Smith BB, Boswell MR, Matzek LJ, Smith MM. Thrombocytosis: Perioperative Considerations for Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:772-781. [DOI: 10.1053/j.jvca.2019.07.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/21/2019] [Accepted: 07/11/2019] [Indexed: 11/11/2022]
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Ivanov I, Verhamme IM, Sun MF, Mohammed B, Cheng Q, Matafonov A, Dickeson SK, Joseph K, Kaplan AP, Gailani D. Protease activity in single-chain prekallikrein. Blood 2020; 135:558-567. [PMID: 31800958 PMCID: PMC7033373 DOI: 10.1182/blood.2019002224] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/19/2019] [Indexed: 12/23/2022] Open
Abstract
Prekallikrein (PK) is the precursor of the trypsin-like plasma protease kallikrein (PKa), which cleaves kininogens to release bradykinin and converts the protease precursor factor XII (FXII) to the enzyme FXIIa. PK and FXII undergo reciprocal conversion to their active forms (PKa and FXIIa) by a process that is accelerated by a variety of biological and artificial surfaces. The surface-mediated process is referred to as contact activation. Previously, we showed that FXII expresses a low level of proteolytic activity (independently of FXIIa) that may initiate reciprocal activation with PK. The current study was undertaken to determine whether PK expresses similar activity. Recombinant PK that cannot be converted to PKa was prepared by replacing Arg371 with alanine at the activation cleavage site (PK-R371A, or single-chain PK). Despite being constrained to the single-chain precursor form, PK-R371A cleaves high-molecular-weight kininogen (HK) to release bradykinin with a catalytic efficiency ∼1500-fold lower than that of kallikrein cleavage of HK. In the presence of a surface, PK-R371A converts FXII to FXIIa with a specific activity ∼4 orders of magnitude lower than for PKa cleavage of FXII. These results support the notion that activity intrinsic to PK and FXII can initiate reciprocal activation of FXII and PK in solution or on a surface. The findings are consistent with the hypothesis that the putative zymogens of many trypsin-like proteases are actually active proteases, explaining their capacity to undergo processes such as autoactivation and to initiate enzyme cascades.
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Affiliation(s)
- Ivan Ivanov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Ingrid M Verhamme
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Mao-Fu Sun
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Bassem Mohammed
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Qiufang Cheng
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - Anton Matafonov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | - S Kent Dickeson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
| | | | - Allen P Kaplan
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN
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Application of a Modified Extracorporeal Circulation Perfusion Method During Surgery for Acute Stanford Type A Aortic Dissection. Heart Lung Circ 2020; 29:1203-1209. [PMID: 32059950 DOI: 10.1016/j.hlc.2019.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/10/2019] [Accepted: 11/23/2019] [Indexed: 11/20/2022]
Abstract
AIM The aim of this study was to investigate the effect of the modified extracorporeal circulation perfusion method during surgery for acute Stanford type A aortic dissection in patients who underwent stented elephant trunk implantation and arch replacement. METHOD A total of 69 patients with acute Stanford type A aortic dissection who underwent stented elephant trunk implantation and arch replacement were retrospectively analysed from 2017 to 2018. According to the perfusion method of extracorporeal circulation, patients were divided into a routine perfusion (RP) group and a modified perfusion (MP) group. Clinical data were collected, including the time of extracorporeal circulation and deep hypothermic circulatory arrest, incidence of acute kidney injury and neurological complications, and comparisons between the two groups were conducted by using independent sample t-tests for normally distributed qualitative data, the Mann-Whitney U-test for skewed qualitative data, and the chi square test or Fisher's exact test for categorical data. RESULTS There were 55 (80%) males and 14 (20%) females in the entire cohort, and the mean ± standard deviation age was 50.4±9.0 years. A total of 53 (77%) patients were included in the RP group, and 16 (23%) were included in the MP group. Patients in the MP group were older (55.5±7.8 vs 48.8±8.9 years), and the difference was significant (p=0.008). Compared with the RP group, the time of extracorporeal circulation (218.0 [44.7] vs 246.0 [58.0] min; p=0.005) and deep hypothermic circulatory arrest (4.0 [2.0] vs 25.0 [10.0] min; p<0.001) was shorter, and the incidence of postoperative acute kidney injury (n=6 [37.5%] vs n=36 [67.9%]; p=0.029) was lower in the MP group; the differences were significant. Six (6) patients died in the RP group; no patients died in the MP group. The total in-hospital mortality rate was 8.7%. CONCLUSIONS The modified extracorporeal circulation perfusion method is feasible, with satisfactory results.
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Wallisch M, Lorentz CU, Lakshmanan HHS, Johnson J, Carris MR, Puy C, Gailani D, Hinds MT, McCarty OJT, Gruber A, Tucker EI. Antibody inhibition of contact factor XII reduces platelet deposition in a model of extracorporeal membrane oxygenator perfusion in nonhuman primates. Res Pract Thromb Haemost 2020; 4:205-216. [PMID: 32110750 PMCID: PMC7040549 DOI: 10.1002/rth2.12309] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/20/2019] [Accepted: 12/27/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The contact factor XII (FXII) activates upon contact with a variety of charged surfaces. Activated FXII (FXIIa) activates factor XI, which activates factor IX, resulting in thrombin generation, platelet activation, and fibrin formation. In both in vitro and in vivo rabbit models, components of medical devices, including extracorporeal oxygenators, are known to incite fibrin formation in a FXII-dependent manner. Since FXII has no known role in hemostasis and its inhibition is therefore likely a safe antithrombotic approach, we investigated whether FXII inhibition also reduces accumulation of platelets in extracorporeal oxygenators. OBJECTIVES We aimed to determine the effect of FXII inhibition on platelet deposition in perfused extracorporeal membrane oxygenators in nonhuman primates. METHODS A potent FXII neutralizing monoclonal antibody, 5C12, was administered intravenously to block contact activation in baboons. Extracorporeal membrane oxygenators were temporarily deployed into chronic arteriovenous access shunts. Radiolabeled platelet deposition in oxygenators was quantified in real time using gamma camera imaging. Biochemical assays were performed to characterize the method of action of 5C12. RESULTS The anti-FXII monoclonal antibody 5C12 recognized both the alpha and beta forms of human and baboon FXII by binding to the protease-containing domain, and inhibited FXIIa activity. Administration of 5C12 to baboons reduced platelet deposition and fibrin formation in the extracorporeal membrane oxygenators, in both the presence and absence of systemic low-dose unfractionated heparin. The antiplatelet dose of 5C12 did not cause measurable increases in template bleeding times in baboons. CONCLUSIONS FXII represents a possible therapeutic and safe target for reducing platelet deposition and fibrin formation during medical interventions including extracorporeal membrane oxygenation.
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Affiliation(s)
- Michael Wallisch
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
| | - Christina U. Lorentz
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
| | | | - Jennifer Johnson
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
| | - Marschelle R. Carris
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
| | - Cristina Puy
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
| | - David Gailani
- Department of Pathology, Microbiology, and ImmunologyVanderbilt University School of MedicineNashvilleTNUSA
| | - Monica T. Hinds
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
| | - Owen J. T. McCarty
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Division of Hematology & Medical OncologyDepartment of MedicineOregon Health & Science UniversityPortlandORUSA
| | - András Gruber
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
- Division of Hematology & Medical OncologyDepartment of MedicineOregon Health & Science UniversityPortlandORUSA
| | - Erik I. Tucker
- Department of Biomedical EngineeringOregon Health & Science UniversityPortlandORUSA
- Aronora, Inc.PortlandORUSA
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Törnudd M, Ramström S, Kvitting JPE, Alfredsson J, Pihl R, Berg S. Protamine stimulates platelet aggregation in vitro with activation of the fibrinogen receptor and alpha-granule release, but impairs secondary activation via ADP and thrombin receptors. Platelets 2020; 32:90-96. [PMID: 31992110 DOI: 10.1080/09537104.2020.1719992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Heparin and protamine are fundamental in the management of anticoagulation during cardiac surgery. Excess protamine has been associated with increased bleeding. Interaction between protamine and platelet function has been demonstrated but the mechanism remains unclear. We examined the effect of protamine on platelet function in vitro using impedance aggregometry, flow cytometry, and thrombin generation. Platelets were exposed to protamine at final concentrations of 0, 20, 40, and 80 µg/mL, alone or together with adenosine diphosphate (ADP) or thrombin PAR1 receptor-activating peptide (TRAP). We found that in the absence of other activators, protamine (80 µg/mL) increased the proportion of platelets with active fibrinogen receptor (binding of PAC-1) from 3.6% to 97.0% (p < .001) measured with flow cytometry. Impedance aggregometry also increased slightly after exposure to protamine alone. When activated with ADP or TRAP protamine at 80 µg/mL reduced aggregation, from 73.8 ± 29.4 U to 46.9 ± 21.1 U (p < .001) with ADP and from 126.4 ± 16.1 U to 94.9 ± 23.7 U (p < .01) with TRAP. P-selectin exposure (a marker of alpha-granule release) measured by median fluorescence intensity (MFI) increased dose dependently with protamine alone, from 0.76 ± 0.20 (0 µg/mL) to 10.2 ± 3.1 (80 µg/mL), p < .001. Protamine 80 µg/mL by itself resulted in higher MFI (10.16 ± 3.09) than activation with ADP (2.2 ± 0.7, p < .001) or TRAP (5.7 ± 2.6, p < .01) without protamine. When protamine was combined with ADP or TRAP, there was a concentration-dependent increase in the alpha-granule release. In conclusion, protamine interacts with platelets in vitro having both a direct activating effect and impairment of secondary activation of aggregation by other agonists.
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Affiliation(s)
- Mattias Törnudd
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
| | - Sofia Ramström
- Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University , Linköping, Sweden.,Cardiovascular Research Centre, School of Medical Sciences, Örebro University , Örebro, Sweden
| | | | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
| | - Richard Pihl
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden.,Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University , Linköping, Sweden
| | - Sören Berg
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
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58
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Shah A, Palmer AJR, Klein AA. Strategies to minimize intraoperative blood loss during major surgery. Br J Surg 2020; 107:e26-e38. [DOI: 10.1002/bjs.11393] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.
