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Kharnaf M, Zafar F, Hogue S, Rosenfeldt L, Cantrell RL, Sharma BK, Pearson A, Sprague C, Leino D, Abplanalp WA, Zelek WM, McCrae KR, Shim YJ, Morales D, Tweddell J, Qualls JE, Palumbo JS. Factor XII promotes the thromboinflammatory response in a rat model of venoarterial extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2024; 168:e37-e53. [PMID: 37683721 PMCID: PMC10918029 DOI: 10.1016/j.jtcvs.2023.08.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/26/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Factor XII (FXII) is a multifunctional protease capable of activating thrombotic and inflammatory pathways. FXII has been linked to thrombosis in extracorporeal membrane oxygenation (ECMO), but the role of FXII in ECMO-induced inflammatory complications has not been studied. We used novel gene-targeted FXII- deficient rats to evaluate the role of FXII in ECMO-induced thromboinflammation. METHODS FXII-deficient (FXII-/-) Sprague-Dawley rats were generated using CRISPR/Cas9. A minimally invasive venoarterial (VA) ECMO model was used to compare wild-type (WT) and FXII-/- rats in 2 separate experimental cohorts: rats placed on ECMO without pharmacologic anticoagulation and rats anticoagulated with argatroban. Rats were maintained on ECMO for 1 hour or until circuit failure occurred. Comparisons were made with unchallenged rats and rats that underwent a sham surgical procedure without ECMO. RESULTS FXII-/- rats were maintained on ECMO without pharmacologic anticoagulation with low resistance throughout the 1-hour experiment. In contrast, WT rats placed on ECMO without anticoagulation developed thrombotic circuit failure within 10 minutes. Argatroban provided a means to maintain WT and FXII-/- rats on ECMO for the 1-hour time frame without thrombotic complications. Analyses of these rats demonstrated that ECMO resulted in increased neutrophil migration into the liver that was significantly blunted by FXII deficiency. ECMO also resulted in increases in high molecular weight kininogen cleavage and complement activation that were abrogated by genetic deletion of FXII. CONCLUSIONS FXII initiates hemostatic system activation and key inflammatory sequelae in ECMO, suggesting that therapies targeting FXII could limit both thromboembolism and inopportune inflammatory complications in this setting.
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Affiliation(s)
- Mousa Kharnaf
- The Heart Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Spencer Hogue
- The Heart Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Leah Rosenfeldt
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rachel L Cantrell
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Bal Krishan Sharma
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amelia Pearson
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Cassandra Sprague
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Daniel Leino
- Department of Pathology, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - William A Abplanalp
- The Heart Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Wioleta M Zelek
- Systems Immunity Research Institute and Dementia Research Institute, Cardiff University, Cardiff, United Kingdom
| | - Keith R McCrae
- Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Young Jun Shim
- Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Cleveland, Ohio
| | - David Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James Tweddell
- The Heart Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joseph E Qualls
- Department of Biological Sciences, St Elizabeth College of Natural and Health Sciences, Thomas More University, Crestview Hills, Ky
| | - Joseph S Palumbo
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio.
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2
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Witzdam L, White T, Rodriguez-Emmenegger C. Steps Toward Recapitulating Endothelium: A Perspective on the Next Generation of Hemocompatible Coatings. Macromol Biosci 2024:e2400152. [PMID: 39072925 DOI: 10.1002/mabi.202400152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 06/26/2024] [Indexed: 07/30/2024]
Abstract
Endothelium, the lining in this blood vessel, orchestrates three main critical functions such as protecting blood components, modulating of hemostasis by secreting various inhibitors, and directing clot digestion (fibrinolysis) by activating tissue plasminogen activator. No other surface can perform these tasks; thus, the contact of blood and blood-contacting medical devices inevitably leads to the activation of coagulation, often causing device failure, and thromboembolic complications. This perspective, first, discusses the biological mechanisms of activation of coagulation and highlights the efforts of advanced coatings to recapitulate one characteristic of endothelium, hereafter single functions of endothelium and noting necessity of the synergistic integration of its three main functions. Subsequently, it is emphasized that to overcome the challenges of blood compatibility an endothelium-mimicking system is needed, proposing a synergy of bottom-up synthetic biology, particularly synthetic cells, with passive- and bioactive surface coatings. Such integration holds promise for developing advanced biomaterials capable of recapitulating endothelial functions, thereby enhancing the hemocompatibility and performance of blood-contacting medical devices.
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Affiliation(s)
- Lena Witzdam
- Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Carrer de Baldiri Reixac, 10, 12, Barcelona, 08028, Spain
- DWI - Leibniz Institute for Interactive Materials, Forckenbeckstraße 50, 52074, Aachen, Germany
- Institute of Technical and Macromolecular Chemistry, RWTH Aachen University, Worringerweg 2, 52074, Aachen, Germany
| | - Tom White
- Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Carrer de Baldiri Reixac, 10, 12, Barcelona, 08028, Spain
| | - Cesar Rodriguez-Emmenegger
- Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology (BIST), Carrer de Baldiri Reixac, 10, 12, Barcelona, 08028, Spain
- DWI - Leibniz Institute for Interactive Materials, Forckenbeckstraße 50, 52074, Aachen, Germany
- Catalan Institution for Research and Advanced Studies (ICREA), Passeig Lluís Companys 23, Barcelona, 08010, Spain
- Biomedical Research Networking, Center in Bioengineering, Biomaterials and Nanomedicine, The Institute of Health Carlos III, Madrid, 28029, Spain
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Shimoda T, Liu C, Mathis BJ, Goto Y, Ageyama N, Kato H, Matsubara M, Ohigashi T, Gosho M, Suzuki Y, Hiramatsu Y. Effect of cardiopulmonary bypass on coagulation factors II, VII and X in a primate model: an exploratory pilot study. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad194. [PMID: 38015856 PMCID: PMC10701202 DOI: 10.1093/icvts/ivad194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/05/2023] [Accepted: 11/27/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVES The use of cardiopulmonary bypass (CPB) in cardiac surgery is a major risk factor for postoperative bleeding. We hypothesized that consumptive coagulopathy and haemodilution influence the coagulation factors; therefore, we aimed to estimate the activity profiles of coagulation factors II, VII and X during CPB circulation. METHODS A 120-min bypass was surgically established in cynomolgus monkeys (n = 7). Activities of coagulation factors II, VII and X were measured at 6 time points during the experiment (baseline, 0, 30, 60, 120 min of bypass and 60 min after bypass). To assess the influence of consumptive coagulopathy, the values were adjusted for haemodilution using the haematocrit values. Data were expressed as mean (standard deviation). RESULTS Activities of coagulation factors decreased during the experiment. In particular, the activities for II, VII and X were decreased the most by 44.2% (5.0), 61.4% (4.3) and 49.0% (3.7) at 30 min following CPB initiation (P < 0.001, P < 0.001 and P < 0.001, respectively). Following adjustments for haemodilution, change magnitudes lessened but remained significant for factor VII. The adjusted concentration of factor VII was observed to decrease from the baseline to the initiation of bypass circulation. CONCLUSIONS In conclusion, coagulation factor II, VII and X concentrations decreased during CPB. Following adjustment for haemodilution, a decrease in concentration was observed with factor VII.
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Affiliation(s)
- Tomonari Shimoda
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Chang Liu
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Bryan J Mathis
- International Medical Center, University of Tsukuba Hospital, Ibaraki, Japan
| | - Yukinobu Goto
- Department of Thoracic Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naohide Ageyama
- Tsukuba Primate Research Center, National Institute of Biomedical Innovation, Tsukuba, Ibaraki, Japan
| | - Hideyuki Kato
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Muneaki Matsubara
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tomohiro Ohigashi
- Tsukuba Clinical Research & Development Organization, University of Tsukuba Hospital, Ibaraki, Japan
| | - Masahiko Gosho
- Department of Biostatistics, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yasuyuki Suzuki
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yuji Hiramatsu
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
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Li T, Bo F, Meng X, Wang D, Ma J, Dai Z. The effect of perioperative antithrombin supplementation on blood conservation and postoperative complications after cardiopulmonary bypass surgery: A systematic review, meta-analysis and trial sequential analysis. Heliyon 2023; 9:e22266. [PMID: 38053853 PMCID: PMC10694320 DOI: 10.1016/j.heliyon.2023.e22266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
Study objective Antithrombin (AT) activity is reduced during cardiopulmonary bypass (CPB) surgery. Guidelines has demonstrated that perioperative AT supplementation contributed to blood conservation and prevent perioperative thrombotic complications and target organ injury owing to its role in reducing thrombin generation. But these recommends is lack of support of meta-analysis in the guidelines. This meta-analysis aims to include all the relevant randomized controlled trails (RCT) on patients who experienced cardiac surgeries with CPB and investigate the effect of perioperative AT on blood conservation and complications after cardiac surgery. Methods Standard published RCTs were searched from bibliographic databases to identify all evidence reporting perioperative AT supplementation for patients undergoing cardiovascular surgeries. The primary outcome was postoperative blood loss, the secondary outcomes were blood component transfusion (red blood cell (RBC), fresh frozen plasma (FFP), platelet and autologous blood), postoperative morbidity and in hospital mortality. The relative risk (RR) for dichotomous outcomes and the standardized mean difference (SMD) for continuous outcomes were estimated using a random-effects model. Trial sequential analysis (TSA) was performed using TSA software 0.9.5.10. Results 13 RCTs with 996 participants undergoing different cardiovascular surgeries were included. Meta-analysis showed AT did not decrease postoperative blood loss (SMD -0.01, 95%CI -0.2 to 0.19). Subgroup analysis showed the effect of AT on postoperative blood loss was not associated with age, RCT type, surgery type, injection time of AT and AT deficiency. TSA further suggested that no additional studies were required for the stable result. Perioperative AT also did not reduce RBC ((SMD 0.10, 95%CI -0.66 to 0.85), (RR 0.99, 95%CI 0.83 to 1.19)), FFP ((SMD 0.11, 95%CI -0.19 to 0.41), (RR 1.30, 95%CI 0.90 to 1.87)), platelet (RR 1.10, 95%CI 0.83 to 1.46) and autologous blood (SMD 0.46, 95%CI -0.12 to 1.8504) transfusions. Perioperative AT significantly increased in hospital mortality (RR 2.53, 95%CI 1.02 to 6.28) and acute kidney injury (AKI) (RR 3.72, 95%CI 1.73 to 8.04) incidence. There was no significant difference in postoperative reexploration, thromboembolism, ECMO/IABP support, and stroke incidence between AT and non-AT group. Conclusions With the improvement of AT level and heparin sensitivity, perioperative AT has no significant effect on blood conservation. And it is noteworthy that the treatment increased in hospital mortality and the incidence of AKI after cardiac surgery.
