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Crivellari M, Landoni G, D'Andria Ursoleo J, Ferrante L, Oriani A. Protamine and Heparin Interactions: A Narrative Review. Ann Card Anaesth 2024; 27:202-212. [PMID: 38963354 DOI: 10.4103/aca.aca_117_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 12/08/2023] [Indexed: 07/05/2024] Open
Abstract
ABSTRACT Protamine, first isolated from salmon fish sperm and now produced through recombinant biotechnology, is an antidote that neutralizes the anticoagulant properties of heparin. Protamine function is based on the capacity to dissociate the heparin-antithrombin III (AT III) complex (an important link that promotes blood fluidification by inhibiting coagulation), forming the inactive heparin-protamine complex. Protamine has itself dose-dependent anticoagulant properties: It interferes with coagulation factors and platelet function; it stimulates fibrinolysis; it can lead to thrombocytopenia and reduction in thrombin-related platelet aggregation; it decreases platelet response to thrombin receptor agonist in a dose-dependent manner. In this review, we will focus on protamine and its interaction with heparin. Notably, protamine is able to antagonize not only unfractionated heparin (UFH) but also low molecular weight heparins to various degrees. Protamine-allergic and anaphylactoid systemic reactions may affect up to 1 in 10 people and should be prevented and treated early.
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Affiliation(s)
- Martina Crivellari
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Via Olgettina, 58, 20132, Milan, Italy
| | | | - Luca Ferrante
- Vita-Salute San Raffaele University, Via Olgettina, 58, 20132, Milan, Italy
| | - Alessandro Oriani
- IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132, Milan, Italy
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2
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Krissanaprasit A, Mihalko E, Meinhold K, Simpson A, Sollinger J, Pandit S, Dupont DM, Kjems J, Brown AC, LaBean TH. A functional RNA-origami as direct thrombin inhibitor with fast-acting and specific single-molecule reversal agents in vivo model. Mol Ther 2024:S1525-0016(24)00302-2. [PMID: 38720458 DOI: 10.1016/j.ymthe.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 03/29/2024] [Accepted: 05/03/2024] [Indexed: 05/21/2024] Open
Abstract
Injectable anticoagulants are widely used in medical procedures to prevent unwanted blood clotting. However, many lack safe, effective reversal agents. Here, we present new data on a previously described RNA origami-based, direct thrombin inhibitor (HEX01). We describe a new, fast-acting, specific, single-molecule reversal agent (antidote) and present in vivo data for the first time, including efficacy, reversibility, preliminary safety, and initial biodistribution studies. HEX01 contains multiple thrombin-binding aptamers appended on an RNA origami. It exhibits excellent anticoagulation activity in vitro and in vivo. The new single-molecule, DNA antidote (HEX02) reverses anticoagulation activity of HEX01 in human plasma within 30 s in vitro and functions effectively in a murine liver laceration model. Biodistribution studies of HEX01 in whole mice using ex vivo imaging show accumulation mainly in the liver over 24 h and with 10-fold lower concentrations in the kidneys. Additionally, we show that the HEX01/HEX02 system is non-cytotoxic to epithelial cell lines and non-hemolytic in vitro. Furthermore, we found no serum cytokine response to HEX01/HEX02 in a murine model. HEX01 and HEX02 represent a safe and effective coagulation control system with a fast-acting, specific reversal agent showing promise for potential drug development.
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Affiliation(s)
- Abhichart Krissanaprasit
- Department of Materials Science and Engineering, College of Engineering, North Carolina State University, Raleigh, NC 27695, USA.