Methods
This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.
Results
Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.
Conclusion
Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.
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Affiliation(s)
- A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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59
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Wise-Faberowski L, Machovec K. Platelet Administration During Cardiopulmonary Bypass in Neonates: A Universal Therapy Applied in a Novel Way. World J Pediatr Congenit Heart Surg 2019; 11:77-78. [DOI: 10.1177/2150135119890248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Advances in pharmaceuticals (eg, factor concentrates), laboratory testing (eg, rotational thromboelastometry), and processes (eg, transfusion protocols) have contributed to improved outcomes regarding transfusion in neonates undergoing surgical repair for congenital heart disease. A novel strategy, platelets administered during the rewarming phase of cardiopulmonary bypass, as a solution to improved hemostasis, was prospectively evaluated in 42 neonates. Improved intraoperative and postoperative hemostasis was observed in neonates given platelets during the rewarming phase of cardiopulmonary bypass.
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60
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Vadlamudi R, Chan J, Sniecinski RM. Catastrophic Intracardiac Thrombosis During Emergency Repair of an Expanding Aortic Pseudoaneurysm: A Case Report. A A Pract 2019; 13:342-345. [PMID: 31567269 DOI: 10.1213/xaa.0000000000001079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Catastrophic thrombosis is a rare but frequently fatal event following complex cardiac surgery. It is most often encountered following separation from cardiopulmonary bypass (CPB) and reversal of heparin anticoagulation, and somewhat paradoxically, at the time when bleeding from post-CPB coagulopathy is being treated. We report the case of a 41-year-old female taken to the operating room for repair of an expanding ascending aortic pseudoaneurysm. Following a prolonged operation, she developed intracardiac thrombus during transfusion of hemostatic blood products and procoagulant agents. Potential contributing factors are discussed.
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Affiliation(s)
- Ratna Vadlamudi
- From the Department of Anesthesiology, Emory University School of Medicine, Emory University Hospital, Atlanta, Georgia
| | - Jay Chan
- US Anesthesia Partners, Florida Hospital, Maitland, Florida
| | - Roman M Sniecinski
- From the Department of Anesthesiology, Emory University School of Medicine, Emory University Hospital, Atlanta, Georgia
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61
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Alaifan T, Alenazy A, Xiang Wang D, Fernando SM, Spence J, Belley-Cote E, Fox-Robichaud A, Ainswoth C, Karachi T, Kyeremanteng K, Zarychanski R, Whitlock R, Rochwerg B. Tranexamic acid in cardiac surgery: a systematic review and meta-analysis (protocol). BMJ Open 2019; 9:e028585. [PMID: 31530593 PMCID: PMC6756438 DOI: 10.1136/bmjopen-2018-028585] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Bleeding during cardiac surgery is associated with increased morbidity and mortality. Tranexamic acid is an antifibrinolytic with proven efficacy in major surgeries. Current clinical practice guidelines recommend intraoperative use in cardiac procedures. However, several complications have been reported with tranexamic acid including seizures. This review intends to summarise the evidence examining the efficacy and safety of tranexamic acid in patients undergoing cardiac surgery. METHODS/DESIGN We will search MEDLINE, Embase, PubMED, ACPJC, CINAHL and the Cochrane trial registry for eligible randomised controlled trials, the search dates for all databases will be from inception until 1 January 2019, investigating the perioperative use of topical and/or intravenous tranexamic acid as a stand-alone antifibrinolytic agent compared with placebo in patients undergoing open cardiac surgery. We categorised outcomes as patient critical or patient important. Selected patient-critical outcomes are: mortality (intensive care unit, hospital and 30-day endpoints), reoperation within 24 hours, postoperative bleeding requiring transfusion of packed red blood cells, myocardial infarction, stroke, pulmonary embolism, bowel infarction, upper or lower limb deep vein thrombosis and seizures. Those outcomes, we perceived as clinical experts to be most patient valued and patients were not involved in outcomes selection process. We will not apply publication date, language, journal or methodological quality restrictions. Two reviewers will independently screen and identify eligible studies using predefined eligibility criteria and then review full reports of all potentially relevant citations. A third reviewer will resolve disagreements if consensus cannot be achieved. We will present the results as relative risk with 95% CIs for dichotomous outcomes and as mean difference or standardised mean difference for continuous outcomes with 95% CIs. We will assess the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION Formal ethical approval is not required as primary data will not be collected. The results will be disseminated through a peer-reviewed publication TRIAL REGISTRATION NUMBER: CRD42018105904.
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Affiliation(s)
- Thamer Alaifan
- Department of Medicine, Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Ahmed Alenazy
- Department of Medicine, Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Dominic Xiang Wang
- Schulich School of Medicine and Dentistry, University of Western, London, Ontario, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jessica Spence
- Departments of Anesthesia and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Cote
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Critical Care, Cardiology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Alison Fox-Robichaud
- Department of Medicine, Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Craig Ainswoth
- Department of Medicine, Critical Care, Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Tim Karachi
- Department of Medicine, Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Kwadwo Kyeremanteng
- Critical Care, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine and of Hematology/Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Richard Whitlock
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Surgery, Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Critical Care, McMaster University, Hamilton, Ontario, Canada
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Predicting mortality in patients with disseminated intravascular coagulation after cardiopulmonary bypass surgery by utilizing two scoring systems. Blood Coagul Fibrinolysis 2019; 30:11-16. [PMID: 30431447 DOI: 10.1097/mbc.0000000000000781] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
: We evaluated clinical and laboratory biomarkers of disseminated intravascular coagulation (DIC) following cardiac surgery in the cardiothoracic surgical ICU (CTICU) to predict mortality. We retrospectively analyzed CTICU patients with suspected DIC identified from the hospital laboratory database, and calculated International Society on Thrombosis and Haemostasis (ISTH) and the Japanese Association for Acute Medicine (JAAM) DIC scores to predict DIC-related mortality. The predictive accuracy of the JAAM and ISTH DIC scoring system were then assessed by logistic regression analysis and receiver operative characteristics analysis, and compared to other potential predictors of mortality (e.g., Acute Physiology and Chronic Health Evaluation II, systemic inflammatory response syndrome criteria, laboratory variables). Our study showed a 30-day mortality rate of 71% in CTICU patients with DIC. The JAAM DIC score offered the best predictive accuracy [area under the curve (AUC): 0.723, 95% % confidence interval (CI): 0.638-0.947, P = 0.021], when compared with ISTH DIC score (AUC: 0.707, 95% CI: 0.491-0.923, P = 0.066) and Acute Physiology and Chronic Health Evaluation II (AUC: 0.687, 95% CI: 0.483-0.891, P = 0.110). A JAAM DIC score at least 6 was reported in 89% of the nonsurvivors and 46% of survivors (P = 0.010), and predicted mortality [odds ratio: 9.33 (1.50-58.20)] with a 73% sensitivity and a 78% specificity. Our results also show a strong relationship between acid-base derangement and mortality. This initial evaluation of DIC-related mortality in the CTICU found the standardized JAAM DIC scoring system in combination with acid-base laboratory values were most useful to predict mortality in postcardiac surgery patients with DIC. Additional prospective studies are needed to further validate our findings.
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63
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Ho LTS, Lenihan M, McVey MJ, Karkouti K, Wijeysundera DN, Rao V, Crowther M, Grocott HP, Pinto R, Scales DC, Achen B, Brar S, Morrison D, Wong D, Bussières JS, Waal T, Harle C, Médicis É, McAdams C, Syed S, Tran D, Waters T. The association between platelet dysfunction and adverse outcomes in cardiac surgical patients. Anaesthesia 2019; 74:1130-1137. [PMID: 30932171 DOI: 10.1111/anae.14631] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypass-associated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.
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Affiliation(s)
- L T S Ho
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - M Lenihan
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - M J McVey
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, ON, Canada
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada.,Toronto General Research Institute and the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, ON, Canada
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64
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Faraoni D, DiNardo JA. Recombinant Activated Factor VII in Children Undergoing Cardiac Surgery: Remember How and Why to Use It. J Cardiothorac Vasc Anesth 2019; 33:1276-1278. [PMID: 30770180 DOI: 10.1053/j.jvca.2019.01.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Indexed: 11/11/2022]
Affiliation(s)
- David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - James A DiNardo
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Sharma S, Kumar S, Tewari P, Pande S, Murari M. Utility of thromboelastography versus routine coagulation tests for assessment of hypocoagulable state in patients undergoing cardiac bypass surgery. Ann Card Anaesth 2018; 21:151-157. [PMID: 29652276 PMCID: PMC5914215 DOI: 10.4103/aca.aca_174_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction: Peri-operative monitoring of coagulation is important to diagnose potential cause of hemorrhage, to manage coagulopathy and guide treatment with blood products in patients undergoing cardiac surgery with cardiopulmonary bypass. This study was done to evaluate usefulness of Thromboelastography (TEG) and routine coagulation tests (RCT) in assessing hemostatic changes and predicting postoperative bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: Fifty adult patients undergoing cardiac surgery with cardiopulmonary bypass were enrolled in this prospective study. Preoperative and post-operative samples were collected for routine coagulation tests and TEG. Regression analysis and test of significance using Pearson's correlation coefficient was performed to assess correlation between routine coagulation tests and corresponding TEG parameters. Regression analysis was done to study relation between blood loss at 24 hours and various coagulation parameters. Results: The Routine coagulation test i.e. PT, INR, APTT showed no significant correlation with corresponding TEG parameters in pre-operative samples. However platelet count significantly correlated (p = 0.004) with MA values in postoperative samples. A significant correlation (p = 0.001) was seen between fibrinogen levels and alpha angles as well as with MA in both baseline preoperative and postoperative samples. TEG parameters R time and MA in postoperative samples were the only parameters that predicted bleeders with fair accuracy. Conclusion: Though the techniques of RCT and TEG are different, a few RCT e.g. platelet count and fibrinogen correlated with corresponding TEG parameters i.e. MA and Alpha angle. TEG parameters (R time and MA in postoperative samples) were able to predict blood loss better than RCT.