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Affiliation(s)
- Tao Li
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - FengShan Bo
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - XiangRui Meng
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - Di Wang
- Department of Internal Medicine, Yantai Haigang Hospital, Yantai, 264000, Shandong, China
| | - Jiahai Ma
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - Zhao Dai
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
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5
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Yi Y, Card S, Dalia A, Bardia A. Intracardiac Echogenicity During Cardiopulmonary Bypass in a Vasoplegic Patient Undergoing Coronary Artery Bypass Grafting: To Explore or To Ignore. J Cardiothorac Vasc Anesth 2023; 37:673-675. [PMID: 36639260 DOI: 10.1053/j.jvca.2022.12.020] [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: 12/10/2022] [Revised: 12/18/2022] [Accepted: 12/21/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Yangtian Yi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shika Card
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Adam Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Amit Bardia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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6
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Chao Y, Wang F. Arterial line waveform dampening, during weaning from cardiopulmonary bypass. Heliyon 2022; 8:e11134. [PMID: 36303896 PMCID: PMC9593208 DOI: 10.1016/j.heliyon.2022.e11134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/03/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
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Saleem Y, Darbari A, Sharma R, Vashisth A, Gupta A. Recent advancements in pediatric cardiopulmonary bypass technology for better outcomes of pediatric cardiac surgery. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00084-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pediatric cardiac surgery is in itself very enigmatic and individualized. Presently, there has been a slew of new developments aimed primarily toward pediatric cardiopulmonary bypass for safer, patient-centered pediatric cardiac surgery. Still, lot of technological challenges need to be resolved, and their safer application in pediatric and neonate patients requires further refinement.
Main body of the abstract
Considering various significant yet unresolved issues of pediatric cardiac bypass, an exhaustive literature search was done on various internet databases with standard keywords. There are various new recent improvements; as the first oxygenator explicitly designed for neonatal patients; pediatric oxygenators with low prime volumes and surface areas that allow flows up to 2 L/min; pediatric oxygenators with integrated arterial filters; and miniature ultrafiltration devices that allow for high rates of ultrafiltrate removal. These advancements can significantly reduce cardiopulmonary bypass circuit surface areas and prime volumes. These advancements could reduce or eliminate the requirement for homologous red blood cells during or after surgery with reduction or eliminate bypass-related hemodilution, and inflammation. Because of the immaturity of the neonatal hemostatic system, conventional coagulation tests alone are insufficient to guide neonatal hemostatic therapy. Myocardial preservation techniques, safe temperature with duration are still debatable and yet to be fully explored.
Short conclusion
This review is based on Standards for Quality Improvement Reporting Excellence guidelines to provide a framework for reporting new knowledge to find better management strategy for pediatric cardiac cases.
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8
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Moront MG, Woodward MK, Essandoh MK, Avery EG, Reece TB, Brzezinski M, Spiess B, Shore-Lesserson L, Chen J, Henriquez W, Barceló M, Despotis G, Karkouti K, Levy JH, Ranucci M, Mondou E. A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial of Preoperative Antithrombin Supplementation in Patients at Risk for Antithrombin Deficiency After Cardiac Surgery. Anesth Analg 2022; 135:757-768. [PMID: 35877927 DOI: 10.1213/ane.0000000000006145] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Antithrombin (AT) activity is reduced during cardiac operations with cardiopulmonary bypass (CPB), which is associated with adverse outcomes. Preoperative AT supplementation, to achieve >58% and <100% AT activity, may potentially reduce postoperative morbidity and mortality in cardiac operations with CPB. This prospective, multicenter, randomized, double-blind, placebo-controlled study was designed to evaluate the safety and efficacy of preoperative treatment with AT supplementation in patients at risk for low AT activity after undergoing cardiac surgery with CPB. METHODS A total of 425 adult patients were randomized (1:1) to receive either a single dose of AT (n = 213) to achieve an absolute increase of 20% above pretreatment AT activity or placebo (n = 212) before surgery. The study duration was approximately 7 weeks. The primary efficacy end point was the percentage of patients with any component of a major morbidity composite (postoperative mortality, stroke, acute kidney injury [AKI], surgical reexploration, arterial or venous thromboembolic events, prolonged mechanical ventilation, and infection) in the 2 groups. Secondary end points included AT activity, blood loss, transfusion requirements, duration of intensive care unit (ICU), and hospital stays. Safety was also assessed. RESULTS Overall, 399 patients (men, n = 300, 75.2%) with a mean (standard deviation [SD]) age of 66.1 (11.7) years, with the majority undergoing complex surgical procedures (n = 266, 67.9%), were analyzed. No differences in the percentage of patients experiencing morbidity composite outcomes between groups were observed (AT-treated 68/198 [34.3%] versus placebo 58/194 [29.9%]; P = .332; relative risk, 1.15). After AT infusion, AT activity was significantly higher in the AT group (108% [42-143]) versus placebo group (76% [40-110]), and lasted up to postoperative day 2. At ICU, the frequency of patients with AT activity ≥58% in the AT group (81.5%) was significantly higher (P < .001) versus placebo group (43.2%). Secondary end point analysis did not show any advantage of AT over placebo group. There were significantly more patients with AKI (P < .001) in the AT group (23/198; 11.6%) than in the placebo group (5/194, 2.6%). Safety results showed no differences in treatment-emergent adverse events nor bleeding events between groups. CONCLUSIONS AT supplementation did not attenuate adverse postoperative outcomes in our cohort of patients undergoing cardiac surgery with CPB.
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Affiliation(s)
- Michael George Moront
- From the, Department of Cardiothoracic Sugery, Promedical Toledo Hospital, Toledo, Ohio
| | | | - Michael K Essandoh
- Department of Anesthesiology' Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Edwin G Avery
- Department of Anesthesiology and Perioperative Medicine, University Hospital Case Medical Center, Cleveland, Ohio
| | - T Brett Reece
- Department of Surgery' Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Marek Brzezinski
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Bruce Spiess
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | | | - Junliang Chen
- Bioscience Research Group, Grifols, Barcelona, Spain
| | | | | | - George Despotis
- Departments of Pathology, Immunology and Anesthesiology, Washington University School of Medicine, St. Louis, Missouri
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCSS Policlinico San Donato, Milan, Italy
| | - Elsa Mondou
- Bioscience Research Group, Grifols, Barcelona, Spain
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9
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Chabata CV, Frederiksen JW, Olson LB, Naqvi IA, Hall SE, Gunaratne R, Kraft BD, Que LG, Chen L, Sullenger BA. Combining Heparin and a FX/Xa Aptamer to Reduce Thrombin Generation in Cardiopulmonary Bypass and COVID-19. Nucleic Acid Ther 2022; 32:139-150. [PMID: 35021888 PMCID: PMC9221171 DOI: 10.1089/nat.2021.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
Known limitations of unfractionated heparin (UFH) have encouraged the evaluation of anticoagulant aptamers as alternatives to UFH in highly procoagulant settings such as cardiopulmonary bypass (CPB). Despite progress, these efforts have not been totally successful. We take a different approach and explore whether properties of an anticoagulant aptamer can complement UFH, rather than replace it, to address shortcomings with UFH use. Combining RNA aptamer 11F7t, which targets factor X/Xa, with UFH (or low molecular weight heparin) yields a significantly enhanced anticoagulant cocktail effective in normal and COVID-19 patient blood. This aptamer-UFH combination (1) supports continuous circulation of human blood through an ex vivo membrane oxygenation circuit, as is required for patients undergoing CPB and COVID-19 patients requiring extracorporeal membrane oxygenation, (2) allows for a reduced level of UFH to be employed, (3) more effectively limits thrombin generation compared to UFH alone, and (4) is rapidly reversed by the administration of protamine sulfate, the standard treatment for reversing UFH clinically following CPB. Thus, the combination of factor X/Xa aptamer and UFH has significantly improved anticoagulant properties compared to UFH alone and underscores the potential of RNA aptamers to improve medical management of acute care patients requiring potent yet rapidly reversible anticoagulation.