| | - Emily Mihalko
- Joint Department of Biomedical Engineering, College of Engineering, North Carolina State University and University of North Carolina-Chapel Hill, Raleigh, NC 27695, USA
| | - Katherine Meinhold
- Department of Materials Science and Engineering, College of Engineering, North Carolina State University, Raleigh, NC 27695, USA
| | - Aryssa Simpson
- Joint Department of Biomedical Engineering, College of Engineering, North Carolina State University and University of North Carolina-Chapel Hill, Raleigh, NC 27695, USA
| | - Jennifer Sollinger
- Joint Department of Biomedical Engineering, College of Engineering, North Carolina State University and University of North Carolina-Chapel Hill, Raleigh, NC 27695, USA
| | - Sanika Pandit
- Joint Department of Biomedical Engineering, College of Engineering, North Carolina State University and University of North Carolina-Chapel Hill, Raleigh, NC 27695, USA
| | - Daniel M Dupont
- Interdisciplinary Nanoscience Center (iNANO), Department of Molecular Biology and Genetics, Aarhus University, Aarhus C, 8000 Aarhus, Denmark
| | - Jørgen Kjems
- Interdisciplinary Nanoscience Center (iNANO), Department of Molecular Biology and Genetics, Aarhus University, Aarhus C, 8000 Aarhus, Denmark
| | - Ashley C Brown
- Joint Department of Biomedical Engineering, College of Engineering, North Carolina State University and University of North Carolina-Chapel Hill, Raleigh, NC 27695, USA; Comparative Medicine Institute, North Carolina State University and University of North Carolina, Chapel Hill, NC 27695, USA
| | - Thomas H LaBean
- Department of Materials Science and Engineering, College of Engineering, North Carolina State University, Raleigh, NC 27695, USA; Comparative Medicine Institute, North Carolina State University and University of North Carolina, Chapel Hill, NC 27695, USA.
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Vandenheuvel M, Vandewiele K, De Somer F, Wouters PF. On the Reporting of Protamine Dosage in Cardiac Surgery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00305-7. [PMID: 38960806 DOI: 10.1053/j.jvca.2024.04.048] [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: 05/08/2023] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 07/05/2024]
Affiliation(s)
| | | | - Filip De Somer
- Department of Perfusion, Ghent University Hospital, Ghent, Belgium
| | - Patrick F Wouters
- Department of Anesthesiology, Ghent University Hospital, Ghent, Belgium; Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Sarkar S, Chakraborty G, Pal H. Surfactant-based supramolecular dye assembly: A highly selective and economically viable platform for quantification of heparin antidote. Colloids Surf B Biointerfaces 2024; 237:113839. [PMID: 38492411 DOI: 10.1016/j.colsurfb.2024.113839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/23/2024] [Accepted: 03/09/2024] [Indexed: 03/18/2024]
Abstract
Herein, we have employed a supramolecular assembly of a cationic dye, LDS-698 and a common surfactant sodium dodecyl sulfate (SDS) as a turn-on fluorescent sensor for protamine (Pr) detection. Addition of cationic Pr to the solution of dye-surfactant complex brings negatively charged SDS molecules together through strong electrostatic interaction, assisting aggregation of SDS way before its critical micellar concentration (CMC). These aggregates encapsulate the dye molecules within their hydrophobic region, arresting non-radiative decay channels of the excited dye. Thus, the LDS-698•SDS assembly displays substantial enhancement in fluorescence intensity that follows a nice linear trend with Pr concentration, providing limit of detection (LOD) for Pr as low as 3.84(±0.11) nM in buffer, 124.4(±6.7) nM in 1% human serum and 28.3(±0.5) nM in 100% human urine. Furthermore, high selectivity, low background signal, large stokes shift, and emission in the biologically favorable deep-red region make the studied assembly a promising platform for Pr sensing. As of our knowledge it is the first ever Pr sensory platform, using a very common surfactant (SDS), which is economically affordable and very easily available in the market. This innovative approach can replace the expensive, exotic and specialized chemicals considered for the purpose and thus showcase its potential in practical applications.
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Affiliation(s)
- Soumyadeep Sarkar
- Laser and Plasma Technology Division, Bhabha Atomic Research Centre, Mumbai 400085, India; Indian Institute of Science Education and Research, Campus Road, Mohanpur, Nadia, Kolkata, West Bengal 741246, India
| | - Goutam Chakraborty
- Laser and Plasma Technology Division, Bhabha Atomic Research Centre, Mumbai 400085, India.
| | - Haridas Pal
- Chemistry Group, Bhabha Atomic Research Centre, Mumbai 400085, India; Homi Bhabha National Institute, Anushaktinagar, Mumbai 400094, India.