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Affiliation(s)
- Seema Sharma
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sujeet Kumar
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhat Tewari
- Department of Anesthesia, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shantanu Pande
- Department of Cardiovascular and Thoracic Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Manjula Murari
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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66
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Ivert T, Dalén M, Ander C, Stålesen R, Lordkipanidzé M, Hjemdahl P. Increased platelet reactivity and platelet-leukocyte aggregation after elective coronary bypass surgery. Platelets 2018; 30:975-981. [PMID: 30422037 DOI: 10.1080/09537104.2018.1542122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Inflammatory mechanisms are activated, and thrombotic complications occur during the initial months after coronary artery bypass grafting (CABG). Therefore, changes over time of platelet activation and platelet-leukocyte interactions after CABG are of interest. Whole-blood flow cytometry was performed before, and 4-6 days, one month, and three months after elective CABG in 54 men with stable coronary artery disease treated with acetylsalicylic acid (ASA). Single platelets and platelet-leukocyte aggregates (PLAs) among monocytes (P-Mon), neutrophils (P-Neu), and lymphocytes (P-Lym) were studied without and with stimulation by submaximal concentrations of ADP, thrombin, and the thromboxane analog U46619. White blood cell counts were increased during the initial postoperative course, and platelet counts were increased after one month. Platelet P-selectin expression was significantly enhanced at one month when stimulated by thrombin and U46619 and at three months with ADP and thrombin. All PLAs subtypes were increased at one month without stimulation in vitro. P-Mon and P-Neu stimulated by ADP, thrombin, or U46619 were significantly increased one month after the operation but decreased compared to baseline at three months. Agonist stimulated P-Lyms were increased at one month and remained increased at three months after ADP stimulation. There was significant platelet activation and formation of PLAs unstimulated and after agonist stimulation by ADP, thrombin, and a thromboxane analog after CABG in patients with stable coronary artery disease irrespective of ASA treatment. Changes observed up to three months after CABG support further studies of the clinical implications of protracted increases in platelet activation and platelet-leukocyte interactions.
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Affiliation(s)
- Torbjörn Ivert
- Heart and Vascular Theme, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm , Sweden
| | - Magnus Dalén
- Heart and Vascular Theme, Karolinska University Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm , Sweden
| | - Charlotte Ander
- Department of Clinical Pharmacology, Karolinska University Hospital and Department of Medicine Solna, Karolinska Institutet , Stockholm , Sweden
| | - Ragnhild Stålesen
- Department of Clinical Pharmacology, Karolinska University Hospital and Department of Medicine Solna, Karolinska Institutet , Stockholm , Sweden
| | - Marie Lordkipanidzé
- Faculté de pharmacie, Université de Montréal,and Research center, Montreal Heart Institute , Montréal , Québec , Canada
| | - Paul Hjemdahl
- Department of Clinical Pharmacology, Karolinska University Hospital and Department of Medicine Solna, Karolinska Institutet , Stockholm , Sweden
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Giorni C, Pezzella C, Bojan M, Ricci Z, Pouard P, Raisky O, Tourneur L, La Salvia O, Favia I, Borgel D, Cogo P, Carotti A, Lasne D. Impact of Heparin- or Nonheparin-Coated Circuits on Platelet Function in Pediatric Cardiac Surgery. Ann Thorac Surg 2018; 107:1241-1247. [PMID: 30395857 DOI: 10.1016/j.athoracsur.2018.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/14/2018] [Accepted: 09/14/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Extracorporeal circuit coating has been shown to improve coagulation derangements during pediatric cardiopulmonary bypass (CPB). This study compared platelet function and hemostasis activation in pediatric cardiac surgery conducted with nonheparin coating (Balance; Medtronic, Minneapolis, MN) versus heparin-based coating (Carmeda; Medtronic) circuits. METHODS A prospective, randomized, double-center trial was conducted in children older than 1 month undergoing congenital heart disease treatment. Blood samples were collected at baseline (T0), 15 minutes after the start of CPB (T1), and 15 minutes (T2) and 1 hour after the conclusion of CPB (T3). The primary end point of the study was to detect potential differences in β-thromboglobulin levels between the two groups at T2. Other coagulation and platelet function indicators were analyzed as secondary end points. RESULTS The concentration of β-thromboglobulin increased significantly at T2 in both groups. However, there was no significant difference between the groups across all time points. There was no difference in the secondary end points between the groups. CONCLUSIONS The two circuits showed similar biological effects on platelet function and coagulation. This observation may be useful in optimizing the conduct of CPB and in rationalizing its cost for the treatment of congenital heart disease.
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Affiliation(s)
- Chiara Giorni
- Pediatric Intensive Care, Cardiac Surgery and Perfusion Unit, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Chiara Pezzella
- Pediatric Intensive Care, Cardiac Surgery and Perfusion Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Mirela Bojan
- Department of Anesthesiology and Critical Care, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Paris, France
| | - Zaccaria Ricci
- Pediatric Intensive Care, Cardiac Surgery and Perfusion Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Philippe Pouard
- Department of Anesthesiology and Critical Care, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Paris, France
| | - Olivier Raisky
- Department of Pediatric Cardiac Surgery, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Paris, France
| | - Laurent Tourneur
- Department of Pediatric Cardiac Surgery, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Paris, France
| | - Ondina La Salvia
- Pediatric Intensive Care, Cardiac Surgery and Perfusion Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Isabella Favia
- Pediatric Intensive Care, Cardiac Surgery and Perfusion Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Delphine Borgel
- Hematology Laboratory, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Paris, France; Hémostase Inflammation Thrombose, Unité Mixte de Recherche -S1176, Institut National de la Santé et de la Recherche Médicale, University Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Paola Cogo
- Pediatric Intensive Care, Cardiac Surgery and Perfusion Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Adriano Carotti
- Pediatric Intensive Care, Cardiac Surgery and Perfusion Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Dominique Lasne
- Hematology Laboratory, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Paris, France; Hémostase Inflammation Thrombose, Unité Mixte de Recherche -S1176, Institut National de la Santé et de la Recherche Médicale, University Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
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68
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Tillman BF, Gruber A, McCarty OJT, Gailani D. Plasma contact factors as therapeutic targets. Blood Rev 2018; 32:433-448. [PMID: 30075986 PMCID: PMC6185818 DOI: 10.1016/j.blre.2018.04.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/27/2018] [Accepted: 04/06/2018] [Indexed: 12/20/2022]
Abstract
Direct oral anticoagulants (DOACs) are small molecule inhibitors of the coagulation proteases thrombin and factor Xa that demonstrate comparable efficacy to warfarin for several common indications, while causing less serious bleeding. However, because their targets are required for the normal host-response to bleeding (hemostasis), DOACs are associated with therapy-induced bleeding that limits their use in certain patient populations and clinical situations. The plasma contact factors (factor XII, factor XI, and prekallikrein) initiate blood coagulation in the activated partial thromboplastin time assay. While serving limited roles in hemostasis, pre-clinical and epidemiologic data indicate that these proteins contribute to pathologic coagulation. It is anticipated that drugs targeting the contact factors will reduce risk of thrombosis with minimal impact on hemostasis. Here, we discuss the biochemistry of contact activation, the contributions of contact factors in thrombosis, and novel antithrombotic agents targeting contact factors that are undergoing pre-clinical and early clinical testing.
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Affiliation(s)
- Benjamin F Tillman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andras Gruber
- Department of Biomedical Engineering, Oregon Health & Sciences University, Portland, OR, USA; Division of Hematology and Medical Oncology School of Medicine, Oregon Health & Sciences University, Portland, OR, USA; Aronora, Inc., Portland, OR, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Sciences University, Portland, OR, USA; Division of Hematology and Medical Oncology School of Medicine, Oregon Health & Sciences University, Portland, OR, USA
| | - David Gailani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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69
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Maroney SA, Peterson JA, Zwifelhofer W, Martinez ND, Yan K, Bercovitz RS, Woods RK, Mast AE. Plasma Proteolytic Cascade Activation during Neonatal Cardiopulmonary Bypass Surgery. Thromb Haemost 2018; 118:1545-1555. [PMID: 30086574 DOI: 10.1055/s-0038-1667198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Neonates undergoing cardiopulmonary bypass (CPB) surgery to correct congenital heart defects often experience excessive bleeding. Exposure of blood to artificial materials during CPB may activate coagulation, complement and inflammatory pathways. In addition, the surgical stress placed on the haemostatic system may result in cross-activation of other plasma proteolytic cascades, which could further complicate physiological responses to the surgical procedure and post-operative recovery. Plasma protease inhibitors undergo distinct conformational changes upon interaction with proteases, and, thereby, can serve as endogenous biosensors to identify activation of the different proteolytic cascades. We tested the hypothesis that changes in the concentration and conformation of protease inhibitors regulating plasma proteolytic cascades during neonatal CPB are associated with post-operative bleeding. PATIENTS AND METHODS Plasma samples from 44 neonates were obtained at four time points across the surgical procedure. Anti-thrombin, antitrypsin, anti-chymotrypsin, anti-plasmin, C1-inhibitor and tissue factor pathway inhibitor (TFPI) concentrations and conformations were evaluated by enzyme-linked immunosorbent assay, transverse urea gradient gel electrophoresis and sodium dodecyl sulphate-polyacrylamide gel electrophoresis. RESULTS/CONCLUSION The most striking changes were observed following heparin administration and were associated with the appearance of inactive forms of anti-thrombin and an increase in the plasma concentration of TFPI. Changes in anti-thrombin and TFPI remained evident throughout surgery and into the post-operative period but were not different between patients with or without post-operative bleeding. The concentration of antitrypsin decreased across surgery, but there was no significant accumulation of inactive conformations of any inhibitor besides anti-thrombin, indicating that widespread cross-activation of other plasma proteolytic cascades by coagulation proteases did not occur.