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Affiliation(s)
- Charlene V. Chabata
- Department of Surgery, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
- Department of Pharmacology and Cancer Biology, Duke University, Durham, North Carolina, USA
| | - James W. Frederiksen
- Department of Surgery, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
| | - Lyra B. Olson
- Department of Surgery, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
- Department of Pharmacology and Cancer Biology, Duke University, Durham, North Carolina, USA
- Medical Scientist Training Program, Duke University, Durham, North Carolina, USA
| | - Ibtehaj A. Naqvi
- Department of Surgery, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
- Department of Anesthesiology, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
| | - Sharon E. Hall
- Division of Hematology, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
| | - Ruwan Gunaratne
- Department of Medicine, Stanford University Medical Center, Stanford, California, USA
| | - Bryan D. Kraft
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Loretta G. Que
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lingye Chen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bruce A. Sullenger
- Department of Surgery, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
- Department of Pharmacology and Cancer Biology, Duke University, Durham, North Carolina, USA
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10
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A Case Report of Severe Factor XI Deficiency during Cardiac Surgery: Less Can Be More. J Cardiovasc Dev Dis 2022; 9:jcdd9040118. [PMID: 35448094 PMCID: PMC9027232 DOI: 10.3390/jcdd9040118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/10/2022] [Accepted: 04/14/2022] [Indexed: 01/27/2023] Open
Abstract
Severe congenital Factor XI (FXI) deficiency (<20% normal activity) can be associated with significant bleeding disorders, and there has been great concern for severe bleeding following cardiac surgery requiring cardiopulmonary bypass (CPB) in this patient population. Over the past four decades remarkably different approaches to this problem have been taken, including the administration of blood volumes of fresh frozen plasma, administration of activated recombinant Factor VII, and diminutive administration of heparin. We describe a case wherein the patient was assessed in the perioperative period with a point-of-care, viscoelastic hemostasis device (ROTEM), with changes in the intrinsic/Factor XII-dependent coagulation pathway determined before, during, and after CPB. Fresh frozen plasma was administered in small amounts (5−7.5 mL/kg) just before surgery began and just before cessation of CPB. Administering fresh frozen plasma to the patient to nearly normalize in vitro ROTEM hemostasis values at times when hemostasis was needed resulted in no important bleeding occurring or need of further transfusion of other blood products. In conclusion, by using small amounts of fresh frozen plasma guided by ROTEM, an evidenced-based, precision medicine approach resulted in optimized patient care and outcome.
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11
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Elliott A, Dahyia G, Kalra R, Alexy T, Bartos J, Kosmopoulos M, Yannopoulos D. Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.
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Affiliation(s)
- Andrea Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Garima Dahyia
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Rajat Kalra
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Jason Bartos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Department of Medicine, Division of Cardiology, Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN
| | - Demetri Yannopoulos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
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12
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Trigonis R, Smith N, Porter S, Anderson E, Jennings M, Kapoor R, Hage C, Moiz S, Garcia J, Rahman O. Efficacy of Bivalirudin for Therapeutic Anticoagulation in COVID-19 Patients Requiring ECMO Support. J Cardiothorac Vasc Anesth 2021; 36:414-418. [PMID: 34782234 PMCID: PMC8526440 DOI: 10.1053/j.jvca.2021.10.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 10/12/2021] [Accepted: 10/16/2021] [Indexed: 01/03/2023]
Abstract
Objectives The Coronavirus Disease 2019 (COVID-19) pandemic has been associated with cases of refractory acute respiratory distress syndrome (ARDS) sometimes requiring support with extracorporeal membrane oxygenation (ECMO). Bivalirudin can be used for anticoagulation in patients on ECMO support, but its efficacy and safety in patients with COVID-19 is unknown. The authors set out to compare the pharmacologic characteristics and dosing requirements of bivalirudin in patients requiring ECMO support for ARDS due to COVID-19 versus ARDS from other etiologies. Design and Setting This retrospective case-control study was performed at Indiana University Health Methodist Hospital in Indianapolis, Indiana. Participants Patients were included if they were on venovenous ECMO support between June 2019 and June 2020, and divided into two groups: ARDS secondary to COVID-19 and those with ARDS from another etiology (Non-COVID). Interventions Patient demographics, such as age, sex, weight, chronic comorbid conditions, baseline antiplatelet and anticoagulant use, antiplatelet use during ECMO, and need for renal replacement therapy were collected, and compared between groups. Time to activated partial thromboplastin time (aPTT) goal, percentage of time at aPTT goal, bivalirudin rates, total bivalirudin requirements, total duration on bivalirudin, total duration on ECMO, mortality, and complications associated with ECMO were collected and compared between groups. Measurements and Main Results A total of 42 patients met inclusion criteria (n = 19 COVID-19, n = 23 non-COVID). However, percentages of aPTTs at goal were maintained more consistently in patients with COVID-19 versus non-COVID (86% v 74%: p < 0.01). Higher median (IQR) daily rates (3.1 μg/kg/min [2.3-5.2] v 2.4 μg/kg/min [1.7-3.3]: p = 0.05) and higher median (IQR) maximum rates of bivalirudin (5 μg/kg/min [3.7-7.5] v 3.8 μg/kg/min [2.5-5]: p = 0.03) were required in the COVID-19 group versus the non-COVID group. Time to goal aPTT was similar between groups. There were no differences in complications associated with anticoagulation, as demonstrated by similar rates of bleeding and thrombosis between both groups. Conclusions Patients on ECMO with ARDS from COVID-19 require more bivalirudin overall and higher rates of bivalirudin to maintain goal aPTTs compared with patients without COVID-19. However, COVID-19 patients more consistently maintain goal aPTT. Future randomized trials are needed to support efficacy and safety of bivalirudin for anticoagulation of COVID-19 patients on ECMO.
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Affiliation(s)
| | - Nikki Smith
- Indiana University School of Medicine, Indianapolis, IN
| | - Shelley Porter
- Indiana University Health Methodist Hospital, Indianapolis, IN
| | - Eve Anderson
- Indiana University Health Methodist Hospital, Indianapolis, IN
| | | | - Rajat Kapoor
- Indiana University Health Methodist Hospital, Indianapolis, IN
| | - Chadi Hage
- Indiana University Health Methodist Hospital, Indianapolis, IN
| | | | - Jose Garcia
- Indiana University Health Methodist Hospital, Indianapolis, IN
| | - Omar Rahman
- Indiana University Health Methodist Hospital, Indianapolis, IN.
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13
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Changing of haemostatic system in a pig model during different types of hypothermic circulatory arrest. J Therm Biol 2021; 95:102817. [PMID: 33454045 DOI: 10.1016/j.jtherbio.2020.102817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/09/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hypothermic circulatory arrest is usually used in aortic surgery, congenital heart defect repairs and other complex surgeries. It is frequently associated with excessive postoperative bleeding and the transfusion of allogeneic blood products. The physiopathology of hypothermic circulatory arrest-induced coagulopathy has never been systematically studied. The aim of the study was to investigate this phenomenon in a pig model. METHODS Ten pigs were randomly assigned to 30 min of hypothermic circulatory arrest at either 15 °C (n = 5) or 25 °C (n = 5). Detection of apoptosis and haemostatic system assays were performed in this experiment. Enzyme-linked immunosorbent assays were performed at ten time points in each group to study the changes in the coagulation system in hypothermic circulatory arrest. All of the statistical analyses were performed in SPSS software, version 18.0, and as bilateral tests, and p < 0.05 was considered statistically significant. RESULTS There was no significant difference in the effect of different types of hypothermic circulatory arrest on routine laboratory tests and tissue sample analysis (p > 0.05, for all). Our results demonstrated that more severe systemic activation of the coagulation system (TAT and F1+2) was applied in the deep hypothermic circulatory arrest group but not in the moderate hypothermic circulatory arrest group (TAT/p = 0.01, F1+2/p = 0.03). However, this activation of the coagulation system (AT III and PC) was not associated with changes in the anticoagulation pathway (AT III/p = 0.24, PC/p = 0.33). In addition, analysis of biomarkers of the haemostatic system revealed that the consumption of coagulation is more concentrated on extrinsic coagulation factors (FVII/p = 0.01). CONCLUSIONS Moderate hypothermic circulatory arrest is more suitable for patients with coagulation dysfunction. We believe the application of deep hypothermic circulatory arrest should pay more attention to changes in coagulation rather than the anticoagulation pathway. Extrinsic coagulation factor supplementation is more effective after deep hypothermic circulatory arrest.
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Krishnamoorthy V, Babu S, Koshy T, Devarakonda BV, Palaniswamy N, Dharan BS. Left Ventricular Thrombus Formation During Cardiopulmonary Bypass Diagnosed by Intraoperative Transesophageal Echocardiography in a Case of Anomalous Left Coronary Artery From the Pulmonary Artery. J Cardiothorac Vasc Anesth 2020; 35:2751-2755. [PMID: 32798167 DOI: 10.1053/j.jvca.2020.07.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Vasanth Krishnamoorthy
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Saravana Babu
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
| | - Thomas Koshy
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Bhargava V Devarakonda
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Nithiyanandhan Palaniswamy
- Division of Cardiothoracic and Vascular Anesthesia, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
| | - Baiju S Dharan
- Department of Cardiothoracic and Vascular surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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15
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Seelhammer TG, Rowse P, Yalamuri S. Bivalirudin for Maintenance Anticoagulation During Venovenous Extracorporeal Membrane Oxygenation for COVID-19. J Cardiothorac Vasc Anesth 2020; 35:1149-1153. [PMID: 32660924 PMCID: PMC7315936 DOI: 10.1053/j.jvca.2020.06.059] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 01/22/2023]
Abstract
In its severe manifestation, coronavirus disease 2019 (COVID-19) compromises oxygenation in a manner that is refractory to maximal conventional support and requires escalation to extracorporeal membrane oxygenation (ECMO). Maintaining ECMO support for extended durations requires a delicately balanced anticoagulation strategy to maintain circuit viability by preventing thrombus deposition while avoiding excessive anticoagulation yielding hemorrhage—a task that is complicated in COVID-19 secondary to an inherent hypercoagulable state. Bivalirudin, a member of the direct thrombin inhibitor drug class, offers potential advantages during ECMO, including to its ability to exert its effect by directly attaching to and inhibiting freely circulating and fibrin-bound thrombin. Herein, the successful use of an anticoagulation strategy using the off-label use of a continuous infusion of bivalirudin in a case of severe hypoxemic and hypercarbic respiratory failure caused by COVID-19 requiring venovenous ECMO is reported. Importantly, therapeutic anticoagulation intensity was achieved rapidly with stable pharmacokinetics, and there was no need for any circuit interventions throughout the patient's 27-day ECMO course. In COVID-19, bivalirudin offers a potential option for maintaining systemic anticoagulation during ECMO in a manner that may mitigate the prothrombotic nature of the underlying pathophysiologic state.
