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Kawanishi H, Koremoto M, Franssen CFM, van Londen M. Clotting Propensity of Surface-Treated Membranes in a Hemodialysis Set-up That Avoids Systemic Anticoagulation. Semin Nephrol 2023; 43:151482. [PMID: 38262850 DOI: 10.1016/j.semnephrol.2023.151482] [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] [Indexed: 01/25/2024]
Abstract
The development of biocompatible membranes, aiming to limit the inflammatory response, oxidative stress, and coagulability during hemodialysis, has been an important step in reducing dialysis-related adverse outcomes. This includes a reduction in the risk of clotting of the extracorporeal circuit, thus enabling hemodialysis with a reduced dose or even without systemic anticoagulant drugs in patients with an increased bleeding risk. In this article, we summarize the in vitro research and clinical evidence on the antithrombotic properties of vitamin E- and heparin-coated membranes.
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Affiliation(s)
| | | | - Casper F M Franssen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
| | - Marco van Londen
- Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Dekker NA, Veerhoek D, van Leeuwen AL, Vonk AB, van den Brom CE, Boer C. Microvascular Alterations During Cardiac Surgery Using a Heparin or Phosphorylcholine-Coated Circuit. J Cardiothorac Vasc Anesth 2020; 34:912-919. [DOI: 10.1053/j.jvca.2019.10.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/30/2019] [Accepted: 10/06/2019] [Indexed: 02/02/2023]
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Ontaneda A, Annich GM. Novel Surfaces in Extracorporeal Membrane Oxygenation Circuits. Front Med (Lausanne) 2018; 5:321. [PMID: 30525038 PMCID: PMC6256321 DOI: 10.3389/fmed.2018.00321] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 10/30/2018] [Indexed: 01/01/2023] Open
Abstract
The balance between systemic anticoagulation and clotting is challenging. In normal hemostasis, the endothelium regulates the balance between anticoagulant and prothrombotic systems. It becomes particularly more challenging to maintain this physiologic hemostasis when we are faced with extracorporeal life support therapies, where blood is continuously in contact with a foreign extracorporeal circuit surface predisposing a prothrombotic state. The blood-surface interaction during extracorporeal life support therapies requires the use of systemic anticoagulation to decrease the risk of clotting. Unfractionated heparin is the most common anticoagulant agent widely used in this setting. New trends include the use of direct thrombin inhibitor agents for systemic anticoagulation; and surface modifications that aim to overcome the blood-biomaterial surface interaction by modifying the hydrophilicity or hydrophobicity of the polymer surface; and coating the circuit with substances that will mimic the endothelium or anti-thrombotic agents. To improve hemocompatibility in an extracorporeal circuit, replication of the anti-thrombotic and anti-inflammatory properties of the endothelium is ideal. Surface modifications can be classified into three major groups: biomimetic surfaces (heparin, nitric oxide, and direct thrombin inhibitors); biopassive surfaces [phosphorylcholine, albumin, and poly- 2-methoxyethylacrylate]; and endothelialization of blood contacting surface. The focus of this paper will be to review both present and future novel surface modifications that can obviate the need for systemic anticoagulation during extracorporeal life support therapies.
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Affiliation(s)
- Andrea Ontaneda
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Gail M Annich
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Martens S, Matheis G, Wimmer-Greinecker G, Feuerbach J, Jakob A, Mierdl S, Moritz A. Heparin Coating of the Extracorporeal Circuit Combined with Leukocyte Filtration Reduces Coagulation Activity, Blood Loss and Blood Product Substitution. Int J Artif Organs 2018. [DOI: 10.1177/039139880102400709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Cardiopulmonary bypass is associated with activation of the coagulation cascade. Occasionally, this results in postoperative hemorrhage and consequently the need for blood products associated with increasing costs and risk of infection. Contact activation of the intrinsic coagulation pathway, and damage to cellular blood components with the release of proteolytic substances from neutrophil granulocytes have been linked to these coagulation disorders. Methods Eighteen routine CABG-patients were randomly assigned to totally heparin coated circuits (Bioline coating) combined with leukocyte filtration in a double blind protocol (group I), 34 patients served as controls (group II). Leukocyte filters were activated before release of the aortic crossclamp. Coagulation activity, postoperative blood loss, and substitution with blood products were assessed. Results Blood loss in the first 24h after surgery was significantly lower with combined application of heparin coating and leukocyte filters (group I) vs. controls (group II) (526±78ml vs. 786±88ml; p<0.05). Thrombin formation represented by prothrombin fragments 1+2 was significantly lower in group I vs. group II after declamping of the aorta (2.1±0.3nmol/L vs. 4.0±0.3nmol/L; p<0.05). Group I showed higher AT III plasma than group II (48.8±3.2% vs. 41.5±1.7%; p<0.05). Conclusions Leukocyte filtration during reperfusion in heparin coated cardiopulmonary bypass circuits is associated with lower coagulation activation, decreased blood loss and reduced transfusion of packed red cells in elective CABG patients.