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Affiliation(s)
- Susan A Maroney
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States
| | - Julie A Peterson
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States
| | - Wes Zwifelhofer
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States
| | - Nicholas D Martinez
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States
| | - Ke Yan
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Rachel S Bercovitz
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, United States.,Department of Pathology, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Ronald K Woods
- Division of Pediatric Cardiothoracic Surgery, Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, United States.,Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Alan E Mast
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, Wisconsin, United States.,Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
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70
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Mazzeffi MA, Tanaka K, Roberts A, Rector R, Menaker J, Kon Z, Deatrick KB, Kaczorowski D, Griffith B, Herr D. Bleeding, Thrombosis, and Transfusion With Two Heparin Anticoagulation Protocols in Venoarterial ECMO Patients. J Cardiothorac Vasc Anesth 2018; 33:1216-1220. [PMID: 30181084 DOI: 10.1053/j.jvca.2018.07.045] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the incidence of bleeding and thrombosis between adult venoarterial (VA) extracorporeal membrane oxygenation (ECMO) patients managed with an activated clotting time (ACT)-guided heparin anticoagulation protocol and activated partial thromboplastin time (aPTT) protocol. DESIGN Retrospective cohort study. SETTING Tertiary care, academic medical center. PARTICIPANTS Consecutive adult VA ECMO patients during a 6-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic, medical, transfusion, and ECMO data were collected for all patients. Primary study outcomes were bleeding and thrombosis. Secondary outcomes were stroke and in-hospital mortality. One hundred twenty-one patients were included in the cohort. Fifty patients had ACT monitoring, and 71 had aPTT monitoring. There was no difference in the incidence of bleeding or thrombosis between the 2 groups (78.0% v 67.6% for bleeding [p = 0.21] and 16.0% v 19.7% for thrombosis [p = 1.0]). After adjusting for age and total ECMO days, patients managed with ACT received approximately 30% more red blood cell, fresh frozen plasma, and platelet transfusion (all p < 0.05). CONCLUSION There is no apparent difference in the incidence rate of bleeding or thrombosis between VA ECMO patients managed with an ACT- or aPTT-guided heparin anticoagulation protocol. Patients managed with an ACT-guided protocol received more blood transfusion, which could reflect greater total bleeding. Future randomized controlled trials would help to elucidate optimal anticoagulation strategies for VA ECMO patients.
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Affiliation(s)
- Michael A Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD.
| | - Kenichi Tanaka
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Alia Roberts
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Raymond Rector
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Jay Menaker
- University of Maryland School of Medicine, Department of Surgery Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Zachary Kon
- New York University, Langone Health, New York, NY
| | - Kristopher B Deatrick
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - David Kaczorowski
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Bartley Griffith
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Daniel Herr
- University of Maryland School of Medicine, Department of Surgery Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
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71
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Ghadimi K, Levy JH, Welsby IJ. Perioperative management of the bleeding patient. Br J Anaesth 2018; 117:iii18-iii30. [PMID: 27940453 DOI: 10.1093/bja/aew358] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Perioperative bleeding remains a major complication during and after surgery, resulting in increased morbidity and mortality. The principal causes of non-vascular sources of haemostatic perioperative bleeding are a preexisting undetected bleeding disorder, the nature of the operation itself, or acquired coagulation abnormalities secondary to haemorrhage, haemodilution, or haemostatic factor consumption. In the bleeding patient, standard therapeutic approaches include allogeneic blood product administration, concomitant pharmacologic agents, and increasing application of purified and recombinant haemostatic factors. Multiple haemostatic changes occur perioperatively after trauma and complex surgical procedures including cardiac surgery and liver transplantation. Novel strategies for both prophylaxis and therapy of perioperative bleeding include tranexamic acid, desmopressin, fibrinogen and prothrombin complex concentrates. Point-of-care patient testing using thromboelastography, rotational thromboelastometry, and platelet function assays has allowed for more detailed assessment of specific targeted therapy for haemostasis. Strategic multimodal management is needed to improve management, reduce allogeneic blood product administration, and minimize associated risks related to transfusion.
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Affiliation(s)
- K Ghadimi
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - J H Levy
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - I J Welsby
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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72
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Gunaratne R, Kumar S, Frederiksen JW, Stayrook S, Lohrmann JL, Perry K, Bompiani KM, Chabata CV, Thalji NK, Ho MD, Arepally G, Camire RM, Krishnaswamy S, Sullenger BA. Combination of aptamer and drug for reversible anticoagulation in cardiopulmonary bypass. Nat Biotechnol 2018; 36:606-613. [PMID: 29863725 PMCID: PMC6349032 DOI: 10.1038/nbt.4153] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 03/27/2018] [Indexed: 02/05/2023]
Abstract
Unfractionated heparin (UFH), the standard anticoagulant for cardiopulmonary bypass (CPB) surgery, carries a risk of post-operative bleeding and is potentially harmful in patients with heparin-induced thrombocytopenia-associated antibodies. To improve the activity of an alternative anticoagulant, the RNA aptamer 11F7t, we solved X-ray crystal structures of the aptamer bound to factor Xa (FXa). The finding that 11F7t did not bind the catalytic site suggested that it could complement small-molecule FXa inhibitors. We demonstrate that combinations of 11F7t and catalytic-site FXa inhibitors enhance anticoagulation in purified reaction mixtures and plasma. Aptamer-drug combinations prevented clot formation as effectively as UFH in human blood circulated in an extracorporeal oxygenator circuit that mimicked CPB, while avoiding side effects of UFH. An antidote could promptly neutralize the anticoagulant effects of both FXa inhibitors. Our results suggest that drugs and aptamers with shared targets can be combined to exert more specific and potent effects than either agent alone.
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Affiliation(s)
- Ruwan Gunaratne
- Duke University, Department of Pharmacology and Cancer Biology, Durham, NC 27710
- Duke University, Medical Scientist Training Program, Durham, NC 27710
| | - Shekhar Kumar
- Research Institute, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
| | | | - Steven Stayrook
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA 19104
| | | | - Kay Perry
- Northeastern Collaborative Access Team (NE-CAT) and Departments of Chemistry and Chemical Biology, Cornell University, Argonne National Laboratory, Argonne, IL 60439
| | | | - Charlene V. Chabata
- Duke University, Department of Pharmacology and Cancer Biology, Durham, NC 27710
| | - Nabil K. Thalji
- Research Institute, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA 19104
| | - Michelle D. Ho
- Research Institute, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
| | | | - Rodney M. Camire
- Research Institute, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA 19104
| | - Sriram Krishnaswamy
- Research Institute, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA 19104
| | - Bruce A. Sullenger
- Duke University, Department of Pharmacology and Cancer Biology, Durham, NC 27710
- Duke University, Department of Surgery, Durham, NC 27710
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73
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Gurrieri C, Smith BB, Nuttall GA, Pruthi RK, Said SM, Smith MM. Essential Thrombocythemia and Cardiac Surgery: A Case Series and Review of the Literature. Ann Thorac Surg 2018; 106:482-490. [DOI: 10.1016/j.athoracsur.2018.03.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/09/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
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74
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Seelhammer TG, Mangla J, Demirci O. The Use of Thromboelastography to Titrate Tranexamic Acid Therapy for Abatement of Lysis-Induced Hemorrhagic Complications During Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2018; 33:1059-1062. [PMID: 30765211 DOI: 10.1053/j.jvca.2018.07.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| | - Jimmi Mangla
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Onur Demirci
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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75
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Hussain M, Rupp F, Wendel HP, Gehring FK. Bioapplications of acoustic crystals, a review. Trends Analyt Chem 2018. [DOI: 10.1016/j.trac.2018.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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76
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Längin M, Konrad M, Reichart B, Bauer A, Lison S. Acquired Factor VIII Inhibitor and Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2018; 32:952-955. [DOI: 10.1053/j.jvca.2017.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Indexed: 11/11/2022]
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77
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Stability enhanced, repeatability improved Parylene-C passivated on QCM sensor for aPTT measurement. Biosens Bioelectron 2017. [DOI: 10.1016/j.bios.2017.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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78
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Blaine KP, Sakai T. Viscoelastic Monitoring to Guide Hemostatic Resuscitation in Liver Transplantation Surgery. Semin Cardiothorac Vasc Anesth 2017; 22:150-163. [PMID: 29099334 DOI: 10.1177/1089253217739121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Coagulopathic bleeding must be anticipated during liver transplantation (LT) surgery. Patients with end-stage liver disease (ESLD) often present with disease-related hematologic disturbances, including the loss of hepatic procoagulant and anticoagulant clotting factors and thrombocytopenia. Transplantation surgery itself presents additional hemostatic changes, including hyperfibrinolysis. Viscoelastic monitoring (VEM) is often used to provide targeted, personalized hemostatic therapies for complex bleeding states including cardiac surgery and major trauma. The use in these coagulopathic conditions led to its application to LT, although the mechanisms of coagulopathy in these patients are quite different. While VEM is often used during transplant surgeries in Europe and North America, evidence supporting its use is limited to a few small clinical studies. The theoretical and clinical applications of the standard and specialized VEM assays are discussed in the setting of LT and ESLD.
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Affiliation(s)
- Kevin P Blaine
- 1 Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Tetsuro Sakai
- 2 University of Pittsburgh Medical Center Health System, Pittsburgh, PA, USA
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79
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Olsson A, Alfredsson J, Ramström S, Svedjeholm R, Kenny D, Håkansson E, Berglund JS, Berg S. Better platelet function, less fibrinolysis and less hemolysis in re-transfused residual pump blood with the Ringer’s chase technique – a randomized pilot study. Perfusion 2017; 33:185-193. [DOI: 10.1177/0267659117733891] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Residual pump blood from the cardiopulmonary bypass (CPB) circuit is often collected into an infusion bag (IB) and re-transfused. An alternative is to chase the residual blood into the circulation through the arterial cannula with Ringer’s acetate. Our aim was to assess possible differences in hemostatic blood quality between these two techniques. Methods: Forty adult patients undergoing elective coronary artery bypass graft surgery with CPB were randomized to receive the residual pump blood by either an IB or through the Ringer’s chase (RC) technique. Platelet activation and function (impedance aggregometry), coagulation and hemolysis variables were assessed in the re-transfused blood and in the patients before, during and after surgery. Results are presented as median (25-75 quartiles). Results: Total hemoglobin and platelet levels in the re-transfused blood were comparable with the two methods, as were soluble platelet activation markers P-selectin and soluble glycoprotein VI (GPVI). Platelet aggregation (U) in the IB blood was significantly lower compared to the RC blood, with the agonists adenosine diphosphate (ADP) 24 (10-32) vs 46 (33-65), p<0.01, thrombin receptor activating peptide (TRAP) 50 (29-73) vs 69 (51-92), p=0.04 and collagen 24 (17-28) vs 34 (26-59), p<0.01. The IB blood had higher amounts of free hemoglobin (mg/L) (1086 (891-1717) vs 591(517-646), p<0.01) and D-dimer 0.60 (0.33-0.98) vs 0.3 (0.3-0.48), p<0.01. Other coagulation variables showed no difference between the groups. Conclusions: The handling of blood after CPB increases hemolysis, impairs platelet function and activates coagulation and fibrinolysis. The RC technique preserved the blood better than the commonly used IB technique.