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Affiliation(s)
- Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| | - Phillip Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Suraj Yalamuri
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
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16
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Han I, Cho YW, Park SE, An MG, Kang HJ, Lee AR. Acute normovolemic hemodilution for a patient with secondary polycythemia undergoing aortic valve replacement due to severe aortic stenosis - A case report. Anesth Pain Med (Seoul) 2020; 15:181-186. [PMID: 33329811 PMCID: PMC7713815 DOI: 10.17085/apm.2020.15.2.181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/29/2019] [Accepted: 09/18/2019] [Indexed: 11/17/2022] Open
Abstract
Background A high hematocrit level in patients with erythrocytosis is linked with increased blood viscosity and increased risk of thromboembolism. Therefore, it is necessary to adequately lower the hematocrit level before performing a high-risk surgery. Case A 67-year-old male was scheduled for aortic valve replacement due to severe aortic stenosis. The preoperative hematocrit level of this patient was very high due to secondary polycythemia by hypoxia. We decided to perform acute normovolemic hemodilution after anesthetic induction to reduce the risk of thromboembolism in the patient. The patient was discharged after a successful surgery and a post-operative period without any side effects.
Conclusions We estimate that patients with secondary polycythemia may benefit from acute normovolemic hemodilution to reduce their hematocrit levels while undergoing cardiac surgery using cardiopulmonary bypass. However, it is necessary to control the hematocrit level, since a significant decrease can cause side effects.
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Affiliation(s)
- Ilsang Han
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Young Woo Cho
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Soon Eun Park
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Min Gi An
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Ho June Kang
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
| | - A-Ran Lee
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, Ulsan, Korea
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17
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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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18
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Labarrere CA, Dabiri AE, Kassab GS. Thrombogenic and Inflammatory Reactions to Biomaterials in Medical Devices. Front Bioeng Biotechnol 2020; 8:123. [PMID: 32226783 PMCID: PMC7080654 DOI: 10.3389/fbioe.2020.00123] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 02/10/2020] [Indexed: 12/17/2022] Open
Abstract
Blood-contacting medical devices of different biomaterials are often used to treat various cardiovascular diseases. Thrombus formation is a common cause of failure of cardiovascular devices. Currently, there are no clinically available biomaterials that can totally inhibit thrombosis under the more challenging environments (e.g., low flow in the venous system). Although some biomaterials reduce protein adsorption or cell adhesion, the issue of biomaterial associated with thrombosis and inflammation still exists. To better understand how to develop more thrombosis-resistant medical devices, it is essential to understand the biology and mechano-transduction of thrombus nucleation and progression. In this review, we will compare the mechanisms of thrombus development and progression in the arterial and venous systems. We will address various aspects of thrombosis, starting with biology of thrombosis, mathematical modeling to integrate the mechanism of thrombosis, and thrombus formation on medical devices. Prevention of these problems requires a multifaceted approach that involves more effective and safer thrombolytic agents but more importantly the development of novel thrombosis-resistant biomaterials mimicking the biological characteristics of the endothelium and extracellular matrix tissues that also ameliorate the development and the progression of chronic inflammation as part of the processes associated with the detrimental generation of late thrombosis and neo-atherosclerosis. Until such developments occur, engineers and clinicians must work together to develop devices that require minimal anticoagulants and thrombolytics to mitigate thrombosis and inflammation without causing serious bleeding side effects.
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Affiliation(s)
| | - Ali E Dabiri
- California Medical Innovations Institute, San Diego, CA, United States
| | - Ghassan S Kassab
- California Medical Innovations Institute, San Diego, CA, United States
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Cashen K, Meert K, Dalton H. Anticoagulation in Neonatal ECMO: An Enigma Despite a Lot of Effort! Front Pediatr 2019; 7:366. [PMID: 31572699 PMCID: PMC6753198 DOI: 10.3389/fped.2019.00366] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 08/21/2019] [Indexed: 12/30/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a valuable modality used to support neonates, children, and adults with cardiorespiratory failure refractory to conventional therapy. It requires use of anticoagulation to prevent clotting in the extracorporeal circuit. Balancing bleeding from excessive anticoagulation with thrombotic risk remains a difficult aspect of ECMO care. Despite many advances in ECMO technology, better understanding of the coagulation cascade and new monitoring schemes to adjust anticoagulation, bleeding and thrombosis remain the most frequent complications in ECMO and are associated with morbidity and mortality. In neonates, ECMO is also complicated by the immature hemostatic system, laboratory testing norms which are not specific for neonates, lack of uniformity in management, and paucity of high-quality evidence to determine best practices. Traditional anticoagulation focuses on the use of unfractionated heparin. Direct thrombin inhibitors are also used but have not been well-studied in the neonatal ECMO population. Anticoagulation monitoring is complex and currently available assays do not take into account thrombin generation or platelet contribution to clot formation. Global assays may add valuable information to guide therapy. This review provides an overview of hemostatic alterations, anticoagulation, monitoring and management, novel anticoagulant use, and circuit modifications for neonatal ECMO. Future considerations are also presented.
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Affiliation(s)
- Katherine Cashen
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
| | - Heidi Dalton
- Division of Critical Care Medicine, Department of Pediatrics, INOVA Heart and Vascular Institute, Inova Fairfax Medical Institute, Falls Church, VA, United States
- Department of Surgery, George Washington University, Washington, DC, United States
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20
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Kotlarek D, Vorobii M, Ogieglo W, Knoll W, Rodriguez-Emmenegger C, Dostálek J. Compact Grating-Coupled Biosensor for the Analysis of Thrombin. ACS Sens 2019; 4:2109-2116. [PMID: 31364363 DOI: 10.1021/acssensors.9b00827] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A compact optical biosensor for direct detection of thrombin in human blood plasma (HBP) is reported. This biosensor platform is based on wavelength spectroscopy of diffraction-coupled surface plasmons on a chip with a periodically corrugated gold film that carries an antifouling thin polymer layer consisting of poly[(N-(2-hydroxypropyl)methacrylamide)-co-(carboxybetaine methacrylamide)] (poly(HPMA-co-CBMAA)) brushes. This surface architecture provides superior resistance to nonspecific and irreversible adsorption of abundant compounds in the analyzed HBP samples in comparison to standard surface modifications. The carboxylate groups along the polymer brushes were exploited for the covalent immobilization of aptamer ligands. These ligands were selected to specifically capture the target thrombin analyte from the analyzed HBP sample in a way that does not activate the coagulatory process at the biosensor surface with poly(HPMA-co-CBMAA) brushes. Direct label-free analysis of thrombin in the medically relevant concentration range (1-20 nM) is demonstrated without the need for diluting the HBP samples or using additional steps for signal enhancement. The reported platform constitutes the first step toward a portable and sensitive point-of-care device for direct detection of thrombin in human blood.
