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Argiriadou H, Antonitsis P, Gkiouliava A, Papapostolou E, Deliopoulos A, Anastasiadis K. Minimal invasive extracorporeal circulation preserves platelet function after cardiac surgery: a prospective observational study. Perfusion 2019; 35:138-144. [DOI: 10.1177/0267659119866289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Cardiac surgery on conventional cardiopulmonary bypass induces a combination of thrombocytopenia and platelet dysfunction which is strongly related to postoperative bleeding. Minimal invasive extracorporeal circulation has been shown to preserve coagulation integrity, though effect on platelet function remains unclear. We aimed to prospectively investigate perioperative platelet function in a series of patients undergoing cardiac surgery on minimal invasive extracorporeal circulation using point-of-care testing. Methods: A total of 57 patients undergoing elective cardiac surgery on minimal invasive extracorporeal circulation were prospectively recruited. Anticoagulation strategy was based on individualized heparin management and heparin level–guided protamine titration performed in all patients with a specialized point-of-care device (Hemostasis Management System – HMS Plus; Medtronic, Minneapolis, MN, USA). Platelet function was evaluated with impedance aggregometry using the ROTEM platelet (TEM International GmbH, Munich, Germany). ADPtest and TRAPtest values were assessed before surgery and after cardiopulmonary bypass. Results: ADPtest value was preserved during surgery on minimal invasive extracorporeal circulation (58.2 ± 20 U vs. 53.6 ± 21 U; p = 0.1), while TRAPtest was found significantly increased (90 ± 27 U vs. 103 ± 38 U; p = 0.03). Postoperative ADPtest and TRAPtest values were inversely related to postoperative bleeding (correlation coefficient: −0.29; p = 0.03 for ADPtest and correlation coefficient: −0.28; p = 0.04 for TRAPtest). The preoperative use of P2Y12 inhibitors was identified as the only independent predictor of a low postoperative ADPtest value (OR = 15.3; p = 0.02). Conclusion: Cardiac surgery on minimal invasive extracorporeal circulation is a platelet preservation strategy, which contributes to the beneficial effect of minimal invasive extracorporeal circulation in coagulation integrity.
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Affiliation(s)
- Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
| | | | - Anna Gkiouliava
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
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Argiriadou H, Antonitsis P, Deliopoulos A, Anastasiadis K. Point-of-care coagulation management during surgery with minimal invasive extracorporeal circulation. J Thorac Dis 2019; 11:S1519-S1524. [PMID: 31293803 PMCID: PMC6586579 DOI: 10.21037/jtd.2019.02.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/18/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
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Platelet Reactivity Unit in Predicting Risk of Bleeding in Patients Undergoing Coronary Artery Bypass Graft Surgery. Am J Ther 2015; 23:e1537-e1541. [PMID: 25909923 DOI: 10.1097/mjt.0000000000000208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Bleeding is a common complication of cardiac surgery, accounting for a significant proportion of the total transfusions performed in the United States and Europe. The relationship between platelet reactivity, bleeding, and other adverse events after coronary artery bypass graft surgery (CABGS) has been incompletely characterized. This study investigated the relationship between platelet reactivity and bleeding as a clinical outcome after successful CABGS. A total of 238 patients who underwent CABGS were retrospectively followed for postoperative bleeding. Platelet reactivity unit (PRU) values for all patients were obtained preoperatively to assess the platelet reactivity. The data showed that a range of 180-200 PRU suggests the likelihood of bleeding after CABGS (P = 0.004), with a statistically significant association only for dual antiplatelet therapy with aspirin and clopidogrel. In conclusion, by using PRU values as a method to assess platelet reactivity and antiplatelet responsiveness, our findings suggest that it may be possible to stratify patients undergoing CABGS for the risk of postoperative bleeding particularly patients on dual antiplatelet therapy.