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Affiliation(s)
- S. Martens
- Department of Thoracic and Cardiovascular Surgery, J.W. Goethe University, Frankfurt am Main - Germany
| | - G. Matheis
- Department of Thoracic and Cardiovascular Surgery, J.W. Goethe University, Frankfurt am Main - Germany
| | - G. Wimmer-Greinecker
- Department of Thoracic and Cardiovascular Surgery, J.W. Goethe University, Frankfurt am Main - Germany
| | - J. Feuerbach
- Department of Thoracic and Cardiovascular Surgery, J.W. Goethe University, Frankfurt am Main - Germany
| | - A. Jakob
- Department of Thoracic and Cardiovascular Surgery, J.W. Goethe University, Frankfurt am Main - Germany
| | - S. Mierdl
- Department of Thoracic and Cardiovascular Surgery, J.W. Goethe University, Frankfurt am Main - Germany
| | - A. Moritz
- Department of Thoracic and Cardiovascular Surgery, J.W. Goethe University, Frankfurt am Main - Germany
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Mueller X, Tevaearai H, Von Segesser K. Intra-Aortic Balloon: Evaluation of Heparin-Coating under Various Experimental Conditions. Int J Artif Organs 2018. [DOI: 10.1177/039139889902200906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- X.M. Mueller
- Clinic for Cardiovascular Surgery - CHUV (Centre Hospitalier Universitaire Vaudois), Lausanne - Switzerland
| | - H.T. Tevaearai
- Clinic for Cardiovascular Surgery - CHUV (Centre Hospitalier Universitaire Vaudois), Lausanne - Switzerland
| | - K. Von Segesser
- Clinic for Cardiovascular Surgery - CHUV (Centre Hospitalier Universitaire Vaudois), Lausanne - Switzerland
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Khilnani P. Anticoagulation on extracorporeal membrane oxygenation (ECMO). Qatar Med J 2017. [PMCID: PMC5474588 DOI: 10.5339/qmj.2017.swacelso.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Ferraris V, Ferraris S. Thrombin and cardiopulmonary bypass – A paradigm for evaluation of the regulation of hemostasis. Int J Angiol 2011. [DOI: 10.1007/s00547-005-2016-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Butler J, Murithi EW, Pathi VL, MacArthur KJD, Berg GA. Duroflo II heparin bonding does not attenuate cytokine release or improve pulmonary function. Ann Thorac Surg 2002; 74:139-42. [PMID: 12118746 DOI: 10.1016/s0003-4975(02)03594-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Comparison of the cytokine generation and leukocyte activation properties of Duroflo II heparin bonded bypass circuit (Baxter Healthcare Corp, Compton, UK) and the conventional cardiopulmonary bypass circuit. Attempt to correlate these to pulmonary dysfunction postoperatively. METHODS Forty patients undergoing elective, isolated coronary artery bypass grafting were randomly allocated to have either plain extracorporeal circuits (group C) or heparin bonded extracorporeal circuits (group H). Full systemic heparinization was used in all patients. The inflammatory response was assessed by measuring plasma levels of interleukin-6, interleukin-8, interleukin-10, and polymorphonuclear elastase. Gas exchange was assessed by measuring the PaO2/FIO2 ratio. RESULTS Significant impairment of oxygenation was seen in both groups with the lowest values at the end of the operation before a gradual return to normal during the next 6 hours. There were no differences between the groups in gas exchange or times to extubation. There were significant elevations in all the cytokines, with interleukin-6 levels peaking at 4 hours in group H and 24 hours in group C, before starting to return to normal at 48 hours. The patterns of interleukin-8 and interleukin-10 rise were identical in the two groups. Polymorphonuclear elastase reached a peak at the end of the operation in group H and remained elevated up to 24 hours, whereas levels continued to rise in group C up to 4 hours. There were no significant differences in levels between groups at any time. There were no differences between the groups in blood loss or blood product usage. CONCLUSIONS Cardiopulmonary bypass induces a systemic inflammatory response with release of cytokines and activation of leukocytes. This correlates with the severe deterioration in pulmonary gas exchange from preoperative levels up to 6 hours postoperatively (p < 0.05). In the presence of systemic heparinization, Duroflo II heparin bondingtf the circuits has minor effects on the pattern of evolution of this inflammatory response.
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Affiliation(s)
- John Butler
- Department of Cardiac Surgery, Western Infirmary, Glasgow, Scotland, United Kingdom.