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Affiliation(s)
- Daria Kotlarek
- Biosensor Technologies, AIT-Austrian Institute of Technology GmbH, Konrad-Lorenz-Straße 24, 3430 Tulln an der Donau, Austria
| | - Mariia Vorobii
- DWI − Leibniz Institute for Interactive Materials and Institute of Technical and Macromolecular Chemistry, RWTH Aachen University, Forckenbeckstraße 50, 52074 Aachen, Germany
| | - Wojciech Ogieglo
- DWI − Leibniz Institute for Interactive Materials and Institute of Technical and Macromolecular Chemistry, RWTH Aachen University, Forckenbeckstraße 50, 52074 Aachen, Germany
| | - Wolfgang Knoll
- Biosensor Technologies, AIT-Austrian Institute of Technology GmbH, Konrad-Lorenz-Straße 24, 3430 Tulln an der Donau, Austria
| | - Cesar Rodriguez-Emmenegger
- DWI − Leibniz Institute for Interactive Materials and Institute of Technical and Macromolecular Chemistry, RWTH Aachen University, Forckenbeckstraße 50, 52074 Aachen, Germany
| | - Jakub Dostálek
- Biosensor Technologies, AIT-Austrian Institute of Technology GmbH, Konrad-Lorenz-Straße 24, 3430 Tulln an der Donau, Austria
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Ranucci M, Baryshnikova E. Inflammation and coagulation following minimally invasive extracorporeal circulation technologies. J Thorac Dis 2019; 11:S1480-S1488. [PMID: 31293797 DOI: 10.21037/jtd.2019.01.27] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Minimally invasive extracorporeal perfusion technologies are based on the use of a minimally invasive extracorporeal circulation (MiECC) system. This includes a closed CPB circuit; biologically inert blood contact surfaces; reduced priming volume; a centrifugal pump; a membrane oxygenator; a heat exchanger; a cardioplegia system; a venous bubble trap/venous air removing device; and a shed blood management system. Some of these items, alone or in combination, are able to modify the blood activation usually elicited by cardiopulmonary bypass (CPB). The hemostatic system activation is less activated and lower degrees of thrombin generation and platelet activation have been found in numerous studies. Additionally, the reduced level of hemodilution plays an important role in preserving clot firmness after CPB with MiECC. These biochemical changes are reflected by a blood loss containment, a reduced need for allogeneic blood transfusions, and, in some studies, by a lower thromboembolic complications rate. The activation of the inflammatory cascade is in turn limited by MiECC, both directly (through a blunting of the contact-phase activation) and indirectly (through a limited thrombin generation, platelet activation, and consequent lower release of pro-inflammatory cytokines). The clinical consequences of this are mainly demonstrated by a lower rate of postoperative atrial fibrillation; other inflammation-derived outcomes appear favorably affected by MiECC (lung function, acute kidney injury) but the multi-factorial nature of these complications makes difficult to clearly attribute this pattern to a lower degree of inflammation. Overall, the existing body of evidence is in favor of MiECC with respect to standard CPB.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Ekaterina Baryshnikova
- Department of Cardiovascular Anesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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22
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Di Dedda U, Ranucci M, Porta A, Bari V, Ascari A, Fantinato A, Baryshnikova E, Cotza M. The combined effects of the microcirculatory status and cardiopulmonary bypass on platelet count and function during cardiac surgery. Clin Hemorheol Microcirc 2019; 70:327-337. [PMID: 29710690 DOI: 10.3233/ch-180391] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass is associated with important changes in the microcirculation, usually attributed to endothelial dysfunction. Another common finding of cardiac surgery is postoperative thrombocytopenia and platelet loss of function. OBJECTIVE To investigate the association between microvascular flow pattern and postoperative changes in platelet count and function in cardiac surgery patients. METHODS Twelve adult cardiac surgery patients received microvascular circulation (sidestream darkfield sublingual mucosa analysis) and platelet count and function (multiple electrode aggregometry ADPtest and TRAPtest) assessment before and after cardiopulmonary bypass. RESULTS After cardiopulmonary bypass, sublingual microcirculation showed a significantly (P = 0.001) decreased microvascular flow index and increased heterogeneity index (P = 0.006). Platelet function significantly decrease after cardiopulmonary bypass both at ADPtest (P = 0.011) and TRAPtest (P = 0.002). Preoperative patterns of poor microvascular perfusion (low perfused vessels density and total vessels density) were significantly associated with lower values of post-cardiopulmonary bypass platelet function (ADPtest, P = 0.009, TRAPtest, P = 0.031) and count (P = 0.048). CONCLUSIONS A preoperative disturbance of the microcirculation is associated with a greater postoperative platelet dysfunction. Endothelial damage, chemical and mechanical stimuli are the possible link between the two patterns.
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Affiliation(s)
- Umberto Di Dedda
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marco Ranucci
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alberto Porta
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Vlasta Bari
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alice Ascari
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Angela Fantinato
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Ekaterina Baryshnikova
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Mauro Cotza
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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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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Jooste EH, Scholl R, Wu YH, Jaquiss RDB, Lodge AJ, Ames WA, Homi HM, Machovec KA, Greene NH, Donahue BS, Shah N, Benkwitz C. Double-Blind, Randomized, Placebo-Controlled Trial Comparing the Effects of Antithrombin Versus Placebo on the Coagulation System in Infants with Low Antithrombin Undergoing Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 33:396-402. [PMID: 30072263 DOI: 10.1053/j.jvca.2018.05.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine whether precardiopulmonary bypass (CPB) normalization of antithrombin levels in infants to 100% improves heparin sensitivity and anticoagulation during CPB and has beneficial effects into the postoperative period. DESIGN Randomized, double-blinded, placebo-controlled prospective study. SETTING Multicenter study performed in 2 academic hospitals. PARTICIPANTS The study comprised 40 infants younger than 7 months with preoperative antithrombin levels <70% undergoing CPB surgery. INTERVENTIONS Antithrombin levels were increased with exogenous antithrombin to 100% functional level intraoperatively before surgical incision. MEASUREMENTS AND MAIN RESULTS Demographics, clinical variables, and blood samples were collected up to postoperative day 4. Higher first post-heparin activated clotting times (sec) were observed in the antithrombin group despite similar initial heparin dosing. There was an increase in heparin sensitivity in the antithrombin group. There was significantly lower 24-hour chest tube output (mL/kg) in the antithrombin group and lower overall blood product unit exposures in the antithrombin group as a whole. Functional antithrombin levels (%) were significantly higher in the treatment group versus placebo group until postoperative day 2. D-dimer was significantly lower in the antithrombin group than in the placebo group on postoperative day 4. CONCLUSION Supplementation of antithrombin in infants with low antithrombin levels improves heparin sensitivity and anticoagulation during CPB without increased rates of bleeding or adverse events. Beneficial effects may be seen into the postoperative period, reflected by significantly less postoperative bleeding and exposure to blood products and reduced generation of D-dimers.
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Affiliation(s)
- Edmund H Jooste
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Rebecca Scholl
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Yi-Hung Wu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Robert D B Jaquiss
- Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center and Children's Medical Center, Dallas, TX
| | - Andrew J Lodge
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Duke University Medical Center, Durham
| | - Warwick A Ames
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - H Mayumi Homi
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Kelly A Machovec
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Nathaniel H Greene
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Brian S Donahue
- Division of Pediatric Cardiac Anesthesiology, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Nirmish Shah
- Division of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, NC
| | - Claudia Benkwitz
- Department of Anesthesia and Perioperative Care, UCSF Benioff Children's Hospital, San Francisco, CA
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Coagulation Profile Is Not a Predictor of Acute Cerebrovascular Events in Pediatric Extracorporeal Membrane Oxygenation Patients. ASAIO J 2018; 63:793-801. [PMID: 28678046 DOI: 10.1097/mat.0000000000000571] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We performed a retrospective matched case-control study evaluating whether the traditional coagulation profile predicts cerebrovascular events in children on extracorporeal membrane oxygenation (ECMO) in a 71 bed intensive care unit at a tertiary children's hospital. Between 2009 and 2014, 241 neonates and children were initiated on ECMO. The cumulative 5 year incidence of intracranial hemorrhage and infarct was 9.2% and 7.9%, respectively. Thirty-six cases were individually matched 1:1 with control subjects based on age, primary diagnosis, ECMO type, cannulation site, and the presence of pre-ECMO coagulopathy. In-hospital mortality was higher among the cases compared with control subjects (78 vs. 22%, p < 0.01). The median laboratory values that assisted with heparin anticoagulation monitoring (activated clotting time, partial thromboplastin time, and antifactor Xa) and the laboratory data that assisted with blood product administration (platelet count, prothrombin time, fibrinogen, and d-dimer) during the 24 and 72 hour periods before the cerebrovascular event did not show any significant difference between the hemorrhage group and their controls or between the infarct group and their controls. The traditional coagulation profile did not predict acute cerebrovascular events in our cohort. Other markers of neurologic injury on ECMO are yet to be elucidated. Prospective studies to determine better predictors of cerebrovascular complications in pediatric ECMO patients are required.
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26
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Meesters MI, Veerhoek D, de Lange F, de Vries JW, de Jong JR, Romijn JWA, Kelchtermans H, Huskens D, van der Steeg R, Thomas PWA, Burtman DTM, van Barneveld LJM, Vonk ABA, Boer C. Effect of high or low protamine dosing on postoperative bleeding following heparin anticoagulation in cardiac surgery. Thromb Haemost 2018; 116:251-61. [DOI: 10.1160/th16-02-0117] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/06/2016] [Indexed: 11/05/2022]
Abstract
SummaryWhile experimental data state that protamine exerts intrinsic anticoagulation effects, protamine is still frequently overdosed for heparin neutralisation during cardiac surgery with cardiopulmonary bypass (CPB). Since comparative studies are lacking, we assessed the influence of two protamine-to-heparin dosing ratios on perioperative haemostasis and bleeding, and hypothesised that protamine overdosing impairs the coagulation status following cardiac surgery. In this open-label, multicentre, single-blinded, randomised controlled trial, patients undergoing on-pump coronary artery bypass graft surgery were assigned to a low (0.8; n=49) or high (1.3; n=47) protamine-to-heparin dosing group. The primary outcome was 24-hour blood loss. Patient haemostasis was monitored using rotational thromboelastometry and a thrombin generation assay. The low protamine-to-heparin dosing ratio group received less protamine (329 ± 95 vs 539 ± 117 mg; p<0.001), while post-protamine activated clotting times were similar among groups. The high dosing group revealed increased intrinsic clotting times (236 ± 74 vs 196 ± 64 s; p=0.006) and the maximum post-protamine thrombin generation was less suppressed in the low dosing group (38 ± 40% vs 6 ± 9%; p=0.001). Postoperative blood loss was increased in the high dosing ratio group (615 ml; 95% CI 500–830 ml vs 470 ml; 95% CI 420–530 ml; p=0.021) when compared to the low dosing group, respectively. More patients in the high dosing group received fresh frozen plasma (11% vs 0%; p=0.02) and platelet concentrate (21% vs 6%; p=0.04) compared to the low dosing group. Our study confirms in vitro data that abundant protamine dosing is associated with increased postoperative blood loss and higher transfusion rates in cardiac surgery.