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Bosio G, Destrempes F, Roy Cardinal MH, Cloutier G. Effect of rt-PA on Shear Wave Mechanical Assessment and Quantitative Ultrasound Properties of Blood Clot Kinetics In Vitro. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:829-840. [PMID: 38205972 DOI: 10.1002/jum.16411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/21/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVE The consequences associated with blood clots are numerous and are responsible for many deaths worldwide. The assessment of treatment efficacy is necessary for patient follow-up and to detect treatment-resistant patients. The aim of this study was to characterize the effect of treatment on blood clots in vitro using quantitative ultrasound parameters. METHODS Blood from 10 pigs was collected to form three clots per pig in gelatin phantoms. Clots were subjected to 1) no treatment, 2) rt-PA (recombinant tissue plasminogen activator) treatment after 20 minutes of clotting, and 3) rt-PA treatment after 60 minutes of clotting. Clots were weighted before and after the experiment to assess the treatment effect by the mass loss. The clot kinetics was studied over 100 minutes using elastography (Young's modulus, shear wave dispersion, and shear wave attenuation). Homodyne K-distribution (HKD) parameters derived from speckle statistics were also studied during clot formation and dissolving (diffuse-to-total signal power ratio and intensity parameters). RESULTS Treated clots loosed significantly more mass than non-treated ones (P < .005). A significant increase in Young's modulus was observed over time (P < .001), and significant reductions were seen for treated clots at 20 or 60 minutes compared with untreated ones (P < .001). The shear wave dispersion differed for treated clots at 60 minutes versus no treatments (P < .001). The shear wave attenuation decreased over time (P < .001), and was different for clots treated at 20 minutes versus no treatments (P < .031). The HKD intensity parameter varied over time (P < .032), and was lower for clots treated at 20 and 60 minutes than those untreated (P < .001 and P < .02). CONCLUSION The effect of rt-PA treatment could be confirmed by a decrease in Young's modulus and HKD intensity parameter. The shear wave dispersion and shear wave attenuation were sensitive to late and early treatments, respectively. The Young's modulus, shear wave attenuation, and HKD intensity parameter varied over time despite treatment.
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Affiliation(s)
- Guillaume Bosio
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- Institute of Biomedical Engineering, University of Montreal, Montreal, Quebec, Canada
| | - François Destrempes
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Marie-Hélène Roy Cardinal
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
| | - Guy Cloutier
- Laboratory of Biorheology and Medical Ultrasonics, University of Montreal Hospital Research Center (CRCHUM), Montreal, Quebec, Canada
- Institute of Biomedical Engineering, University of Montreal, Montreal, Quebec, Canada
- Department of Radiology, Radio-Oncology and Nuclear Medicine, University of Montreal, Montreal, Quebec, Canada
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Musalem P, Pedreros-Rosales C, Müller-Ortiz H. Anticoagulation in renal replacement therapies: Why heparin should be abandoned in critical ill patients? Int Urol Nephrol 2024; 56:1383-1393. [PMID: 37755609 DOI: 10.1007/s11255-023-03805-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023]
Abstract
Extracorporeal circuits used in renal replacement therapy (RRT) can develop thrombosis, leading to downtimes and reduced therapy efficiency. To prevent this, anticoagulation is used, but the optimal anticoagulant has not yet been identified. Heparin is the most widely used anticoagulant in RRT, but it has limitations, such as unpredictable pharmacokinetics, nonspecific binding to plasma proteins and cells, and the possibility of suboptimal anticoagulation or bleeding complications, specifically in critically ill patients with acute renal failure who are already at high risk of bleeding. Citrate anticoagulation is a better alternative, being considered a standard for continuous renal replacement therapy, since it is associated with a lower risk of bleeding complications and better efficacy, even in patients with acute renal failure or liver disease. The aim of this article is to provide an updated review of the different strategies of anticoagulation in renal replacement therapies that can be implemented in critical scenarios, focusing on the advantages and disadvantages of each one and the beneficial aspects of using citrate over heparin in critical ill patients.
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Affiliation(s)
- Pilar Musalem
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
- Nephrology, Dialysis and Transplantation Service, Hospital Las Higueras, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
| | - Cristian Pedreros-Rosales
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile.