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Pasha SF, Acosta R, Chandrasekhara V, Chathadi KV, Eloubeidi MA, Fanelli R, Faulx AL, Fonkalsrud L, Khashab MA, Lightdale JR, Muthusamy VR, Saltzman JR, Shaukat A, Wang A, Cash B. Routine laboratory testing before endoscopic procedures. Gastrointest Endosc 2014; 80:28-33. [PMID: 24836749 DOI: 10.1016/j.gie.2014.01.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/14/2014] [Indexed: 02/08/2023]
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Assessment of Platelet Function in Patients on Antiplatelet Therapy Undergoing Cardiac Surgery: A Review. Heart Lung Circ 2012; 21:455-62. [DOI: 10.1016/j.hlc.2012.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 03/12/2012] [Accepted: 03/14/2012] [Indexed: 02/07/2023]
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Perakis PG, Yunus T, Long G, Cheema ZF, Hammond R, Shanley CJ. Platelet Function after Cessation of Chronic Clopidogrel Therapy. Am Surg 2012. [DOI: 10.1177/000313481207800133] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Surgeons increasingly encounter patients on clopidogrel therapy who are preparing to undergo surgery. The goal of this study was to examine the change in platelet function after the common clinical scenario of discontinuing chronic clopidogrel therapy in those patients preparing to undergo an elective surgery, and the time course of platelet function recovery after clopidogrel discontinuation. Patients on clopidogrel therapy scheduled for an elective surgical procedure had their platelet function tested using a Verify Now P2Y12 device (Accumetrics, San Diego, CA). Platelet inhibition was evaluated at baseline before clopidogrel discontinuation, and subsequently studied every other day in the week before their scheduled procedure. Mean platelet inhibition was 32.1 per cent on Day 0 (before clopidogrel discontinuation), decreasing to 3.7 per cent on Day 4. Platelet inhibition decreased significantly after discontinuation of clopidogrel in a time-dependent manner ( P = 0.011), although a considerable interindividual variability of P2Y12 reaction units values was observed over the study period. Patients on concomitant proton pump inhibitors and clopidogrel demonstrated a decreased effect of clopidogrel. In conclusion, individual platelet function monitoring may assist the surgeon in perioperative decision-making in patients receiving clopidogrel therapy preparing to undergo elective surgery.
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Affiliation(s)
- Peter G. Perakis
- Department of Surgery, Beaumont Health System, Royal Oak, Michigan
| | - Tahir Yunus
- Department of Surgery, Beaumont Health System, Royal Oak, Michigan
| | - Graham Long
- Department of Surgery, Beaumont Health System, Royal Oak, Michigan
| | | | - Robert Hammond
- Department of Surgery, Beaumont Health System, Royal Oak, Michigan
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Lordkipanidzé M, Pharand C, Schampaert E, Palisaitis DA, Diodati JG. Heterogeneity in platelet cyclooxygenase inhibition by aspirin in coronary artery disease. Int J Cardiol 2011; 150:39-44. [DOI: 10.1016/j.ijcard.2010.02.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 01/12/2010] [Accepted: 02/13/2010] [Indexed: 11/29/2022]
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Seleem M, Ratnapala DN, Stride PJO, Wood P, Lambrianides AL, Gupta S. Managing Patients on Antiplatelet Drugs Requiring Emergency Non-Cardiac Surgery. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2011. [DOI: 10.1002/j.2055-2335.2011.tb00680.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Mostafa Seleem
- Advanced Trainee in General Medicine, and School of Medicine; The University of Queensland, and Department of Medicine, Redcliffe Hospital
| | | | - Peter JO Stride
- School of Medicine; The University of Queensland, and Department of Medicine, Redcliffe Hospital
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Impact of platelet count on results obtained from multiple electrode platelet aggregometry (Multiplate). Eur J Med Res 2010; 15:214-9. [PMID: 20562061 PMCID: PMC3352011 DOI: 10.1186/2047-783x-15-5-214] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Use of potent antiplatelet drugs requires evaluation of platelet function. While platelet function in elective cases is usually assessed in a central laboratory environment, there is also an urgent need for rapid perioperative point-of-care assessment. Recently, multiple electrode platelet aggregometry has been developed and assumed to measure platelet function independent from platelet count. We tested the hypothesis that results of multiple electrode platelet aggregometry are affected by platelet count, in particular if platelet count is below normal range. METHODS Whole blood samples from 20 healthy volunteers were prepared containing platelet concentrations of 50,000, 100,000, 150,000, 200,000, and 250,000 microl(-1) while maintaining hematocrit. Platelet aggregation was induced by collagen, thrombin receptor activating peptide 6 (TRAP-6), adenosine-diphoshate (ADP), and arachidonic acid, respectively, and aggregation was measured by multiple electrode platelet aggregometry (Multiplate). RESULTS Results of multiple electrode platelet aggregometry significantly decreased in blood samples with platelet count below normal range. Compared to results measured in blood samples with platelet count within normal range, aggregometry results decreased by 18.4 % (p<0.001) and 37.2 % (p<0.001) in blood samples with a platelet count of 100.000 and 50.000 microl(-1), respectively. On the other hand, large interindividual variation has been observed and some blood samples showed normal results even with platelet counts of 50.000 microl(-1). CONCLUSION The results obtained with Multiplate. Analyzer are influenced by platelet function as well as platelet count thus displaying the overall platelet aggregability within the blood sample rather than platelet function alone.