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Kanda H, Hirasaki Y, Iida T, Kanao-Kanda M, Toyama Y, Chiba T, Kunisawa T. Perioperative Management of Patients With End-Stage Renal Disease. J Cardiothorac Vasc Anesth 2017; 31:2251-2267. [DOI: 10.1053/j.jvca.2017.04.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Indexed: 12/17/2022]
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28
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Bosch YPJ, Bloemen S, de Laat B, Weerwind PW, Mochtar B, Maessen JG, Wagenvoord RJ, Al Dieri R, Coenraad Hemker H, Kremers RMW. A reduction of prothrombin conversion by cardiac surgery with cardiopulmonary bypass shifts the haemostatic balance towards bleeding. Thromb Haemost 2017; 116:442-51. [DOI: 10.1160/th16-02-0094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/31/2016] [Indexed: 11/05/2022]
Abstract
SummaryCardiac surgery with cardiopulmonary bypass (CPB) is associated with blood loss and post-surgery thrombotic complications. The process of thrombin generation is disturbed during surgery with CPB because of haemodilution, coagulation factor consumption and heparin administration. We aimed to investigate the changes in thrombin generation during cardiac surgery and its underlying pro- and anticoagulant processes, and to explore the clinical consequences of these changes using in silico experimentation. Plasma was obtained from 29 patients undergoing surgery with CPB before heparinisation, after heparinisation, after haemodilution, and after protamine administration. Thrombin generation was measured and prothrombin conversion and thrombin inactivation were quantified. In silico experimentation was used to investigate the reaction of patients to the administration of procoagulant factors and/or anticoagulant factors. Surgery with CPB causes significant coagulation factor consumption and a reduction of thrombin generation. The total amount of prothrombin converted and the rate of prothrombin conversion decreased during surgery. As the surgery progressed, the relative contribution of α2-macroglobulin-dependent thrombin inhibition increased, at the expense of antithrombin-dependent inhibition. In silico restoration of post-surgical prothrombin conversion to pre-surgical levels increased thrombin generation excessively, whereas co-administration of antithrombin resulted in the normalisation of post-surgical thrombin generation. Thrombin generation is reduced during surgery with cardiopulmonary bypass because of a balance shift between prothrombin conversion and thrombin inactivation. According to in silico predictions of thrombin generation, this new balance increases the risk of thrombotic complications with prothrombin complex concentrate administration, but not if antithrombin is co-administered.
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29
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Scrascia G, Rotunno C, Simone S, Montemurno E, Amorese L, De Palo M, Castellano G, Pertosa GB, Gesualdo L, Paparella D. Acute kidney injury in high-risk cardiac surgery patients: roles of inflammation and coagulation. J Cardiovasc Med (Hagerstown) 2017; 18:359-365. [PMID: 26657082 DOI: 10.2459/jcm.0000000000000343] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Acute kidney injury (AKI) is a common complication following cardiac surgery. Cardiopulmonary bypass elicits coagulation and inflammation activation and oxidative stress, all involved in AKI but never simultaneously assessed. We aimed to evaluate relations between oxidative stress, inflammatory and coagulation systems activation and postoperative renal function in patients with normal preoperative renal function. METHODS Forty-one high-risk patients (EuroSCORE >6 and preoperative haemoglobin <12 g/dl in women and <13 g/dl in men) were prospectively enrolled. Prothrombin fragment 1.2 (coagulation marker), interleukin-6 and interleukin-10 (pro/anti-inflammatory markers) and 8-oxo-2'-deoxyguanosine (oxidative stress marker) were evaluated until postoperative day 5. RESULTS Patients were divided into two groups according to estimated glomerular filtration rate reduction observed postoperatively (reduction <25% in 26 patients: NO-AKI group; reduction >25% in 15 patients: AKI group). No differences were found for inflammatory markers. Oxidative stress slightly increased in the AKI group. Twenty-four hours after the operation prothrombin fragment 1.2 levels were significantly higher in the AKI group (506.6 ± 548 vs. 999 ± 704.1 pmol/l; P = 0.018), and they were independently associated with estimated glomerular filtration rate reduction, with an area under the receiving operating characteristic of 0.744. CONCLUSION Thrombin generation is higher in patients with renal function worsening, and it is an independent risk factor for AKI in patients with anaemia, possibly leading to microcirculation impairment and tubular cells damage.
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Affiliation(s)
- Giuseppe Scrascia
- aDivision of Cardiac Surgery, Department of Emergency and Organs Transplant, University of Bari 'Aldo Moro', Bari bDivision of Cardiac Surgery, 'Vito Fazzi' Hospital, Lecce cDivision of Nephrology, Dialysis and Transplantation, Department of Emergency and Organs Transplant, University of Bari 'Aldo Moro', Bari, Italy
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30
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Liu Y, Han L, Li J, Gong M, Zhang H, Guan X. Consumption coagulopathy in acute aortic dissection: principles of management. J Cardiothorac Surg 2017; 12:50. [PMID: 28606160 PMCID: PMC5468986 DOI: 10.1186/s13019-017-0613-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/06/2017] [Indexed: 12/31/2022] Open
Abstract
Background The effect of acute aortic dissection itself on coagulopathy or surgery-related coagulopathy has never been specifically studied. The aim of the present study was to perioperatively describe consumption coagulopathy in patients with acute aortic dissection. Methods Sixty-six patients with acute type A aortic dissection were enrolled in this study from January 2015 to September 2016. Thirty-six patients with thoracic aortic aneurysms were used as a control group during the same period. Consumption coagulopathy was evaluated using standard laboratory tests, enzyme-linked immunosorbent assay and thromboelastograghy at five perioperative time-points. Results A significant reduction in clotting factors and fibrinogen was observed at the onset of acute aortic dissection. Enzyme-linked immunosorbent assay and thromboelastograghy also revealed a persistent systemic activation of the coagulation system and the consumption of clotting factors. In contrast, although platelet counts were consistently low, we did not find that platelet function was more impaired in the acute aortic dissection group than the control group. Conclusions After surgery, clotting factors and fibrinogen were more impaired than platelet function. Thus, we proposed that hemostatic therapy should focus on the rapid and sufficient supplementation of clotting factors and fibrinogen to improve consumption coagulopathy in patients with acute aortic dissection.
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Affiliation(s)
- Yuyong Liu
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Lab for Cardiovascular Precision Medicine, and Beijing Engineering Research Center of Vascular Prostheses, No. 2 Anzhen Street, Beijing, 100029, China
| | - Lu Han
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Lab for Cardiovascular Precision Medicine, and Beijing Engineering Research Center of Vascular Prostheses, No. 2 Anzhen Street, Beijing, 100029, China
| | - Jiachen Li
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Lab for Cardiovascular Precision Medicine, and Beijing Engineering Research Center of Vascular Prostheses, No. 2 Anzhen Street, Beijing, 100029, China
| | - Ming Gong
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Lab for Cardiovascular Precision Medicine, and Beijing Engineering Research Center of Vascular Prostheses, No. 2 Anzhen Street, Beijing, 100029, China
| | - Hongjia Zhang
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Lab for Cardiovascular Precision Medicine, and Beijing Engineering Research Center of Vascular Prostheses, No. 2 Anzhen Street, Beijing, 100029, China
| | - Xinliang Guan
- Department of Cardiac Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Lab for Cardiovascular Precision Medicine, and Beijing Engineering Research Center of Vascular Prostheses, No. 2 Anzhen Street, Beijing, 100029, China.
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31
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Cho HJ, Kim DW, Kim GS, Jeong IS. Anticoagulation Therapy during Extracorporeal Membrane Oxygenator Support in Pediatric Patients. Chonnam Med J 2017; 53:110-117. [PMID: 28584789 PMCID: PMC5457945 DOI: 10.4068/cmj.2017.53.2.110] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/22/2017] [Accepted: 04/28/2017] [Indexed: 02/01/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a salvage therapy for critically ill patients. Although ECMO is becoming more common, hemorrhagic and thromboembolic complications remain the major causes of death in patients undergoing ECMO treatments. These complications commence upon blood contact with artificial surfaces of the circuit, blood pump, and oxygenator system. Therefore, anticoagulation therapy is required in most cases to prevent these problems. Anticoagulation is more complicated in pediatric patients than in adults, and the foreign surface of ECMO only increases the complexity of systemic anticoagulation. In this review, we discuss the pathophysiology of coagulation, anticoagulants, and monitoring tools in pediatric patients receiving ECMO.