- Nephrology, Dialysis and Transplantation Service, Hospital Las Higueras, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile.
| | - Hans Müller-Ortiz
- Departamento de Medicina Interna, Facultad de Medicina, Universidad de Concepción, Concepción, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
- Nephrology, Dialysis and Transplantation Service, Hospital Las Higueras, Alto Horno 777, 4270918, Talcahuano, Región del Bío Bío, Chile
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La CC, Smith SA, Kalathottukaren MT, Haynes CA, Morrissey JH, Kizhakkedathu JN. External Trigger Free Charge Switchable Cationic Ligands in the Design of Safe and Effective Universal Heparin Antidote. Adv Healthc Mater 2024:e2400108. [PMID: 38537246 DOI: 10.1002/adhm.202400108] [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: 01/10/2024] [Revised: 03/06/2024] [Indexed: 04/05/2024]
Abstract
Thrombosis, the formation of blood clots within a blood vessel, can lead to severe complications including pulmonary embolism, cardiac arrest, and stroke. The most widely administered class of anticoagulants is heparin-based anticoagulants such as unfractionated heparin, low-molecular weight heparins (LMWHs), and fondaparinux. Protamine is the only FDA-approved heparin antidote. Protamine has limited efficacy neutralizing LMWHs and no reversal activity against fondaparinux. The use of protamine can lead to complications, including excessive bleeding, hypotension, and hypersensitivity, and has narrow therapeutic window. In this work, a new concept in the design of a universal heparin antidote: switchable protonation of cationic ligands, is presented. A library of macromolecular polyanion inhibitors (MPIs) is synthesized and screened to identify molecules that can neutralize all heparins with high selectivity and reduced toxicity. MPIs are developed by assembling cationic binding groups possessing switchable protonation states onto a polymer scaffold. By strategically selecting the identity and modulating the density of cationic binding groups on the polymer scaffold, a superior universal heparin reversal agent is developed with improved heparin-binding activity and increased hemocompatibility profiles leading to minimal effect on hemostasis. The activity of this heparin antidote is demonstrated using in vitro and in vivo studies.
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Affiliation(s)
- Chanel C La
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Chemistry, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Stephanie A Smith
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Manu Thomas Kalathottukaren
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - Charles A Haynes
- Department of Chemical and Biological Engineering, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
| | - James H Morrissey
- Department of Biological Chemistry, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Life Sciences Institute, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Chemistry, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 1Z3, Canada
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Halldorsdottir H, Lindbom L, Ebberyd A, Oldner A, Weitzberg E. The effect of heparins on plasma concentration of heparin-binding protein: a pilot study. BJA OPEN 2024; 9:100256. [PMID: 38318270 PMCID: PMC10839136 DOI: 10.1016/j.bjao.2023.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/17/2023] [Indexed: 02/07/2024]
Abstract
Background Neutrophil-derived heparin-binding protein (HBP) plays a role in the pathophysiology of impaired endothelial dysfunction during inflammation. HBP has been suggested as a predictor of organ dysfunction and disease progression in sepsis. We investigated the effects of heparins on plasma concentrations of HBP in patients undergoing surgery. Methods We studied three groups of patients receiving heparins during or after surgery. The vascular surgery group received 3000-7500 U, whereas the cardiac surgery group received 27 500-40 000 U. After major general surgery, the third group received 5000 U of low-molecular-weight heparin (LMWH) subcutaneously. Serial plasma HBP concentrations were measured after these treatments with two different methods: Axis-Shield ELISA and Joinstar FIC-Q100. In addition, plasma myeloperoxidase and syndecan-1 were measured in the cardiac surgery group. Results During vascular surgery, heparin induced a six-fold increase in HBP within 2 min, from 3.6 (2.4-5.4) to 21.4 (9.0-35.4) ng ml-1 (P<0.001). During cardiac surgery, the higher dose of heparin elevated HBP concentrations from 5.3 (2.7-6.1) to 48.7 (38.4-70.1) ng ml-1 (P<0.0001) within 3 min. Patients receiving LMWH showed an increase from a baseline of 5.7 (3.7-12.1) ng ml-1 to a peak HBP concentration of 14.8 (9.5-18.1) ng ml-1 (P<0.0001) after 3 h. Plasma concentrations of myeloperoxidase, but not syndecan-1, also responded with a rapid increase after heparin. There was a strong correlation between the two methods for HBP analysis (r=0.94). Conclusions Plasma concentrations of HBP increased rapidly and dose-dependently after heparin administration. Subcutaneous administration of LMWH increases plasma HBP, but to a lesser degree. Clinical trial registration ClinicalTrials.gov identifier: NCT04146493.