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Affiliation(s)
- Anki Olsson
- Blekinge Institute of Technology, Department of Health Science, Karlskrona, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Cardio-Thoracic Surgery, Blekinge Hospital, Karlskrona, Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Sofia Ramström
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Rolf Svedjeholm
- Department of Cardio-Thoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Dermot Kenny
- Clinical Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eric Håkansson
- Department of Cardio-Thoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Sören Berg
- Department of Cardio-Thoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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80
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Auxiliary activation of the complement system and its importance for the pathophysiology of clinical conditions. Semin Immunopathol 2017; 40:87-102. [PMID: 28900700 PMCID: PMC5794838 DOI: 10.1007/s00281-017-0646-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/03/2017] [Indexed: 12/26/2022]
Abstract
Activation and regulation of the cascade systems of the blood (the complement system, the coagulation/contact activation/kallikrein system, and the fibrinolytic system) occurs via activation of zymogen molecules to specific active proteolytic enzymes. Despite the fact that the generated proteases are all present together in the blood, under physiological conditions, the activity of the generated proteases is controlled by endogenous protease inhibitors. Consequently, there is remarkable little crosstalk between the different systems in the fluid phase. This concept review article aims at identifying and describing conditions where the strict system-related control is circumvented. These include clinical settings where massive amounts of proteolytic enzymes are released from tissues, e.g., during pancreatitis or post-traumatic tissue damage, resulting in consumption of the natural substrates of the specific proteases and the available protease inhibitor. Another example of cascade system dysregulation is disseminated intravascular coagulation, with canonical activation of all cascade systems of the blood, also leading to specific substrate and protease inhibitor elimination. The present review explains basic concepts in protease biochemistry of importance to understand clinical conditions with extensive protease activation.
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81
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Tillman B, Gailani D. Inhibition of Factors XI and XII for Prevention of Thrombosis Induced by Artificial Surfaces. Semin Thromb Hemost 2017; 44:60-69. [PMID: 28898903 DOI: 10.1055/s-0037-1603937] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Exposure of blood to a variety of artificial surface induces contact activation, a process that contributes to the host innate response to foreign substances. On the foreign surface, the contact factors, factor XII (FXII), and plasma prekallikrein undergo reciprocal conversion to their fully active protease forms (FXIIa and α-kallikrein, respectively) by a process supported by the cofactor high-molecular-weight kininogen. Contact activation can trigger blood coagulation by conversion of factor XI (FXI) to the protease FXIa. There is interest in developing therapeutic inhibitors to FXIa and FXIIa because these activated factors can contribute to thrombosis in certain situations. Drugs targeting these proteases may be particularly effective in thrombosis triggered by exposure of blood to the surfaces of implantable medical devices. Here, we review clinical data supporting roles for FXII and FXI in thrombosis induced by medical devices, and preclinical data suggesting that therapeutic targeting of these proteins may limit surface-induced thrombosis.
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Affiliation(s)
- Benjamin Tillman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Gailani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
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82
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Cavalca V, Rocca B, Veglia F, Petrucci G, Porro B, Myasoedova V, De Cristofaro R, Turnu L, Bonomi A, Songia P, Cavallotti L, Zanobini M, Camera M, Alamanni F, Parolari A, Patrono C, Tremoli E. On-pump Cardiac Surgery Enhances Platelet Renewal and Impairs Aspirin Pharmacodynamics: Effects of Improved Dosing Regimens. Clin Pharmacol Ther 2017; 102:849-858. [DOI: 10.1002/cpt.702] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 03/27/2017] [Accepted: 03/29/2017] [Indexed: 12/11/2022]
Affiliation(s)
- V Cavalca
- Monzino Cardiology Center, IRCCS; Milan Italy
- University of Milan; Milan Italy
| | - B Rocca
- Department of Pharmacology; Catholic University; Rome Italy
| | - F Veglia
- Monzino Cardiology Center, IRCCS; Milan Italy
| | - G Petrucci
- Department of Pharmacology; Catholic University; Rome Italy
| | - B Porro
- Monzino Cardiology Center, IRCCS; Milan Italy
| | | | | | - L Turnu
- Monzino Cardiology Center, IRCCS; Milan Italy
- University of Milan; Milan Italy
| | - A Bonomi
- Monzino Cardiology Center, IRCCS; Milan Italy
| | - P Songia
- Monzino Cardiology Center, IRCCS; Milan Italy
- University of Milan; Milan Italy
| | | | - M Zanobini
- Monzino Cardiology Center, IRCCS; Milan Italy
| | - M Camera
- Monzino Cardiology Center, IRCCS; Milan Italy
- University of Milan; Milan Italy
| | - F Alamanni
- Monzino Cardiology Center, IRCCS; Milan Italy
- University of Milan; Milan Italy
| | - A Parolari
- Policlinico San Donato Hospital, IRCCS; San Donato Milanese Italy
| | - C Patrono
- Department of Pharmacology; Catholic University; Rome Italy
| | - E Tremoli
- Monzino Cardiology Center, IRCCS; Milan Italy
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83
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Tang M, Fenger-Eriksen C, Wierup P, Greisen J, Ingerslev J, Hjortdal V, Sørensen B. Rational and timely haemostatic interventions following cardiac surgery - coagulation factor concentrates or blood bank products. Thromb Res 2017; 154:73-79. [DOI: 10.1016/j.thromres.2017.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 02/18/2017] [Accepted: 04/04/2017] [Indexed: 01/08/2023]
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84
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Levy JH, Ghadimi K, Quinones QJ, Bartz RR, Welsby I. Adjuncts to Blood Component Therapies for the Treatment of Bleeding in the Intensive Care Unit. Transfus Med Rev 2017; 31:258-263. [PMID: 28552276 DOI: 10.1016/j.tmrv.2017.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/11/2017] [Accepted: 04/21/2017] [Indexed: 11/19/2022]
Abstract
Patients who are critically ill following surgical or traumatic injury often present with coagulopathy as a component of the complex multisystem dysfunction that clinicians must rapidly diagnose and treat in the intensive care environment. Failure to recognize coagulopathy while volume resuscitation with crystalloid or colloid takes place, or an unbalanced transfusion strategy focused on packed red blood cell transfusion can all significantly worsen coagulopathy, leading to increased transfusion requirements and poor outcomes. Even an optimized transfusion strategy directed at correcting coagulopathy and maintaining clotting factor levels carries the risk of a number of transfusion reactions including transfusion-related acute lung injury, transfusion-related circulatory overload, anaphylaxis, and septic shock. A number of adjunctive strategies can be used either to augment a balanced transfusion approach or as alternatives to blood component therapy. Coupled with an appropriate and timely laboratory testing, this approach can quickly diagnose a patient's specific coagulopathy and work to correct it as quickly as possible, minimizing the requirement of blood transfusion and the pathophysiologic effects of excessive bleeding and fibrinolysis. We will review the literature supporting this approach and provide insight into how these approaches can be best used to care for bleeding patients in the intensive care unit. Finally, the increasing use of several novel oral anticoagulants, novel antiplatelet drugs, and low-molecular weight heparin to clinical practice has complicated the care of the coagulopathic patient when these drugs are involved. Many clinicians familiar with heparin and warfarin reversal are not familiar with the optimal way to reverse the action of these new drugs. Patients treated with these drugs for a wide variety of conditions including atrial fibrillation, stroke, coronary artery stent, deep venous thrombosis, and pulmonary embolism will present for emergency surgery and will require management of pharmacologically induced postoperative coagulopathy. We will discuss optimized strategies for reversal of these agents and strategies that are currently under development.
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Affiliation(s)
- Jerrold H Levy
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC.
| | - Kamrouz Ghadimi
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
| | - Quintin J Quinones
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
| | - Raquel R Bartz
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
| | - Ian Welsby
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
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85
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Choi YJ, Yoon SZ, Joo BJ, Lee JM, Jeon YS, Lim YJ, Lee JH, Ahn H. [Postoperative excessive blood loss after cardiac surgery can be predicted with International Society on Thrombosis and Hemostasis scoring system]. Rev Bras Anestesiol 2017; 67:508-515. [PMID: 28551057 DOI: 10.1016/j.bjan.2016.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 12/30/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Prediction of postoperative excessive blood loss is useful for management of Intensive Care Unit after cardiac surgery. The aim of present study was to examine the effectiveness of International Society on Thrombosis and Hemostasis scoring system in patients with cardiac surgery. METHOD After obtaining approval from the institutional review board, the medical records of patients undergoing elective cardiac surgery using Cardio-Pulmonary Bypass between March 2010 and February 2014 were retrospectively reviewed. International Society on Thrombosis and Hemostasis score was calculated in intensive care unit and patients were divided with overt disseminated intravascular coagulation group and non-overt disseminated intravascular coagulation group. To evaluate correlation with estimated blood loss, student t-test and correlation analyses were used. RESULTS Among 384 patients with cardiac surgery, 70 patients with overt disseminated intravascular coagulation group (n=20) or non-overt disseminated intravascular coagulation group (n=50) were enrolled. Mean disseminated intravascular coagulation scores at intensive care unit admission was 5.35±0.59 (overt disseminated intravascular coagulation group) and 2.66±1.29 (non-overt disseminated intravascular coagulation group) and overt disseminated intravascular coagulation was induced in 29% (20/70). Overt disseminated intravascular coagulation group had much more EBL for 24h (p=0.006) and maintained longer time of intubation time (p=0.005). CONCLUSION In spite of limitation of retrospective design, management using International Society on Thrombosis and Hemostasis score in patients after cardiac surgery seems to be helpful for prediction of the post- cardio-pulmonary bypass excessive blood loss and prolonged tracheal intubation duration.