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Affiliation(s)
- Hwa Jin Cho
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea.,Extracorporeal Life Support Organization, Asia-Pacific Chapter, Ann Arbor, MI, USA
| | - Do Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gwan Sic Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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32
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Stansfield BK, Wise L, Ham PB, Patel P, Parman M, Jin C, Mathur S, Harshfield G, Bhatia J. Outcomes following routine antithrombin III replacement during neonatal extracorporeal membrane oxygenation. J Pediatr Surg 2017; 52:609-613. [PMID: 27847121 DOI: 10.1016/j.jpedsurg.2016.10.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/05/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND We sought to examine the effect of routine antithrombin III (AT3) infusion on hemorrhagic and thrombotic complications, blood product utilization, and circuit lifespan in neonatal extracorporeal membrane oxygenation (ECMO). METHODS We performed a retrospective cohort study of 162 infants placed on ECMO for hypoxic respiratory failure. Infants requiring ECMO for primary cardiac support were excluded. Demographic data, time on ECMO, blood product usage, coagulation profile, and complications were compared between 90 control patients and 72 patients treated with AT3. RESULTS Infants receiving AT3 during ECMO had less thrombotic and similar bleeding complications as compared to infants receiving standard anticoagulation therapy. Total blood product infusion during ECMO was decreased (54.7±20.1 vs. 67.4±34.9mL/kg per day, p=0.001) in infants receiving AT3 during ECMO. Tighter control of activated clotting time and higher serum heparin anti-Xa levels were observed in the AT3 cohort during the first days of ECMO support. 1st ECMO circuit lifespan did not differ between groups. CONCLUSIONS Routine administration of AT3 in neonates receiving ECMO therapy was associated with tighter control of anticoagulation and a reduction in thrombotic events without increasing unwanted bleeding. However, circuit lifespan was unaffected. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Brian K Stansfield
- Department of Pediatrics, Augusta University, Augusta, GA, USA; Vascular Biology Center, Augusta University, Augusta, GA, USA.
| | - Linda Wise
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - P Benson Ham
- Department of Surgery, Augusta University, Augusta, GA, USA
| | - Pinkal Patel
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Malinda Parman
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Chan Jin
- Department of Biostatistics and Epidemiology, Augusta University, Augusta, GA
| | - Sunil Mathur
- Department of Biostatistics and Epidemiology, Augusta University, Augusta, GA
| | - Gregory Harshfield
- Department of Pediatrics, Augusta University, Augusta, GA, USA; Georgia Prevention Institute, Augusta University, Augusta, GA, USA
| | - Jatinder Bhatia
- Department of Pediatrics, Augusta University, Augusta, GA, USA
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33
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Paparella D, Parolari A, Rotunno C, Vincent J, Myasoedova V, Guida P, De Palo M, Margari V, Devereaux PJ, Lamy A, Alamanni F, Yusuf S, Whitlock R. The Effects of Steroids on Coagulation Dysfunction Induced by Cardiopulmonary Bypass: A Steroids in Cardiac Surgery (SIRS) Trial Substudy. Semin Thorac Cardiovasc Surg 2017; 29:35-44. [DOI: 10.1053/j.semtcvs.2017.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 11/11/2022]
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34
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Kosova EC, Bonaca MP, Dellborg M, He P, Morais J, Oude Ophuis T, Scirica BM, Tendera M, Theroux P, Braunwald E, Morrow DA. Vorapaxar in patients with coronary artery bypass grafting: Findings from the TRA 2°P-TIMI 50 trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:164-172. [DOI: 10.1177/2048872616644910] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ethan C Kosova
- Department of Medicine, Brigham and Women’s Hospital, Boston, USA
| | - Marc P Bonaca
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, USA
| | - Mikael Dellborg
- Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ping He
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, USA
| | | | | | - Benjamin M Scirica
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, USA
| | - Michal Tendera
- Third Division of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Pierre Theroux
- Montreal Heart Institute, University of Montreal, Canada
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, USA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, USA
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Beyer JT, Schoeppler KE, Zanotti G, Weiss GM, Mueller SW, MacLaren R, Fish DN, Kiser TH. Antithrombin Administration During Intravenous Heparin Anticoagulation in the Intensive Care Unit: A Single-Center Matched Retrospective Cohort Study. Clin Appl Thromb Hemost 2016; 24:145-150. [PMID: 27624738 DOI: 10.1177/1076029616668407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Unfractionated heparin (UFH) is a frequently utilized indirect anticoagulant that induces therapeutic effect by enhancing antithrombin (AT)-mediated procoagulant enzyme inhibition. In suspected heparin resistance (HR) during cardiopulmonary bypass, AT activity may be decreased and AT supplementation helps restore UFH responsiveness. The benefit of AT supplementation in HR over longer durations of UFH therapy is unclear. The objective of this study was to describe and evaluate the use of AT III concentrate in the intensive care units (ICUs) at our institution for improving UFH therapy response over 72 hours. A total of 44 critically ill patients were included in the analysis-22 patients received at least 1 dose of AT and 22 patients received no AT. Thirty (68.2%) of the 44 patients were receiving mechanical circulatory support. Baseline characteristics were similar between groups. The average AT activity prior to AT supplementation was 57.9% in the treatment group, and the median cumulative dose of AT was 786.5 U (9.26 U/kg) per patient. There were no significant differences observed in proportion of time spent in therapeutic range (31.9% vs 35.2%, P = .65), time to therapeutic goal (16.5 vs 15.5 hours, P = .97), or patients who experienced a bleeding event (5 vs 5, P = .99) between groups. In conclusion, AT supplementation had minimal impact on anticoagulant response in this cohort of ICU patients with mild to moderate HR receiving a prolonged UFH infusion. Additional research is needed to define AT activity targets and to standardize AT supplementation practices in patients receiving prolonged heparin infusion.
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Affiliation(s)
- Jacob T Beyer
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Kelly E Schoeppler
- 2 Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Giorgio Zanotti
- 3 Department of Surgery, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Gregory M Weiss
- 4 Department of Anesthesiology, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Scott W Mueller
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Robert MacLaren
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Douglas N Fish
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Tyree H Kiser
- 1 Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Guan X, Li J, Gong M, Lan F, Zhang H. The hemostatic disturbance in patients with acute aortic dissection: A prospective observational study. Medicine (Baltimore) 2016; 95:e4710. [PMID: 27603366 PMCID: PMC5023888 DOI: 10.1097/md.0000000000004710] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Coagulopathy is still a frequent complication in the surgical treatment of acute aortic dissection. However, the physiopathology of surgically induced coagulopathy has never been systematically and comprehensively studied in patients with acute aortic dissection. The aim of the present study was to describe the perioperative hemostatic system in patients with acute aortic dissection.The 87 patients who underwent aortic arch surgery for acute Stanford type A aortic dissection from January 2013 to September 2015 were enrolled in this study. The perioperative biomarkers of hemostatic system were evaluated using standard laboratory tests and enzyme-linked immunosorbent assays (ELISAs) at 5 time points: anesthesia induction (T1), lowest nasopharyngeal temperature (T2), protamine reversal (T3), 4 hours after surgery (T4), and 24 hours after surgery (T5).The ELISAs biomarkers revealed activation of coagulation (thrombin-antithrombin III complex [TAT] and prothrombin fragment 1 + 2 [F1 + 2] were elevated), suppression of anticoagulation (antithrombin III [AT III] levels were depressed), and activation of fibrinolysis (plasminogen was decreased and plasmin-antiplasmin complex [PAP] was elevated). The standard laboratory tests also demonstrated that surgery resulted in a significant reduction in platelet counts and fibrinogen concentration.Systemic activation of coagulation and fibrinolysis, and inhibition of anticoagulation were observed during the perioperative period in patients with acute aortic dissection. Indeed, these patients exhibited consumption coagulopathy and procoagulant state perioperatively. Therefore, we believe that this remarkable disseminated intravascular coagulation (DIC)-like coagulopathy has a high risk of bleeding and may influence postoperative outcome of patients with acute aortic dissection.
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Affiliation(s)
| | | | | | | | - Hongjia Zhang
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
- Correspondence: Hongjia Zhang, Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, No. 2 Anzhen Street, Beijing 100029, China (e-mail: )
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Baryshnikova E, Ranucci M. Point-of-care haemostasis and coagulation monitoring in cardiac surgery at IRCCS Policlinico San Donato. Eur Heart J Suppl 2016; 18:E42-E48. [PMID: 28533716 DOI: 10.1093/eurheartj/suw013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
A rational management of perioperative and postoperative bleeding in modern cardiac surgery requires a thorough application of point-of-care (POC) monitoring in order to prevent and readily treat alterations of the haemostatic process. Preoperative platelet dysfunction, residual heparin after extracorporeal circulation, coagulation factors, and/or fibrinogen deficiency could be ruled out and specifically addressed with an appropriate treatment. Our approach includes preoperative platelet function testing of patients administered with thienopyridines or ticagrelor within 7-10 days before planned surgery and platelet function testing-based surgery timing. In the case of postoperative bleeding, residual heparin is tested and additional protamine is eventually administered. Simultaneously, an overall activity of coagulation factors (except fibrinogen) is assessed and, if significantly reduced, correction with prothrombotic complex concentrate is considered. If fibrinogen deficiency is suspected, a specific test is run, and in the case of severe reduction, the deficiency is compensated by fibrinogen concentrate or appropriate volume of fresh-frozen plasma. If both coagulation factors and fibrinogen activity are reduced, fibrinogen is usually considered for correction as first line, followed by prothrombin complex concentrate in the case of further bleeding. It is our clinical practice not to test nor to treat patients until postoperative bleeding appears clinically relevant. At IRCCS Policlinico San Donato, we firmly believe in the importance of the POC-based strategy for haemostatic treatment and constantly update our knowledge through research projects targeted in answering clinically relevant questions.
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Affiliation(s)
- Ekaterina Baryshnikova
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy
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Gielen CL, Brand A, van Heerde WL, Stijnen T, Klautz RJ, Eikenboom J. Hemostatic alterations during coronary artery bypass grafting. Thromb Res 2016; 140:140-146. [DOI: 10.1016/j.thromres.2015.12.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 11/16/2015] [Accepted: 12/23/2015] [Indexed: 11/28/2022]
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Paparella D. Hemostatic alteration during coronary artery bypass grafting: Which is the target? Thromb Res 2016; 140:147-148. [PMID: 26928139 DOI: 10.1016/j.thromres.2016.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 02/13/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Domenico Paparella
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari "Aldo Moro", Bari, Italy.