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Affiliation(s)
- Halla Halldorsdottir
- Department of Clinical Sciences, Division of Anaesthesia and Intensive Care, Karolinska Institutet, Danderyd Hospital, Danderyd, Sweden
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Lennart Lindbom
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Anette Ebberyd
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Anders Oldner
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Eddie Weitzberg
- Department of Physiology and Pharmacology, Section of Anaesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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Mondal S, Abuelkasem E, Vesselinov R, Henderson R, Choi S, Mousa A, Zaza KJ, Tanaka KA. Protamine dosing and its impact in cardiac surgery transfusion practice-A retrospective bi-institutional analysis. Transfusion 2024; 64:467-474. [PMID: 38264767 DOI: 10.1111/trf.17730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Bleeding after cardiac surgery is common and continues to require 10-20% of the national blood supply. Transfusion of allogeneic blood is associated with increased morbidity and mortality. Excessive protamine in the absence of circulating heparin after weaning off CPB can cause anticoagulation and precipitate bleeding. Hence, adequate dose calculation of protamine is crucial yet under evaluated. STUDY DESIGN Retrospective cohort study. METHODS We conducted a retrospective bi-institutional analysis of cardiac surgical patients who underwent cardiopulmonary bypass (CPB)-assisted cardiac surgery to assess the impact of protamine dosing in transfusion practice. Total 762 patients were identified from two institutions using electronic medical records and the Society of Thoracic Surgery (STS) database who underwent cardiac surgery using CPB. Patients were similar in demographics and other baseline characteristics. We divided patients into two groups based on mg of protamine administered to neutralize each 100 U of unfractionated heparin (UFH)-low-ratio group (Protamine: UFH ≤ 0.8) and high-ratio group (Protamine: UFH > 0.8). RESULTS We observed a higher rate of blood transfusion required in high-ratio group (ratio >0.8) compared with low-ratio group (ratio ≤0.8) (p < .001). The increased requirement was consistently demonstrated for intraoperative transfusions of red blood cells, plasma, platelets, and cryoprecipitate. CONCLUSION High protamine to heparin ratio may cause increased bleeding and transfusion in cardiac surgical patients. Protamine to heparin ratio of 0.8 or lower is sufficient to neutralize circulating heparin after weaning off cardiopulmonary bypass.
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Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, Cardiothoracic Division, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ezeldeen Abuelkasem
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Roumen Vesselinov
- Department of Epidemiology and Public Health, Biostatistics Division; Department of Anesthesiology, National Study Center, University of Maryland, Baltimore, Maryland, USA
| | - Reney Henderson
- Department of Anesthesiology, Cardiothoracic Division, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Seung Choi
- Department of Anesthesiology, WakeMed Health System, Raleigh, North Carolina, USA
| | - Ahmad Mousa
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Khaled J Zaza
- Department of Anesthesiology, Cardiothoracic Division, University of Pittsburgh School of Medicine and UPMC, Pennsylvania, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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10
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Lasne D, Toussaint-Hacquard M, Delassasseigne C, Bauters A, Flaujac C, Savard P, Mouton C, De Maistre E, Stepanian A, Eschwège V, Delrue M, Georges JL, Gros A, Mansour A, Leroy G, Jouffroy R, Mattei M, Beurton A, Pontis A, Neuwirth M, Nedelec-Gac F, Lecompte T, Curis E, Siguret V, Gouin-Thibault I. Factors Influencing Anti-Xa Assays: A Multicenter Prospective Study in Critically Ill and Noncritically Ill Patients Receiving Unfractionated Heparin. Thromb Haemost 2023; 123:1105-1115. [PMID: 37321244 DOI: 10.1055/s-0043-1770096] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND The presence of dextran sulfate (DS) in reagents and the type of blood collection tube (citrate/citrated-theophylline-adenosine-dipyridamole [CTAD]) can lead to discrepancies between unfractionated heparin (UFH) anti-Xa levels. OBJECTIVES To evaluate the extent of the effect (1) of different reagents containing or not containing DS and (2) of the blood collection tubes, on UFH anti-Xa levels, in various clinical situations (NCT04700670). METHODS We prospectively included