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Affiliation(s)
- Yoon Ji Choi
- Pusan National University, Yangsan Hospital, Department of Anesthesiology and Pain Medicine, Yangsan, Gyeongsangnam-do, Coreia do Sul
| | - Seung Zhoo Yoon
- Korea University, College of Medicine, Department of Anesthesiology and Pain Medicine, Seoul, Coreia do Sul.
| | - Beom Joon Joo
- Korea University, College of Medicine, Department of Anesthesiology and Pain Medicine, Seoul, Coreia do Sul
| | - Jung Man Lee
- Seoul National University, Boramae Medical Center, Department of Anesthesiology and Pain Medicine, Seoul, Coreia do Sul
| | - Yun-Seok Jeon
- Seoul National University, College of Medicine, Department of Anesthesiology and Pain Medicine, Seoul, Coreia do Sul
| | - Young Jin Lim
- Seoul National University, College of Medicine, Department of Anesthesiology and Pain Medicine, Seoul, Coreia do Sul
| | - Jong Hwan Lee
- SeongGyunKwan University, College of Medicine, Department of Anesthesiology and Pain Medicine, Seoul, Coreia do Sul
| | - Hyuk Ahn
- Seoul National University, College of Medicine, Department of Thoracic & Cardiovascular Surgery, Seoul, Coreia do Sul
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86
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Sharma R, Letson HL, Smith S, Dobson GP. Tranexamic acid leads to paradoxical coagulation changes during cardiac surgery: a pilot rotational thromboelastometry study. J Surg Res 2017; 217:100-112. [PMID: 28602219 DOI: 10.1016/j.jss.2017.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/19/2017] [Accepted: 05/01/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is increasingly used during major surgery with the goal to reduce excessive bleeding, transfusion requirements, and reexploration. Our aim was to examine the effect of TXA on coagulation at different times during cardiac surgery using rotational thromboelastometry. MATERIALS AND METHODS Nineteen adult males (EuroSCORE 4-5) were recruited consecutively for first-time cardiopulmonary bypass (CPB) surgery. Ten patients received TXA at anesthesia and nine received no TXA. Rotational thromboelastometry analysis occurred before anesthesia (baseline), after sternotomy, after CPB-heparinization and surgery, and after protamine administration-sternal closure. RESULTS A median sternotomy had no effect on clot time (CT), formation, amplitude, or lysis in non-TXA patients. In contrast, TXA patients had twofold prolonged clotting time (all-tests) and ∼30% reduced FIBTEM (A5-30) and maximum clot firmness, indicating reduced thrombin generation and lower clot fibrinogen. After CPB, CTs in both groups were prolonged, possibly linked to overheparinization. In addition, TXA patients had significantly decreased EXTEM (A5-30), suggesting lower clot strength. After protamine-sternal closure, clotting time remained prolonged in both groups, and TXA patients had a persistently 25%-33% lower FIBTEM (A5-30) and maximum clot firmness. TXA patients also had significantly reduced platelet numbers (37% from baseline), which continued Days 1 and 2. Maximum clot lysis was <10% indicating little or no hyperfibrinolysis during cardiac surgery. CONCLUSIONS In this nonrandomized, nonblinded, observational trial, patients in the TXA group displayed prolonged CTs and clot fibrinogen (FIBTEM A5-30) after sternotomy, decreased clot strength (EXTEM) after CPB/surgery, and acute thrombocytopenia after protamine-sternal closure. There was no significant decrease in clot lysis, questioning the need for TXA in this medium-risk group.
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Affiliation(s)
- Rajiv Sharma
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Australia
| | - Hayley L Letson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Australia
| | - Samuel Smith
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Australia
| | - Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Australia.
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87
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Smith BB, Nuttall GA, Pruthi RK, Joyce DL, Schuldes MS, Smith MM. A Novel Approach to Essential Thrombocythemia and Cardiac Surgery. Ann Thorac Surg 2017; 103:e249-e250. [DOI: 10.1016/j.athoracsur.2016.08.065] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/08/2016] [Accepted: 08/18/2016] [Indexed: 10/20/2022]
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88
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Outcomes of Trainees Performing Coronary Artery Bypass Grafting: Does Resident Experience Matter? Ann Thorac Surg 2017; 103:975-981. [DOI: 10.1016/j.athoracsur.2016.10.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 09/05/2016] [Accepted: 10/07/2016] [Indexed: 11/21/2022]
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89
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Desborough MJR, Oakland KA, Landoni G, Crivellari M, Doree C, Estcourt LJ, Stanworth SJ. Desmopressin for treatment of platelet dysfunction and reversal of antiplatelet agents: a systematic review and meta-analysis of randomized controlled trials. J Thromb Haemost 2017; 15:263-272. [PMID: 27893176 DOI: 10.1111/jth.13576] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Indexed: 01/02/2023]
Abstract
Essentials The optimal management of patients with platelet dysfunction undergoing surgery is unclear. This meta-analysis compared perioperative administration of desmopressin to placebo. Desmopressin reduced red cell transfusions, blood loss and risk of re-operation due to bleeding. There were too few events to determine if there was a change in the risk of thrombotic events. SUMMARY Background Platelet dysfunction, including that caused by antiplatelet agents, increases the risk of perioperative bleeding. The optimal management of patients with platelet dysfunction undergoing surgery is unclear. Objectives To assess whether desmopressin reduces perioperative allogeneic red cell transfusion and bleeding in patients with platelet dysfunction. Patients/Methods We searched for randomized controlled trials in The Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Embase, the Transfusion Evidence Library and the ISI Web of Science to 7th July 2016. Data were pooled using mean difference (MD), relative risks or Peto odds ratios (pOR) using a random-effects model. Results Ten trials with 596 participants were identified, all in the setting of cardiac surgery. Platelet dysfunction was due to antiplatelet agents in six trials and cardiopulmonary bypass in four trials. Patients treated with desmopressin were transfused with fewer red cells (MD, -0.65 units; 95% Confidence Interval [CI], -1.16 to -0.13 units), lost less blood (MD, -253.93 mL; 95% CI, -408.01 to -99.85 mL) and had a lower risk of re-operation due to bleeding (pOR, 0.39; 95% CI, 0.18-0.84). The GRADE quality of evidence was very low to moderate, suggesting considerable uncertainty over the results Conclusions Desmopressin may be a useful agent to reduce bleeding and transfusion requirements for people with platelet dysfunction or with a history of recent antiplatelet drug administration undergoing cardiac surgery.
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Affiliation(s)
- M J R Desborough
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
- Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - K A Oakland
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
- Department of Colorectal Surgery, Oxford University Hospitals NHS Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - G Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - M Crivellari
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - C Doree
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - L J Estcourt
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
- Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
| | - S J Stanworth
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
- Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford, UK
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90
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Gautam NK, Cai C, Pawelek O, Rafique MB, Cattano D, Pivalizza EG. Performance of functional fibrinogen thromboelastography in children undergoing congenital heart surgery. Paediatr Anaesth 2017; 27:181-189. [PMID: 27901294 DOI: 10.1111/pan.13048] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Functional Fibrinogen assay of the Thromboelastography (FFTEG), a whole blood viscoelastic hemostatic assay, has been used to estimate fibrinogen levels in adult patients undergoing major surgery but its performance in pediatric patients undergoing cardiac surgery requires evaluation. In this study, we evaluate the correlation between FFTEG parameters and standard laboratory tests for fibrinogen and platelet counts before and after cardiopulmonary bypass in children undergoing repair for congenital heart disease. METHODS In this prospective observational study, whole blood samples were obtained from children less than 5 years of age undergoing congenital heart surgery with cardiopulmonary bypass before surgical incision and immediately after administration of protamine. Blood samples were analyzed for Thromboelastography, Functional Fibrinogen level measured by FFTEG (FLEV), complete blood counts with platelet count and plasma fibrinogen assay (LFib, Clauss). The primary outcome of this study was to assess the correlation between FFTEG parameters, LFib and platelet counts in neonates, infants, and small children less than 5 years old. Additionally, we studied if postbypass FFTEG parameters could predict critical thresholds of hypofibrinogenemia LFib ≤200 mg·dl-1 . RESULTS One hundred and five children (22 neonates, 51 infants, and 32 small children) were included in the final analysis. FLEV estimated higher fibrinogen levels than LFib in all patients. Before bypass, FLEV was on average 133 mg·dl-1 higher than LFib (95% confidence interval, CI, 116-150, P < 0.001) for all the patients; after bypass, FLEV was 48 mg·dl-1 (95% CI: 37-59, P < 0.001) higher than LFib for all the patients. Linear correlation coefficients between FLEV and LFib in all patients were R = 0.41 (95% CI: 0.24-0.56, P < 0.001) before bypass and increased to R = 0.63 (95% CI: 0.51-0.74, P < 0.001) after bypass. Bland Altman analysis performed on postbypass values of FLEV and LFib showed a positive bias of FLEV in estimation of LFib. The magnitude and the variability of the bias for all the patients group was decreased with lower mean of the difference of FLEV and LFib when the average values of FLEV and LFib were <200 mg·dl-1 . Low linear correlations were noticed between maximal amplitude of platelet contribution to FFTEG and platelet counts both before and after bypass. For predicting the clinical thresholds of postbypass hypofibrinogenemia at plasma fibrinogen levels ≤200 mg·dl-1 , FLEV and maximal amplitude of the fibrinogen clot generated area under receiver operative curves at 0.90 (95% CI = 0.76-1.0) in neonates, 0.6 (95% CI- 0.42-0.78) in infants, and 0.97 (95% CI = 0.91-1.0) in small children. Based on the receiver operative curves, values of postbypass hypofibrinogenemia with LFib ≤200 g·dl-1 corresponded to cutoffs of FLEVPOST ≤245 mg·dl-1 and maximal amplitude of the fibrinogen clot ≤13.4 mm. CONCLUSION In pediatric patients undergoing cardiac surgery, FLEV derived from Functional Fibrinogen correlated linearly with plasma fibrinogen levels (Clauss) both before and after CPB. FLEV estimation of plasma fibrinogen was improved after CPB in neonates, infants, and small children. After CPB, FFTEG can be used to predict laboratory diagnosis of critical hypofibrinogenemia (≤200 mg·dl-1 ) during pediatric cardiac surgery. Further studies are required to assess the impact of predictability of FFTEG on component transfusion during pediatric cardiac surgery.