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Wendel HP, Philipp A, Weber N, Birnbaum DE, Ziemer G. Oxygenator thrombosis: worst case after development of an abnormal pressure gradient--incidence and pathway. Perfusion 2001; 16:271-8. [PMID: 11486845 DOI: 10.1177/026765910101600402] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The development of an abnormally high pressure gradient (APG) before the membrane oxygenator (MO) is a complication that occurs during some extracorporeal circulation (ECC) procedures. The present study deals with the incidence of an APG and discusses a probable causative pathway by comparing surface-coated and uncoated oxygenation systems. Five thousand six hundred and seventeen adult ECCs were carried out (2,581 without and 3,036 with surface coatings). The incidence of an APG, therefore, amounted to 0.03% in the group with coated systems and 4.3% in the uncoated group. In addition, an in vitro study demonstrated significantly reduced adhesion and activation of platelets and leucocytes when the surfaces of the MOs were coated with heparin or polypeptides. The advantages of coating surfaces of ECC devices possibly depend on the selective adsorption of particular plasma proteins. These will presumably form a biocompatible membrane on the surface, and minimize pathological deposit of fibrin, platelets and other blood cells, and, therefore, implicate the prevention of an oxygenator failure.
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Affiliation(s)
- H P Wendel
- Clinic for Thoracic, Cardiac and Vascular Surgery, Eberhard-Karls-University, Tuebingen, Germany.
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Wendel HP, Ziemer G. Coating-techniques to improve the hemocompatibility of artificial devices used for extracorporeal circulation. Eur J Cardiothorac Surg 1999; 16:342-50. [PMID: 10554855 DOI: 10.1016/s1010-7940(99)00210-9] [Citation(s) in RCA: 178] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Extracorporeal circulation procedures have been shown to induce complement and leukocyte activation, release of endotoxin and inflammatory mediators, including cytokines, nitric oxide, oxygen free radicals, and platelet activating factors. The contact between the blood and the various artificial surfaces of the extracorporeal system results in an unspecific post-perfusion syndrome. For diminishing these negative side effects several coating-techniques have been developed to create devices with improved hemocompatibility. METHODS This review deals with the current knowledge of heparin-coated and otherwise surface-modified perfusion systems. The pathway how heparin-coated surfaces work is discussed and techniques for surface-coatings, both clinically introduced as well as newly developed are presented. RESULTS Numerous clinical studies compared heparin-coated versus non-coated circuits. Heparin-bonded devices showed lessened humoral and cellular activation, in particular a reduced complement activation with a reduced inflammatory post-perfusion syndrome. Also platelet protection and more favorable post-operative lung function are of particular note. Recent clinical trials demonstrated shortened hospital stays, less drainage bleeding, and reduced cerebral complications using heparin-coated oxygenation systems. The diminished expression of the leukocyte adhesion molecules CD 11b/c in CBAS devices points to a decreased activation of neutrophils. In addition, one research group found a reduced production of oxygen radicals. Heparin-bonding minimizes oxygenator failure by a significant reduced pressure gradient across the oxygenator, probably caused by decreased fibrin and platelet deposition at the hollow fiber surfaces. A meta analysis examined the impact of heparin-bonded systems on clinical outcomes and resulting costs. Using heparin-bonded circuits led to total cost savings from US $1000 to 3000. Several authors demonstrated reduced blood loss and better clinical outcome by reduction of systemic heparinization and the employment of heparin-coated devices. CONCLUSION Above and beyond the long-term applications, routine heart operations have also markedly begun to utilize heparin-coated devices. This trend will assuredly continue in the coming years and is an important step toward higher hemocompatibility of blood-contacting surfaces in the ECC device. Heparin-coatings are merely the beginning of improved hemocompatibility for all materials that come into contact with human blood or tissues. Intelligent materials with almost completely physiological surfaces will be at the surgeon's disposal within the next few years.
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Affiliation(s)
- H P Wendel
- Department of Surgery, Eberhard-Karls-University, Tuebingen, Germany.
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Wendel HP, Weber N, Ziemer G. Increased adsorption of high molecular weight kininogen to heparin-coated artificial surfaces and correlation to hemocompatibility. IMMUNOPHARMACOLOGY 1999; 43:149-53. [PMID: 10596847 DOI: 10.1016/s0162-3109(99)00073-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
During the past 10 years investigations have demonstrated that heparin-coated devices used for extracorporeal circuits show an improved hemocompatibility. We investigated the pathway of adsorption of plasma proteins at heparin-coated artificial surfaces and the further activation of the humoral and cellular defense mechanisms of the blood. Twenty milliliters of fresh human blood (1 IU heparin/ml) filled a 50 cm long tubes (with and without covalent heparin-coating), prepared as an in vitro "Closed-Loop" model and recirculated at a temperature of 37 degrees C. After 5, 15, 30, 60 and 120 min fibrinogen and high molecular weight kininogen (HMWK) adsorption was measured by a newly developed modified ELISA technique. In addition, changes in coagulation and platelet activation were measured by well established assays. High concentrations of fibrinogen were detected after very short blood material contact, both on uncoated as well as heparin-coated tubes. However, high amounts of HMWK were only found on the heparin-bonded surfaces. In addition, the concentrations of the soluble coagulation marker prothrombin fragment F1+2 and the marker for platelet activation beta-thromboglobulin were significantly higher in the non-coated tubes. We presume that adsorption of HMWK to heparin-coated surfaces contributes to the improved hemocompatibility of these bondings.