patients from eight centers: group (G)1, cardiopulmonary bypass (CPB) after heparin neutralization (n = 39); G2, cardiothoracic intensive care unit (ICU) after CPB (n = 35); G3, medical ICU (n = 53); G4, other medical inpatients (n = 38). Blood was collected into citrated and CTAD tubes. Chromogenic anti-Xa assays were centrally performed, using seven reagent/analyzer combinations including two without DS. The association between anti-Xa levels and covariates was tested using a linear mixed-effects model. RESULTS We analyzed 4,546 anti-Xa values from 165 patients. Median anti-Xa levels were systematically higher with reagents containing DS, whatever the patient group, with the greatest effect observed in G1 (0.32 vs. 0.05 IU/mL). Anti-Xa levels were slightly higher in CTAD than in citrate samples, irrespective of the assay. The model showed: (1) a significant dextran-patient group interaction (p < 0.0001), the effect of DS on anti-Xa levels varying from 30.9% in G4 to 296% in G1, and (2) a significant effect of CTAD, varying between patient groups (p = 0.0302). CONCLUSION The variability of anti-Xa levels with a great overestimation of the values, using a reagent containing DS, can lead to different treatment decisions, especially after heparin neutralization by protamine. Clinical consequences of these differences remain to be demonstrated.
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Affiliation(s)
- Dominique Lasne
- AP-HP, Laboratoire d'hématologie générale, Hôpital Necker, INSERM, Univ. Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | | | - Anne Bauters
- CHU Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - Claire Flaujac
- Laboratoire de Biologie Médicale (Secteur Hémostase), Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | | | - Christine Mouton
- Laboratoire Hématologie, Hôpital Haut-Lévêque, CHU Bordeaux, France
| | | | - Alain Stepanian
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | | | - Maxime Delrue
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Jean-Louis Georges
- Service de réanimation medico-chirurgicale, Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | - Antoine Gros
- Service de réanimation medico-chirurgicale, Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes; Univ Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | | | - Romain Jouffroy
- AP-HP, Service de réanimation adulte, Hôpital Necker, Paris, France
| | - Matthieu Mattei
- Unité d'Anesthésie et Réanimation Cardiaque & Réanimation Médicale Brabois, CHRU Nancy, Nancy, France
| | - Antoine Beurton
- Department of Cardiovascular Anaesthesia and Critical care, Surgical Medical Center Magellan, Haut-Lévêque Hospital, Pessac, France
| | - Adeline Pontis
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | - Marie Neuwirth
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Fabienne Nedelec-Gac
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | - Thomas Lecompte
- Department of Pharmacy, Faculté de médecine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université de Lorraine & Université de Namur, Namur, Belgium
- Hématologie Biologique, Hôpital Pontchaillou University Hospital of Rennes, Rennes, France
| | - Emmanuel Curis
- UR 7537 BioSTM, faculté de pharmacie de Paris, université Paris Cité, Paris, France
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP, Paris, France
| | - Virginie Siguret
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Isabelle Gouin-Thibault
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
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11
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Erdoes G, Ahmed A, Kurz SD, Gerber D, Bolliger D. Perioperative hemostatic management of patients with type A aortic dissection. Front Cardiovasc Med 2023; 10:1294505. [PMID: 38054097 PMCID: PMC10694357 DOI: 10.3389/fcvm.2023.1294505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/06/2023] [Indexed: 12/07/2023] Open
Abstract
Coagulopathy is common in patients undergoing thoracic aortic repair for Stanford type A aortic dissection. Non-critical administration of blood products may adversely affect the outcome. It is therefore important to be familiar with the pathologic conditions that lead to coagulopathy in complex cardiac surgery. Adequate care of these patients includes the collection of the medical history regarding the use of antithrombotic and anticoagulant drugs, and a sophisticated diagnosis of the coagulopathy with viscoelastic testing and subsequently adapted coagulation therapy with labile and stable blood products. In addition to the above-mentioned measures, intraoperative blood conservation measures as well as good interdisciplinary coordination and communication contribute to a successful hemostatic management strategy.