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Affiliation(s)
- Nischal K Gautam
- Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA
| | - Chunyan Cai
- Center for Clinical and Translational Sciences, The University of Texas Medical School, Houston, TX, USA
| | - Olga Pawelek
- Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA
| | - Muhammad B Rafique
- Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA
| | - Davide Cattano
- Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA
| | - Evan G Pivalizza
- Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA
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91
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Abstract
Plasma prekallikrein is the liver-derived precursor of the trypsin-like serine protease plasma kallikrein, and circulates in plasma bound to high molecular weight kininogen. Plasma prekallikrein is activated to plasma kallikrein by activated factor XII or prolylcarboxypeptidase. Plasma kallikrein regulates the activity of multiple proteolytic cascades in the cardiovascular system such as the intrinsic pathway of coagulation, the kallikrein-kinin system, the fibrinolytic system, the renin-angiotensin system, and the complement pathways. As such, plasma kallikrein plays a central role in the pathogenesis of thrombosis, inflammation, and blood pressure regulation. Under physiological conditions, plasma kallikrein serves as a cardioprotective enzyme. However, its increased plasma concentration or hyperactivity perpetuates cardiovascular disease (CVD). In this article, we review the biochemistry and cell biology of plasma kallikrein and summarize data from preclinical and clinical studies that have established important functions of this serine protease in CVD states. Finally, we propose plasma kallikrein inhibitors as a novel class of drugs with potential therapeutic applications in the treatment of CVDs.
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92
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Song ST, Bai CM, Zhou JW. Serum TNF-α levels in children with congenital heart disease undergoing cardiopulmonary bypass: A cohort study in China and a meta-analysis of the published literature. J Clin Lab Anal 2016; 31. [PMID: 27957762 DOI: 10.1002/jcla.22112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/14/2016] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To investigate the changes in tumor necrosis factor alpha (TNF-α) serum levels after cardiopulmonary bypass (CPB) in children with congenital heart disease (CHD), followed by a meta-analysis to analyze the clinical value of TNF-α in CPB. METHODS Our cohort study enrolled 67 CHD children, assigned into off-pump group (n=32) and CPB group (n=35). The TNF-α serum levels in two groups were detected by ELISA before the operation (T1), at the end of the operation (0 hour, T2), and after 24 hours of the operation (T3). For meta-analysis, literature search was conducted to identify published case-control articles about the changes of TNF-α serum levels with CPB of CHD. RESULTS The TNF-α levels in CPB group were lower than that in the off-pump group at T3 (P=.006). TNF-α level at T3 was significantly lower than that at T1 and T2 (all P<.05). Meta-analysis results further confirmed that the TNF-α levels of CHD children were dramatically decreased at T3 as compared to that at T1 and T2 (both P<.001). CONCLUSION The TNF-α serum levels showed a transient and dramatic decline after 24 hours of CPB, and it may act as an important biological indicator for monitoring the efficacy of CPB in CHD children.
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Affiliation(s)
- Shu-Tian Song
- Department of Cardiothoracic Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Chuan-Ming Bai
- Department of Cardiothoracic Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Ji-Wu Zhou
- Department of Cardiothoracic Surgery, Cangzhou Central Hospital, Cangzhou, China
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93
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Shen S, Zhang J, Wang W, Zheng J, Xie Y. Impact of intra-operative cell salvage on blood coagulation in high-bleeding-risk patients undergoing cardiac surgery with cardiopulmonary bypass: a prospective randomized and controlled trial. J Transl Med 2016; 14:228. [PMID: 27473326 PMCID: PMC4966771 DOI: 10.1186/s12967-016-0986-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 07/20/2016] [Indexed: 02/06/2023] Open
Abstract
Background Intra-operative cell salvage (CS) was reported to have no impairment on blood coagulation in low-bleeding-risk cardiac surgery with cardiopulmonary bypass (CPB), but studies in high-bleeding-risk cardiac surgery are limited. The objective of this study is to evaluate the impact of CS on blood coagulation in high-bleeding-risk cardiac surgery with CPB. Methods One hundred and ten patients were randomly assigned to either with intra-operative CS group (Group CS) or without intra-operative CS group (Group C). Study endpoints included the incidence of impairment of blood coagulation during perioperative period (peri-op) and the incidence of adverse events during postoperative period (post-op). Peri-op was defined as the period from beginning of anesthesia (anesthesia induction) to 24 h after end of surgery. Post-op was defined as the period from the end of surgery to 24 h after end of surgery. The types of impairment of blood coagulation included heparin residual, coagulopathy due to low PLT, coagulopathy due to low FIB, coagulopathy due to low coagulation factors, hyperfibrinolytic. The sum of above five types was total impairment of blood coagulation. Adverse events included excessive bleeding, resternotomy, etc. Results The incidence of heparin residual measured both at the end of surgery and during post-op were significantly higher in Group CS than in Group C (15.09 vs 4.00, 13.21 vs 2.00 %; p = 0.024, 0.010, respectively). Similarly, the incidence of total impairment of blood coagulation at the end of surgery and during post-op were significantly higher in Group CS than in Group C (32.08 vs 18.00, 26.42 vs 12.00 %; p = 0.043, 0.040, respectively). The incidence of excessive bleeding during post-op was 32.08 % in Group CS compared with 16.00 % in Group C (p = 0.038). Intriguingly, CS was associated with a significantly increase in the relative risk ratios for heparin residual and excessive bleeding (p = 0.034, 0.049, respectively). Conclusions Intra-operative CS could impair blood coagulation in the scenario of high-risk-bleeding cardiac surgery with CPB.
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Affiliation(s)
- Sheliang Shen
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, China.
| | - Jun Zhang
- Department of Orthopedics, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, China
| | - Wenyuan Wang
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, China
| | - Jiayin Zheng
- Department of Probability and Statistics, School of Mathematical Sciences, Beijing University, Beijing, China
| | - Yihong Xie
- Department of Cardiothoracic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, China
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94
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Höfer J, Fries D, Solomon C, Velik-Salchner C, Ausserer J. A Snapshot of Coagulopathy After Cardiopulmonary Bypass. Clin Appl Thromb Hemost 2016; 22:505-11. [DOI: 10.1177/1076029616651146] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cardiac surgery involving cardiopulmonary bypass (CPB) is often associated with important blood loss, allogeneic blood product usage, morbidity, and mortality. Coagulopathy during CPB is complex, and the current lack of uniformity for triggers and hemostatic agents has led to a wide variability in bleeding treatment. The aim of this review is to provide a simplified picture of the data available on patients’ coagulation status at the end of CPB in order to provide relevant information for the development of tailored transfusion algorithms. A nonsystematic literature review was carried out to identify changes in coagulation parameters during CPB. Both prothrombin time and activated partial thromboplastin time increased during CPB, by a median of 33.3% and 17.9%, respectively. However, there was marked variability across the published studies, indicating these tests may be unreliable for guiding hemostatic therapy. Some thrombin generation (TG) parameters were affected, as indicated by a median increase in TG lag time of 55.0%, a decrease in TG peak of 17.5%, and only a slight decrease in endogenous thrombin potential of 7%. The most affected parameters were fibrinogen levels and platelet count/function. Both plasma fibrinogen concentration and FIBTEM maximum clot firmness decreased during CPB (median change of 36.4% and 33.3%, respectively) as did platelet count (44.5%) and platelet component (34.2%). This review provides initial information regarding changes in coagulation parameters during CPB but highlights the variability in the reported results. Further studies are warranted to guide physicians on the parameters most appropriate to guide hemostatic therapy.
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Affiliation(s)
- Judith Höfer
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Dietmar Fries
- Department of Surgical and General Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Cristina Solomon
- Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria
- CSL Behring, Marburg, Germany
| | - Corinna Velik-Salchner
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Julia Ausserer
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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95
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Dzemali O, Ganter MT, Zientara A, Graves K, Behr R, Genoni M, Hofer CK. Evaluation of a New Sonoclot Device for Heparin Management in Cardiac Surgery. Clin Appl Thromb Hemost 2016; 23:20-26. [DOI: 10.1177/1076029616651148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Sonoclot is used to measure kaolin-based activated clotting time (kACT) for heparin management. Apart from measuring kACT, the device assesses the patient’s coagulation status by glass bead–activated tests (gbACTs; measuring also clot rate [CR] and platelet function [PF]). Recently, a new version of the Sonoclot has been released, and the redesign may result in performance changes. The aim of this study was to evaluate and compare the performance of the new (S2) and the previous (S1) Sonoclot. Methods: The S1 was used in the routine management of 30 patients undergoing elective cardiac surgery. Blood samples were taken at baseline (T1), after heparin administration (200 U/kg, 100 U/kg; T2 and T3), during cardiopulmonary bypass (T4), after protamine infusion (T5), and before intensive care unit transfer (T6). Kaolin-based activated clotting time and gbACTs were measured in duplicate by both the old and the new device and performance compared by Bland-Altman analysis and percentage error calculation. Results: A total of 300 kACT and 180 gbACTs were available. Bland-Altman analysis for kACT revealed that S2 consistently reported results in shorter time compared to S1 (overall = −14.7%). Comparing S2 and S1, the glass bead–activated tests showed mean percentage differences of −18.9% (gbACTs), +37.4% (CR), and −3.7% (PF). Conclusion: Since clotting is faster in the new S2 compared to S1, shorter clotting times have to be considered in clinical practice. The use of S2 kACT in heparin management will result in higher heparin and protamine dosing unless heparin kACT target values are adjusted to correct for the differences in results between S1 and S2.