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Affiliation(s)
- H P Wendel
- Department of Surgery, Eberhard-Karls University, Tuebingen, Germany.
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13
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Wimmer-Greinecker G, Matheis G, Martens S, Oremek G, Abdel-Rahman U, Moritz A. Synthetic protein treated versus heparin coated cardiopulmonary bypass surfaces: similar clinical results and minor biochemical differences. Eur J Cardiothorac Surg 1999; 16:211-7. [PMID: 10485423 DOI: 10.1016/s1010-7940(99)00143-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Complications associated with cardiopulmonary bypass (CPB) have gained more attention due to increased interest in coronary artery bypass grafting without CPB. The impact of heparin coating of CPB circuits has been discussed controversially. The present study examines if the treatment of the oxygenator surface with a synthetic protein may serve as an alternative to a completely heparin coated circuit. METHODS Fifty-eight patients undergoing coronary artery bypass grafting with CPB were randomly assigned to completely heparin coated circuits or synthetic protein treated oxygenators in a double blind protocol, focussing on the inflammatory reaction resulting in membrane damage, coagulation changes and markers of cerebral injury or dysfunction. Treatment groups did not differ as to preoperative demographics, and intraoperative clinical data. Patients with any neurologic disease or risk factors for cerebral dysfunction were not included in the study. RESULTS Postoperative clinical data did not differ between groups. Both surface treatments resulted in similar coagulation activation, hyperfibrinolysis and disseminated intravascular coagulation. Platelet count displayed a difference in favour of the heparin coated group (P = 0.029). Increased leukocyte activation reflected by rising myeloperoxidase concentrations on CPB was present in both synthetic protein and heparin coating groups. Interleukins 6 and 8 reacted similarly, but interleukin 8 increased significantly more (P = 0.0061) at the end of surgery in patients treated with protein treated oxygenators. The same pattern was observed for complement activation as determined by total complement complex (P = 0.006). Both surface changes resulted in moderately increased S-100B protein and neuron specific enolase, without difference between groups. Both markers did not reach concentrations associated with clinical manifestation of cerebral injury. CONCLUSIONS These results in routine patients with short bypass time, imply that protein treated oxygenators are associated with a limited increase of biochemical markers similar to heparin coating. However, significantly lower interleukin 8 release and complement activation can be achieved by heparin coating. The protein treatment is a standard feature of the oxygenator examined in both groups. It is not associated with additional cost and therefore appropriate for use in routine patients.
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Affiliation(s)
- G Wimmer-Greinecker
- Department of Thoracic and Cardiovascular Surgery (Klinik für Thorax, Herz- und Gefässchirurgie), Johann Wolfgang Goethe University, Frankfurt/Main, Germany
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Wendel HP, Schulze HJ, Heller W, Hoffmeister HM. Platelet protection in coronary artery surgery: benefits of heparin-coated circuits and high-dose aprotinin therapy. J Cardiothorac Vasc Anesth 1999; 13:388-92. [PMID: 10468249 DOI: 10.1016/s1053-0770(99)90208-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the extent of platelet activation during extracorporeal circulation by using the combination of heparin-coated oxygenation systems and high-dose aprotinin therapy, and to examine the affinity and thereby the protective capacity of aprotinin to the glycoprotein (GP) receptors of the platelet membrane. DESIGN Experimental in vitro study. SETTING Research laboratory of a university hospital. PARTICIPANTS Thirty-two volunteers (blood donors). MEASUREMENTS AND MAIN RESULTS Thirty-two oxygenation circuits of the same construction series (16 heparin-coated and 16 noncoated) were investigated in a closed system of a heart-lung machine model with fresh human whole blood. In each of these two groups, eight circuits with and eight without a high-dose aprotinin application (250 kallikrein inhibitory units [KIU]/mL) were investigated. In all four groups, the number of platelets declined continuously during the 90-minute recirculation period. Group I (no heparin coating, no aprotinin) showed the greatest reduction; group IV (heparin coating, aprotinin) had a significantly smaller decrease in platelet number (p < 0.01). Platelet factor 4 (PF-4) levels, released from the alpha-granule, were in inverse proportion to the platelet loss. After 90 minutes of recirculation, the PF-4 values increased to 615.8% +/- 559.5% and 237.2% +/- 179.0% of the initial value for groups I and IV, respectively (p < 0.01). Affinity chromatography and immunoblotting techniques were used to evaluate the affinity of aprotinin for the GP receptors of the platelet membrane. The affinity appeared in the following order: GPIIb < GPIIIa < GPIb. CONCLUSION Heparin-coated oxygenation systems and additional aprotinin caused significantly less platelet damage in an in vitro cardiopulmonary bypass model. Chromatographic and immunologic methods could prove aprotinin's affinity for the platelet receptor proteins GPIb and GPIIb-IIIa and therefore its probable role in diminishing the triggering of the platelet activation cascade.