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Parolari A, Poggio P, Myasoedova V, Songia P, Pilozzi A, Alamanni F, Tremoli E. Molecular pathways activation in coronary artery bypass surgery. J Cardiovasc Med (Hagerstown) 2016; 17:54-61. [DOI: 10.2459/jcm.0000000000000293] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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41
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Ghazi L, Schwann TA, Engoren MC, Habib RH. Role of blood transfusion product type and amount in deep vein thrombosis after cardiac surgery. Thromb Res 2015; 136:1204-10. [DOI: 10.1016/j.thromres.2015.10.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 10/06/2015] [Accepted: 10/29/2015] [Indexed: 11/30/2022]
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42
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43
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Discriminatory power of the intraoperative cell salvage use in the prediction of platelet and plasma transfusion in patients undergoing cardiac surgery. Transfus Apher Sci 2015; 53:208-12. [DOI: 10.1016/j.transci.2015.03.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 11/20/2022]
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44
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Jaffer IH, Fredenburgh JC, Hirsh J, Weitz JI. Medical device-induced thrombosis: what causes it and how can we prevent it? J Thromb Haemost 2015; 13 Suppl 1:S72-81. [PMID: 26149053 DOI: 10.1111/jth.12961] [Citation(s) in RCA: 305] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Blood-contacting medical devices, such as vascular grafts, stents, heart valves, and catheters, are often used to treat cardiovascular diseases. Thrombus formation is a common cause of failure of these devices. This study (i) examines the interface between devices and blood, (ii) reviews the pathogenesis of clotting on blood-contacting medical devices, (iii) describes contemporary methods to prevent thrombosis on blood-contacting medical devices, (iv) explains why some anticoagulants are better than others for prevention of thrombosis on medical devices, and (v) identifies future directions in biomaterial research for prevention of thrombosis on blood-contacting medical devices.
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Affiliation(s)
- I H Jaffer
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - J C Fredenburgh
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - J Hirsh
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - J I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
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Al‐Riyami AZ, Al‐Khabori M, Baskaran B, Siddiqi M, Al‐Sabti H. Intra‐operative cell salvage in cardiac surgery may increase platelet transfusion requirements: a cohort study. Vox Sang 2015; 109:280-6. [DOI: 10.1111/vox.12280] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Revised: 02/23/2015] [Accepted: 02/27/2015] [Indexed: 11/26/2022]
Affiliation(s)
- A. Z. Al‐Riyami
- Department of Hematology Sultan Qaboos University Hospital Muscat Oman
| | - M. Al‐Khabori
- Department of Hematology Sultan Qaboos University Hospital Muscat Oman
| | - B. Baskaran
- Department of Surgery Cardiothoracic Surgery Division Sultan Qaboos University Hospital Muscat Oman
| | - M. Siddiqi
- Department of Surgery Cardiothoracic Surgery Division Sultan Qaboos University Hospital Muscat Oman
| | - H. Al‐Sabti
- Department of Surgery Cardiothoracic Surgery Division Sultan Qaboos University Hospital Muscat Oman
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Fukui T, Nishida H, Takanashi S. Biocompatibility of cardiopulmonary bypass circuit with new polymer Senko E-Ternal CoatingTM. Perfusion 2015; 30:572-9. [DOI: 10.1177/0267659115580666] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: The aim of this study was to compare the biocompatibility of a new Senko E-Ternal coating (SEC) for cardiopulmonary bypass (CPB) circuits with the well-established poly-2-methoxyethyl acrylate (PMEA) coating. Methods: Forty patients undergoing aortic valve replacement were randomly assigned to either an SEC-coated group (n = 20) or a PMEA-coated group (n = 20). Clinical data and the following markers were analyzed: platelet count, platelet factor (PF) 4, fibrinogen, fibrinogen degradation products (FDPs), antithrombin III (AT III), thrombin-antithrombin complex (TAT), plasminogen, complement hemolytic activity (CH50), complement 3 (C3) and interleukin-6 (IL-6). Blood samples were obtained at five time points in both groups. Results: CPB time, aortic cross-clamp time and blood loss and transfusion were similar in both groups. There were no significant differences between the groups in terms of platelet count, PF4 and all coagulation and fibrinolytic parameters (FDP, AT III, TAT, and plasminogen) at any time points. Inflammatory markers (CH50, C3 and IL-6) were also similar in both groups at all time points. Conclusions: The SEC-coated circuit demonstrated equivalent biocompatibility to the PMEA-coated circuit. SEC-coated circuits are, therefore, favorably comparable to PMEA-coated circuits for clinical use in CPB.
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Affiliation(s)
- T Fukui
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - H Nishida
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - S Takanashi
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
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Inflammatory response and extracorporeal circulation. Best Pract Res Clin Anaesthesiol 2015; 29:113-23. [PMID: 26060024 DOI: 10.1016/j.bpa.2015.03.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 02/11/2015] [Accepted: 03/19/2015] [Indexed: 02/06/2023]
Abstract
Patients undergoing cardiac surgery with extracorporeal circulation (EC) frequently develop a systemic inflammatory response syndrome. Surgical trauma, ischaemia-reperfusion injury, endotoxaemia and blood contact to nonendothelial circuit compounds promote the activation of coagulation pathways, complement factors and a cellular immune response. This review discusses the multiple pathways leading to endothelial cell activation, neutrophil recruitment and production of reactive oxygen species and nitric oxide. All these factors may induce cellular damage and subsequent organ injury. Multiple organ dysfunction after cardiac surgery with EC is associated with an increased morbidity and mortality. In addition to the pathogenesis of organ dysfunction after EC, this review deals with different therapeutic interventions aiming to alleviate the inflammatory response and consequently multiple organ dysfunction after cardiac surgery.
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Association of blood products administration during cardiopulmonary bypass and excessive post-operative bleeding in pediatric cardiac surgery. Pediatr Cardiol 2015; 36:459-67. [PMID: 25293425 DOI: 10.1007/s00246-014-1034-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
Abstract
Our objectives were to study risk factors and post-operative outcomes associated with excessive post-operative bleeding in pediatric cardiac surgeries performed using cardiopulmonary bypass (CPB) support. A retrospective observational study was undertaken, and all consecutive pediatric heart surgeries over 1 year period were studied. Excessive post-operative bleeding was defined as 10 ml/kg/h of chest tube output for 1 h or 5 ml/kg/h for three consecutive hours in the first 12 h of pediatric cardiac intensive care unit (PCICU) stay. Risk factors including demographics, complexity of cardiac defect, CPB parameters, hematological studies, and post-operative morbidity and mortality were evaluated for excessive bleeding. 253 patients were studied, and 107 (42 %) met the criteria for excessive bleeding. Bayesian model averaging revealed that greater volume of blood products transfusion during CPB was significantly associated with excessive bleeding. Multiple logistic regression analysis of blood products transfusion revealed that increased volume of packed red blood cells (PRBCs) administration for CPB prime and during CPB was significantly associated with excessive bleeding (p = 0.028 and p = 0.0012, respectively). Proportional odds logistic regression revealed that excessive bleeding was associated with greater time to achieve negative fluid balance, prolonged mechanical ventilation, and duration of PCICU stay (p < 0.001) after adjusting for multiple parameters. A greater volume of blood products administration, especially PRBCs transfusion for CPB prime, and during the CPB period is associated with excessive post-operative bleeding. Excessive bleeding is associated with worse post-operative outcomes.
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Ranucci M, Colella D, Baryshnikova E, Di Dedda U. Effect of preoperative P 2 Y 12 and thrombin platelet receptor inhibition on bleeding after cardiac surgery. Br J Anaesth 2014; 113:970-6. [DOI: 10.1093/bja/aeu315] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bockeria LA, Samsonova NN, Yurlov IA, Klimovich LG, Kozar EF, Olsen EHN, Zaets SB. Dynamics of factor XIII levels after open heart surgery for congenital heart defects: do cyanotic and acyanotic patients differ? Pediatr Cardiol 2014; 35:1108-15. [PMID: 24714980 DOI: 10.1007/s00246-014-0903-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 03/25/2014] [Indexed: 11/25/2022]
Abstract
Cardiopulmonary bypass (CPB) reduces coagulation factor levels through hemodilution and consumption. Differences in CPB-induced alterations of factor XIII (FXIII) levels in children with cyanotic and acyanotic congenital heart defects (CHDs) are not well characterized. FXIII activity (determined by Berichrom assay), prothrombin index, activated partial thromboplastin time, and fibrinogen were measured before open heart surgery with CPB and 5 days postoperatively for children older than 3 years with acyanotic (n = 30) and cyanotic (n = 30) CHDs. The preoperative FXIII levels did not differ significantly among the children of the compared groups. The cyanotic patients showed a significantly longer duration of CPB (111.4 ± 45.8 vs 71.5 ± 33.6 min; p = 0.026) and aortic cross-clamp (68.0 ± 27.1 vs 45.4 ± 31.4 min; p = 0.034). The drop in FXIII levels after termination of CPB was more profound for the children with cyanotic CHDs (87.1 ± 13.4 to 49.1 ± 13.2 vs 81.5 ± 12.6 to 58.6 ± 11.1 %, respectively; p = 0.018). The cyanotc patients also were restored to their baseline FXIII levels later than the children with acyanotic CHDs (at 48 vs 24 h). The post-CPB dynamics of the majority of the other coagulation parameters in the compared groups of patients were similar. The cyanotic patients experienced significantly greater postoperative blood loss than the acyanotic patients (12.6 ± 4.9 vs 5.0 ± 2.1 mL/kg; p < 0.001) and were transfused with larger volumes of red blood cells (10.4 ± 6.5 vs 4.2 ± 2.5 mL/kg; p = 0.007). The decrease in FXIII levels after CPB is more profound and lasts longer in children with cyanotic CHDs than in acyanotic patients. The rational strategy of postoperative FXIII replacement therapy for these categories of patients needs to be determined.
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Affiliation(s)
- Leo A Bockeria
- Bakoulev Center for Cardiovascular Surgery, Moscow, Russia
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