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Affiliation(s)
- Omer Dzemali
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Michael T. Ganter
- Institute of Anaesthesiology and Pain Medicine, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Alicja Zientara
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Kirk Graves
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Renate Behr
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Michele Genoni
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Christoph K. Hofer
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli City Hospital, Zurich, Switzerland
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96
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Gorki H, Hoenicka M, Rupp P, Müller-Eising K, Deininger S, Kunert A, Liebold A. Similarity of coagulation and inflammation despite different surgical revascularization strategies – a prospective randomized trial. Perfusion 2016; 31:640-647. [DOI: 10.1177/0267659116649426] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Supposedly, minimized extracorporeal circulation or off-pump revascularization as alternatives to conventional extracorporeal circulation (ONCAB) reduce inflammation and coagulation disturbances. Methods: One hundred and twenty coronary artery bypass graft (CABG) patients were prospectively randomized for three surgical techniques. Coagulation and inflammation markers were measured up to 72 hours postoperatively. Results: Coagulation factors I, II, V, X, antithrombin III and C-reactive protein did not differ perioperatively between the groups and increased, as did several other markers, 12 to 72 hours postoperatively. Compared to its alternatives, ONCAB showed the most obvious transient increase in thrombin-antithrombin complexes (p<0.0001), D-dimers (p=0.0059), tissue factor pathway inhibitor (p=0.0005), factor VIII (p=0.0041) and tumor necrosis factor α (p=0.0300) during the operation and up to 12 hours postoperatively. Furthermore, ONCAB generated lower leukocyte and platelet counts and higher values of soluble P-selectin and soluble intercellular adhesion molecule 1 at some time points. Conclusions: With similarity in pivot coagulation factors, a specific detrimental influence of ONCAB on common coagulation pathways was excluded. Higher perioperative concentrations of products from the coagulation cascade most likely indicate activation of pericardial blood – recirculated only in ONCAB. Furthermore, with only temporary differences in markers of inflammation, the alternatives to ONCAB altogether were without advantage at 72 hours postoperatively. In the general answer to surgical trauma, the part of modern extracorporeal circulation is possibly overestimated. The study is registered at the German Clinical Trial Registry. Registration number DRKS00007580. URL: https://drks-neu.uniklinik-freiburg.de/drks_web/ URL: http://apps.who.int/trialsearch/
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Affiliation(s)
- Hagen Gorki
- Department of Cardiothoracic and Vascular Surgery, University of Ulm, Ulm, Germany
| | - Markus Hoenicka
- Department of Cardiothoracic and Vascular Surgery, University of Ulm, Ulm, Germany
| | - Patricia Rupp
- Department of Cardiothoracic and Vascular Surgery, University of Ulm, Ulm, Germany
| | | | - Stefanie Deininger
- Department of Cardiothoracic and Vascular Surgery, University of Ulm, Ulm, Germany
| | - Andreas Kunert
- Department of Cardiothoracic and Vascular Surgery, University of Ulm, Ulm, Germany
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, University of Ulm, Ulm, Germany
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97
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Qin C, Gu J, Hu J, Qian H, Fei X, Li Y, Liu R, Meng W. Platelets activation is associated with elevated plasma mitochondrial DNA during cardiopulmonary bypass. J Cardiothorac Surg 2016; 11:90. [PMID: 27266529 PMCID: PMC4895797 DOI: 10.1186/s13019-016-0481-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/17/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Mitochondrial DNA (mtDNA) was reported as a pro-inflammatory agent. In our previous study, elevation of plasma mtDNA was revealed after cardiac surgery with cardiopulmonary bypass (CPB). Platelets were activated during the cardiac surgery and recent study revealed its ability to release mtDNA. Our present study postulated that the elevated plasma mtDNA comes from activated platelets, which plays a critical role in post-CPB inflammatory responses. METHODS Sixty-eight patients who underwent coronary artery bypass graft (CABG) with CPB were enrolled in our study. Blood samples were collected before induction of anaesthesia (T1), at the end of CPB (T2), 12 h post-CPB (T3), 24 h post-CPB (T4), 48 h post-CPB (T5) and 72 h post-CPB (T6). Blood samples were analyzed for the routine blood test and prepared for plasma isolation. MtDNA concentration was measured by rt-PCR, and TNF-α and IL-6 were examined by specific ELISA kits. Subgroup study was analyzed by activation levels of platelet. Basic information, mtDNA level, TNF-α level and IL-6 level were all carefully studied in each quartile. RESULTS Activation level of platelets increased and peaked at T2, which decreased gradually from T3 to T6 (P < 0.05). MtDNA increased after CPB, peaked at T3, and then backed from T4 to T6 (P < 0.05). Bivariate correlation between peak activation level of platelets and peak plasma mtDNA level showed a positive correlation between these two parameters (r = 0.683, P < 0.0001). Both TNF-α and IL-6 showed similar patterns as mtDNA, with an increase from T1 to T3 and a decrease from T4 to T6 (P < 0.05). Subgroup analysis further demonstrated that patients with higher activation levels of PLT had higher plasma mtDNA levels and inflammatory level (P < 0.05). CONCLUSIONS Our study revealed the dynamic changes of activation level of platelets and identified the interesting association between platelets activation and plasma mtDNA, suggesting a novel potential mechanism of activated platelets-induced post-CPB inflammatory responses.
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Affiliation(s)
- Chaoyi Qin
- Department of Cardiovascular Surgery, West China Hospital, Si Chuan University, Guo Xue Alley 37, Cheng du, Sichuan, 610041, People's Republic of China
| | - Jun Gu
- Department of Cardiovascular Surgery, West China Hospital, Si Chuan University, Guo Xue Alley 37, Cheng du, Sichuan, 610041, People's Republic of China
| | - Jia Hu
- Department of Cardiovascular Surgery, West China Hospital, Si Chuan University, Guo Xue Alley 37, Cheng du, Sichuan, 610041, People's Republic of China
| | - Hong Qian
- Department of Cardiovascular Surgery, West China Hospital, Si Chuan University, Guo Xue Alley 37, Cheng du, Sichuan, 610041, People's Republic of China
| | - Xu Fei
- Department of Anesthesiology, Chengdu Women and Children's Central Hospital, Chengdu, People's Republic of China
| | - Yajiao Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Ruiqi Liu
- Department of Burns and Plastic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Wei Meng
- Department of Cardiovascular Surgery, West China Hospital, Si Chuan University, Guo Xue Alley 37, Cheng du, Sichuan, 610041, People's Republic of China.
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98
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Chowdhry V, Padhi M, Biswal S, Mohanty BB. Perioperative Management of Mitral Valve Replacement in an Individual With Bombay Phenotype. J Cardiothorac Vasc Anesth 2016; 30:1337-9. [PMID: 27039113 DOI: 10.1053/j.jvca.2015.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Suvakanta Biswal
- Cardiothoracic and Vascular Surgery, CARE Hospital, Bhubaneswar, Odisha, India
| | - B B Mohanty
- Cardiothoracic and Vascular Surgery, CARE Hospital, Bhubaneswar, Odisha, India
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99
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May F, Krupka J, Fries M, Thielmann I, Pragst I, Weimer T, Panousis C, Nieswandt B, Stoll G, Dickneite G, Schulte S, Nolte MW. FXIIa inhibitor rHA-Infestin-4: Safe thromboprotection in experimental venous, arterial and foreign surface-induced thrombosis. Br J Haematol 2016; 173:769-78. [DOI: 10.1111/bjh.13990] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/04/2015] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | - Ina Thielmann
- Chair of Vascular Medicine; University Hospital Wuerzburg and Rudolf Virchow Centre for Experimental Biomedicine; Wuerzburg Germany
| | | | | | - Con Panousis
- CSL Limited; Bio21 Institute; Parkville Victoria Australia
| | - Bernhard Nieswandt
- Chair of Vascular Medicine; University Hospital Wuerzburg and Rudolf Virchow Centre for Experimental Biomedicine; Wuerzburg Germany
| | - Guido Stoll
- Department of Neurology; University Hospital Wuerzburg; Wuerzburg Germany
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100
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Mazzeffi M, Lund L, Wallace K, Herrera AV, Tanaka K, Odonkor P, Strauss E, Rock P, Fiskum G. Effect of cardiopulmonary bypass on platelet mitochondrial respiration and correlation with aggregation and bleeding: a pilot study. Perfusion 2016; 31:508-15. [PMID: 26916901 DOI: 10.1177/0267659116634830] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) may cause platelet dysfunction, contributing to bleeding. There are no investigations of how CPB affects platelet mitochondrial respiration and what correlation this has with platelet aggregation and bleeding. METHODS We studied platelet mitochondrial respiration and aggregation in eighteen adult cardiac surgery patients having CPB. The relationships between respiration, aggregation and postoperative bleeding were analyzed. RESULTS Platelet respiration, reflected by the respiratory control ratio (RCR), was unchanged after CPB (mean difference in RCR= -0.02 (95% CI=-1.45 to 1.42), p=0.98). Further, there were no significant relationships between indexed adenosine diphosphate (ADP) or thrombin receptor-activating peptide (TRAP)-induced aggregation and the RCR (p=0.12 and p=0.41). Only post-CPB ADP - induced aggregation correlated with 24-hr chest tube output (p=0.04), but indexing for platelet count attenuated the effect (p=0.07). CONCLUSION Platelet mitochondrial respiration is preserved after CPB and is not correlated with aggregation or bleeding. Only post-CPB, ADP-induced aggregation correlates with postoperative bleeding.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lindsey Lund
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Karin Wallace
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Kenichi Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Patrick Odonkor
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Erik Strauss
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Peter Rock
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gary Fiskum
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
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