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Affiliation(s)
- H P Wendel
- Department of Surgery, University of Tuebingen, Germany
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Abstract
BACKGROUND A mix of cardiac assist options is necessary to meet the diverse indications for cardiac support in a comprehensive heart failure program. At our institution, an adult extracorporeal membrane oxygenation (ECMO) system comprising a centrifugal pump and hollow fiber membrane oxygenator is used for short-term and temporary cardiac assist. METHODS Between December 1991 and August 1997, 82 adult cardiac patients were supported on ECMO. Indications for cardiac assist included postcardiotomy cardiogenic shock (PCCS, 55 patients), high-risk cardiology intervention (27 patients), perioperative cardiac graft failure (4 patients), and emergency cardiac resuscitation (6 patients). Data for analysis were collected by prospective completion of standardized ECMO report forms and retrospective review of hospital charts. RESULTS The ECMO system was inexpensive to operate, uncomplicated to implant, and adaptable for diverse indications. Survival in PCCS was 20 of 55 patients (36%), with an increased survival rate of 56% (18 of 32 patients) in patients with PCCS after isolated coronary bypass. Catheter-based revascularizations were successfully performed in 26 of 27 (96%) high-acuity patients temporarily supported by ECMO, and 23 of 27 patients (85%) survived to discharge. Survival in the cardiac graft failure group was 2 of 4 (50%). No patient supported on ECMO for cardiac resuscitation survived. CONCLUSIONS ECMO provides good cardiopulmonary and end-organ support; survival rates are similar to or higher than those seen with centrifugal pump support in comparable patient populations.
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Affiliation(s)
- G J Magovern
- Department of CardioThoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, USA.
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Mueller XM, Tevaearai HT, Hayoz D, von Segesser LK. Thrombogenicity of deflated intraaortic balloon: impact of heparin coating. Artif Organs 1999; 23:195-8. [PMID: 10027890 DOI: 10.1046/j.1525-1594.1999.06228.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In a calf model, 3 standard and 3 heparin coated intraaortic balloons (IAB) were inserted and left deflated in the descending aorta during 20 min to simulate balloon rupture. At the end of the experiment, the IAB were examined, and 3 samples of each were collected for scanning electron microscopy (SEM) analysis. None of the heparin coated IAB showed any sign of clot or deposit whereas all 3 standard IAB exhibited clots. SEM revealed no deposit on the heparin coated samples while 8 of the 9 standard samples disclosed deposits (p < 0.001). Morphometrically, 16.1+/-21.4% of the surfaces of the standard samples were covered with deposits whereas all the heparin coated samples were free (p = 0.004). The presence of clots on every standard IAB supports the hypothesis that other than local factors of the insertion site can play a role in the vascular complications of IAB. The absence of clots and deposits on the heparin coated IAB suggests a promising role of such devices in circumventing the tendency of clot formation on deflated balloons while avoiding the drawback of systemic anticoagulation.
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Affiliation(s)
- X M Mueller
- Clinic for Cardiovascular Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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Wendel HP, Scheule AM, Eckstein FS, Ziemer G. Haemocompatibility of paediatric membrane oxygenators with heparin-coated surfaces. Perfusion 1999; 14:21-8. [PMID: 10074643 DOI: 10.1177/026765919901400104] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Extracorporeal circulation (ECC) in paediatric patients with heparin-coated oxygenation systems is rarely investigated. The objective of this study was to evaluate, preclinically, the haemocompatibility of paediatric membrane oxygenators with heparin-coated surfaces. We compared 16 paediatric membrane oxygenators (Minimax, Medtronic) in an in vitro heart-lung machine model with fresh human blood. Eight of these oxygenation systems had a covalent heparin coating (Carmeda bioactive surface). After 90 min simulated ECC, the heparin-coated systems showed significantly higher platelet count, lower platelet-factor 4 release, reduced contact activation (factor XIIa and kallikrein), and lower neutrophil elastase levels (p < 0.05), compared to the noncoated oxygenator group. More biocompatible materials for paediatric operations may ameliorate the various postperfusion syndromes arising from ECC procedures, particularly unspecific inflammation, hyperfibrinolysis and blood loss.