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Perry DJ, Fitzmaurice DA, Kitchen S, Mackie IJ, Mallett S. Point-of-care testing in haemostasis. Br J Haematol 2010; 150:501-14. [PMID: 20618331 DOI: 10.1111/j.1365-2141.2010.08223.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Point-of-care testing (POCT) in haematology has seen a significant increase in both the spectrum of tests available and the number of tests performed annually. POCT is frequently undertaken with the belief that this will reduce the turnaround time for results and so improve patient care. The most obvious example of POCT in haemostasis is the out-of-hospital monitoring of the International Normalized Ratio in patients receiving a vitamin K antagonist, such as warfarin. Other areas include the use of the Activated Clotting Time to monitor anticoagulation for patients on cardio-pulmonary bypass, platelet function testing to identify patients with apparent aspirin or clopidogrel resistance and thrombelastography to guide blood product replacement during cardiac and hepatic surgery. In contrast to laboratory testing, POCT is frequently undertaken by untrained or semi-trained individuals and in many cases is not subject to the same strict quality control programmes that exist in the central laboratory. Although external quality assessment programmes do exist for some POCT assays these are still relatively few. The use of POCT in haematology, particularly in the field of haemostasis, is likely to expand and it is important that systems are in place to ensure that the generated results are accurate and precise.
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Affiliation(s)
- David J Perry
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK.
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Lippi G, Favaloro EJ, Salvagno GL, Franchini M. Laboratory assessment and perioperative management of patients on antiplatelet therapy: from the bench to the bedside. Clin Chim Acta 2009; 405:8-16. [PMID: 19351529 DOI: 10.1016/j.cca.2009.03.055] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Revised: 03/25/2009] [Accepted: 03/29/2009] [Indexed: 01/29/2023]
Abstract
The contribution of platelets in the pathophysiology of thromboses has established antiplatelet therapy as a cornerstone for prevention or treatment of these disorders. However, patients on antiplatelet drugs undergoing surgery face the life-threatening dilemma between the risk of perioperative thrombosis by ceasing therapy and restoring platelet function versus the risk of surgical bleeding by its continuation. According to their mechanism of action, antiplatelet drugs can be conventionally classified as agents that inhibit cyclooxygenase, block the platelet adenosine diphosphate P2Y12 receptor, inhibit phosphodiesterase, or block platelet glycoprotein IIb/IIIa. Although several tests have been developed to assess platelet inhibition by most of these compounds, studies to date have not been able to reliably evaluate the diagnostic efficiency of these tests to predict hemorrhage and/or blood loss, and accordingly perioperative assessment of drug-induced platelet inhibition cannot be recommended as yet. Although several management options are available to counteract the hemorrhagic risk of surgical patients using antiplatelet agents, perioperative discontinuation of these drugs is the preferable choice wherever possible. The use of platelet transfusions should be limited where necessary to the treatment of major, life-threatening bleeding. The contribution of newer hemostatic agents, such as desmopressin and recombinant activated factor VII, is yet to be fully determined, and there remain many challenges and unresolved issues in the clinical care of these patients.
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Affiliation(s)
- Giuseppe Lippi
- Sezione di Chimica Clinica, Dipartimento di Scienze Biomediche e Morfologiche, Università di Verona, Italy.
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Levy MJ, Anderson MA, Baron TH, Banerjee S, Dominitz JA, Gan SI, Harrison ME, Ikenberry SO, Jagannath S, Lichtenstein D, Shen B, Fanelli RD, Stewart L, Khan K. Position statement on routine laboratory testing before endoscopic procedures. Gastrointest Endosc 2008; 68:827-32. [PMID: 18984097 DOI: 10.1016/j.gie.2008.06.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Accepted: 06/02/2008] [Indexed: 02/08/2023]
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Snyder-Ramos SA, Mhnle P, Weng YS, Bttiger BW, Kulier A, Levin J, Mangano DT. The ongoing variability in blood transfusion practices in cardiac surgery. Transfusion 2008; 48:1284-99. [DOI: 10.1111/j.1537-2995.2008.01666.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kotze CW, Kong RS, Hutchinson NP, Harper CM, Yusuf SW. Coronary artery stents and non-cardiac surgery. Br J Anaesth 2007; 100:138; author reply 138-9. [PMID: 18070789 DOI: 10.1093/bja/aem355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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