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Affiliation(s)
- H P Wendel
- Department of Surgery, Eberhard-Karls-University, Tuebingen, Germany.
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Abstract
Exposure of blood to an extracorporeal circulation, such as CPB, causes a variety of physiological responses. Haematological derangements are just one of many potential dangers to the patient who undergoes CPB. The paradox of CPB-related problems with the haematological system is that there are some factors tipping the balance towards a bleeding tendency, and others that favour a prothrombotic state. Both of these issues must be dealt with independently to create the safest environment for surgery. It has been demonstrated that platelets play a key role in both haemostatic dysfunction and thrombotic complications of CPB. Much has been achieved, both clinically and in the laboratory, in the understanding of the precise role platelets play in these events, but the exact mechanisms involved have yet to be completely identified. As research progresses, our understanding will increase, but until then clinical practice must be dictated by the current evidence available.
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Affiliation(s)
- J A Hyde
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, Birmingham.
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Abstract
The aim of this study was to use meta-analysis to combine the results of numerous studies and examine the impact of heparin-bonded circuits on clinical outcomes and the resulting costs. Heparin-bonded circuits, both ionically and covalently bonded, are examined separately. The results of the study provide evidence that heparin-bonded circuits result in improved clinical outcomes when compared to the identical nonheparin-bonded circuits. These improved clinical outcomes result in subsequent lower costs per patient with their use. However, differences are apparent in the significance and magnitude of these outcomes between ionically and covalently bonded circuits. Covalently bonded circuits provide a greater magnitude and significance of improvement in clinical outcomes than ionically bonded circuits. Total cost savings can be expected to be three times greater with covalently bonded circuits ($3231 versus $1068). It was concluded that the choice regarding the use of a heparin-bonded circuits and the type of heparin-bonded circuit used has the potential to alter clinical outcomes and subsequent costs. Cost consideration cannot be ignored, but clinical benefits should be the main rationale for the choice of cardiopulmonary bypass circuit. This analysis provides evidence that clinical benefits and cost savings can both be derived from use of the same technology-covalently bonded circuits.
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Affiliation(s)
- C B Mahoney
- Industrial Relations Center, Carlson School of Management, University of Minnesota, Minneapolis 55455-0430, USA
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Rossi M, Storti S, Martinelli L, Varano C, Marra R, Zamparelli R, Possati G, Schiavello R. A pump-prime aprotinin dose in cardiac surgery: appraisal of its effects on the hemostatic system. J Cardiothorac Vasc Anesth 1997; 11:835-9. [PMID: 9412880 DOI: 10.1016/s1053-0770(97)90116-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To examine pump-prime aprotinin action on coagulation and fibrinolysis in patients undergoing primary coronary revascularization. DESIGN A prospective randomized study. SETTING A university hospital. PARTICIPANTS Forty-three patients were randomly assigned to either group A, 21 patients treated with 2 x 10(6) kallikrein inhibitor units (KIU) of aprotinin in the cardiopulmonary bypass (CPB) prime, or group B, 22 patients, untreated. INTERVENTIONS Patients, scheduled for elective coronary surgery, were treated with 2 x 10(6) KIU of aprotinin in the CPB prime. Markers of coagulation and fibrinolysis were evaluated. MEASUREMENTS AND MAIN RESULTS Surgical times, number of reopenings, and allogeneic blood requirements were collected for each patient. Blood samples were obtained before and after surgery for assessing coagulation (prothrombin time [PT], activated partial thromboplastin time [aPTT], ethanol test, factor VII, antithrombin III [AT III], thrombin-antithrombin III complex [TAT], fragment 1.2 of prothrombin [F1.2]) and fibrinolysis (fibrin degradation products [FOP], plasmin-antiplasmin complexes [PAP], D-dimers) markers variations. In group A surgical times were faster, there were fewer reopenings (0 v 3), and fewer blood transfusions (1 patient v 4 patients). The two groups did not differ for PT, aPTT, and fibrinogen measurements. Postoperative FDP (measurable in more patients of group B at the end of the operation), PAP, and D-dimers postoperatory levels (less increased in aprotinin group) show the antifibrinolytic properties of the drug. Regarding the coagulation markers, factor VII decreased, whereas TAT and F1.2 increased, all to a lesser extent in the aprotinin group compared with the untreated patients, at the end of operation. CONCLUSION Pump-prime aprotinin minimized, even if not completely inhibited, the activation of coagulation and fibrinolysis during CPB, possibly ensuring a less complicated and safer postoperative recovery. It seemed to allow the maintenance of a correct balance of hemostatic systems, avoiding the risk of thrombotic phenomena.
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Affiliation(s)
- M Rossi
- Department of Anesthesiology and Intensive Care, Catholic University of the Holy Heart, Rome, Italy
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21
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Kitano Y, Takata M, Miyasaka K, Sasaki N, Zhang Q, Liu D, Tsuchida Y. Evaluation of an extracorporeal membrane oxygenation system using a nonporous membrane oxygenator and a new method for heparin coating. J Pediatr Surg 1997; 32:691-7. [PMID: 9165453 DOI: 10.1016/s0022-3468(97)90007-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A new heparin binding method was applied to a miniature extracorporeal membrane oxygenation (ECMO) system with a nonporous membrane oxygenator (the priming volume, 45 mL; the membrane surface area, 0.4 m2; maximal flow rate, 2 L/min) that is resistant to plasma leakage. The authors evaluated the stability of the immobilized heparin in vitro and the feasibility of this system in animals. Samples of hollow fibers and tubing were rinsed at 40 degrees C for 4 days in normal saline, Ringer's lactate, and 1 mol/L NaCl solution. Heparin activities on hollow fibers after rinsing were 99 +/- 2.3% (mean +/- SD), 96 +/- 3.9%, and 93 +/- 2.0% of the control in each solution, while those of the tubing were 87 +/- 4.1%, 86 +/- 3.1%, and 76 +/- 8.6%, respectively. Veno-arterial ECMO using this heparin-coated system was performed on five beagles (8 to 12 kg) for 10 hours. Neither major thrombus formation nor plasma leakage was detected during the procedure in spite of a low flow rate (300 mL/min) and a reduced activated clotting time (mean, 128 seconds). Platelets decreased to 52% of the control (P < .01) at 1 hour, but no progressive decrease was seen thereafter. Antithrombin-III decreased (P < .01) and thrombin/antithrombin III complex increased (P < .05 at 4 hours and P < .01 at 6, 8, and 10 hours) during bypass, but the changes of fibrinogen and fibrinopeptide A were not significant. Fibrinogen/fibrin degeneration products, fibrinopeptide B beta 15-42, and plasma-free hemoglobin levels did not rise significantly. O2 transfer of the oxygenators at a flow rate of 300 mL/min were 12.3 +/- 0.4 mL/min at 30 minutes, 14.3 +/- 1.2 mL/min at 5 hours, and 14.7 +/- 1.7 mL/min at 10 hours (no statistical difference). Histological examination of the brains and the kidneys showed no evidence of thromboembolic sequela in any of the animals. These results suggest that this new system is a promising device for long-term ECMO in which the amount of systemic heparinization can be reduced with the minimal possibility of plasma leakage.
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Affiliation(s)
- Y Kitano
- Department of Pediatric Surgery, University of Tokyo, Japan
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22
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Abstract
Recent advances in surgical techniques and perfusion technology allow cardiac operations to be performed routinely with low mortality rates. However, patients undergoing cardiac operations with cardiopulmonary bypass (CPB) are still associated with bleeding disorders, thrombotic complications, massive fluid shifts, and the activation of blood components that are collectively known as the whole body inflammatory response. In this review, the effect of cardiopulmonary bypass on various humoral and cellular components of blood is examined. Blood activation caused by interaction with artificial materials of extracorporeal circuit and by material-independent stimuli is discussed. Methods to control blood activation during and after cardiopulmonary bypass are described. These include surface modification of extracorporeal circuit, control of flow dynamics in the circuit, pharmacological intervention, and the use of extracorporeal devices to remove inflammatory mediators. Recent findings on the effects of heparin-coated circuits on inflammatory response and clinical outcome are reviewed. It appears that the causes of inflammatory response to cardiopulmonary bypass are multifactorial and that an integrated strategy is needed to control and eliminate the negative effects of CPB.
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Affiliation(s)
- L C Hsu
- Bentley Division, Baxter Healthcare Corp. Irvine, CA 92714, USA
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23
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Weiss BM, von Segesser LK, Turina MI, Seifert B, Pasch T. Perioperative course and recovery after heparin-coated cardiopulmonary bypass: low-dose versus high-dose heparin management. J Cardiothorac Vasc Anesth 1996; 10:464-70. [PMID: 8776638 DOI: 10.1016/s1053-0770(05)80005-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare two heparin managements for a cardiopulmonary bypass (CPB) procedure with heparin-coated equipment. The hypothesis was that a lower heparin dose may reduce blood loss and homologous transfusion requirements and influence the speed of postoperative recovery. DESIGN Prospective, randomized, and open study. SETTING Operating room and intensive care unit in a university hospital. PARTICIPANTS Twenty-four patients undergoing first-time elective coronary artery surgery. INTERVENTIONS Heparin-coated CPB equipment (Duraflo II; Baxter-Bentley) was used in all patients. The study group (n = 12) received low-dose (100 IU/kg i.v. and 0 to 1,000 IU/L priming; target level of activated coagulation time [ACT] over 180 seconds during CPB; suction in a red cell washing device); and the control group (n = 12) received high-dose (300 IU/kg i.v. and 5,000 IU/L priming; ACT over 480 seconds; standard cardiotomy suction) heparin management. MEASUREMENTS AND MAIN RESULTS ACT remained above 200 seconds after the initial heparin dose in the study group for the CPB duration up to 99 minutes. In 11 of 12 patients in the control group, additional heparin was required during CPB. Total doses of heparin and protamine (mean 8,017 v 50,508 IU and 83 v 325 mg, respectively; p < 0.0001), volume of homologous blood transfusion (median 600 v 1450 mL; p < 0.025), and blood products exposure (median 0.5 v 5.0 units/patients; p < 0.05) were significantly lower in the study group. Postoperative chest drainage showed a trend to lower volume loss (median 705 v 930 mL; p < 0.08) in patients managed with low-dose heparin. Oxygenator resistance during CPB, perioperative laboratory analyses (oxygen and metabolic data, hematocrit, platelet count, prothrombin, thrombin, activated partial thromboplastin time, fibrinogen, D-dimers, creatine kinase, and myocardial band of creatine kinase concentration), fluid balance, and the time periods required for extubation, stay in the intensive care unit, and hospital discharge were not different between the groups. There were no evidences of myocardial infarction in any of 24 patients, and all recovered after the procedure. CONCLUSION Low-dose heparin management enabled uneventful procedures with heparin-coated CPB equipment, significantly decreased protamine and homologous blood requirements, but did not reduce chest drainage or influence the postoperative course and recovery in patients after coronary artery surgery.
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Affiliation(s)
- B M Weiss
- Department of Anesthesiology, University Hospital Zürich, Switzerland
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24
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Affiliation(s)
- D Royston
- Department of Anaesthesia, Harefield Hospital, Middlesex, UK
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25
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Wendel HP, Heller W, Gallimore MJ. Heparin-coated devices and high-dose aprotinin optimally inhibit contact system activation in an in vitro cardiopulmonary bypass model. IMMUNOPHARMACOLOGY 1996; 32:128-30. [PMID: 8796289 DOI: 10.1016/0162-3109(95)00073-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- H P Wendel
- Department of Thoracic and Cardiovascular Surgery, University of Tuebingen, Germany
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26
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Affiliation(s)
- L C Hsu
- Bentley Division, Baxter Healthcare Corporation, Irvine, California 92713-9522, USA
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27
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von Segesser LK. Heparin-bonded surfaces in extracorporeal membrane oxygenation for cardiac support. Ann Thorac Surg 1996; 61:330-5; discussion 340-1. [PMID: 8561600 DOI: 10.1016/0003-4975(95)01011-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Development of increasingly complex perfusion devices with bonded heparin allowed for significant improvement of thromboresistance of most basic components required for cardiopulmonary bypass. In his recent review of heparin-coated cardiopulmonary bypass circuits, Gravlee cited 91 references dealing with heparin-coated surfaces, and far more can be found if the search includes material technology or heparin-coated devices not designed for cardiopulmonary bypass (eg, ventricular assist devices, hemofilters, catheters). The present review is focused on long-term application of heparin-coated equipment in conjunction with basic work on heparin bonding relevant for extracorporeal membrane oxygenation. Experimental open chest cardiopulmonary bypass using heparin-coated equipment without systemic heparinization up to 36 hours has shown improved thromboresistance, and better platelet preservation was demonstrated for perfusion with heparin-coated cardiopulmonary bypass equipment up to 5 days in the experimental set-up. Similar findings were reported for roller pump perfusion with heparin-coated tubing and centrifugal pump perfusion with heparin-coated pump heads. More recently, heparin bonding was also made available for oxygenators with true membranes that preclude plasma leakage. The available knowledge on clinical applications of heparin-coated perfusion equipment is mainly based on short-term applications like ours, which now includes more than 300 patients. Reduced postoperative blood loss and as a result fewer transfusions were the main benefits of heparin-coated equipment allowing for perfusion with low systemic heparinization. There are only a few reports on long-term use of heparin-coated equipment for prolonged circulatory support. However, the longest clinical application of a single device is that of an intravascular gas exchanger that remained fully functional during a 29-day implantation period. Finally, it appears, that circulating protamine interacts with surface-bound heparin. Protamine administration should therefore be avoided during perfusion with heparin-bonded equipment to maintain the improved thromboresistance.
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Affiliation(s)
- L K von Segesser
- Clinic for Cardiovascular Surgery, University Hospital, Zürich, Switzerland
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