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Affiliation(s)
- Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Aamer Ahmed
- Consultant Cardiothoracic Anaesthesiologist, Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Stephan D. Kurz
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
| | - Daniel Gerber
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
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12
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Wargowsky R, Zvara J, Qaddumi N, Gonzalez-Almada A, Lin D, Fernandez X, Tanaka K, Mazzeffi M. In vitro comparison of spatiotemporal fibrin clot formation dynamics in plasma treated with different protamine-heparin ratios. Perfusion 2023; 38:1631-1636. [PMID: 36036659 DOI: 10.1177/02676591221122365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Our study aim was to explore how different protamine-heparin ratios impacted enzymatic coagulation and acellular fibrin clot growth in plasma using an in vitro model. We hypothesized that a low protamine-heparin ratio would be associated with superior fibrin clot growth dynamics. METHODS We performed an in vitro study using 15 plasma samples from a commercial supplier. Different protamine-heparin ratios were added to each donor plasma sample: low ratio (0.7-1), traditional ratio (1-1), and high ratio (1.3-1) and clot formation dynamics were evaluated using a Thrombodynamics analyzer. Study outcomes were initial clot growth velocity and clot size at 30 min. RESULTS Plasma samples treated with a one-to-one protamine-heparin ratio had significantly lower mean initial clot growth velocity compared to samples treated with a low protamine-heparin ratio; mean difference -2.3 μm/min (95% CI = -4.0 to -0.7, p = .004). Plasma samples treated with a one-to-one protamine-heparin ratio also had significantly smaller mean clot size at 30 min compared to samples treated with a low protamine-heparin ratio; mean difference -54.0 μm (95% CI = -107.6 to -0.4, p = .048). There were no significant differences in mean initial clot growth velocity or clot size at 30 min between plasma samples treated with a high protamine-heparin ratio and those treated with a one-to-one or low protamine-heparin ratio (all p > .05). CONCLUSIONS Plasma samples treated with a low protamine-heparin ratio had superior clot growth velocity and larger clot size at 30 min compared to a one-to-one ratio, supporting the notion that a low protamine-heparin ratio may optimize enzymatic coagulation after cardiopulmonary bypass.
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Affiliation(s)
- Richard Wargowsky
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
| | - Jessica Zvara
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
| | - Nidal Qaddumi
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
| | - Alberto Gonzalez-Almada
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
| | - Dora Lin
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
| | - Xiomara Fernandez
- Department of Pathology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Kenichi Tanaka
- Department of Anesthesiology, Oklahoma University College of Medicine, Oklahoma City, OK, USA
| | - Michael Mazzeffi
- Department of Anesthesiology, George Washington University School of Medicine, Washington, DC, USA
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13
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Zhou FN, Gellatly RM. Management of an unintentional enoxaparin overdose: A case report and literature review. Am J Health Syst Pharm 2023; 80:1550-1556. [PMID: 37522871 DOI: 10.1093/ajhp/zxad170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Indexed: 08/01/2023] Open
Abstract
PURPOSE The aim of this article is to describe a case in which protamine was used for a low-molecular-weight heparin (LMWH) overdose and present an up-to-date review of the literature on the management of LMWH overdose in adults. SUMMARY An unintentional administration of enoxaparin 900 mg occurred in a 73-year-old man with coronavirus disease 2019-related pulmonary embolism. Management of the overdose included a protamine bolus followed by an infusion. Anti-factor Xa levels and activated partial thromboplastin time were monitored. Anti-factor Xa levels declined in a linear fashion irrespective of protamine administration. No bleeding or further thrombotic complications occurred in the patient. A review of the literature revealed that the optimal strategy to treat an LMWH overdose is unknown, with treatment of overdoses ranging from clinical observation to aggressive protamine dosing in reported cases. Although protamine effectively neutralizes unfractionated heparin, it is unable to completely reverse LMWH activity and has variable effects on laboratory measures of LMWH anticoagulant activity. CONCLUSION The current case report provides additional data to previous literature suggesting that protamine may have a limited effect in decreasing anti-factor Xa levels in LMWH overdose. Continued reporting on the management of LMWH overdoses is warranted to clarify the optimal treatment strategy.
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Affiliation(s)
- Florian N Zhou
- Department of Pharmacy, Surrey Memorial Hospital, Surrey, BC
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Rochelle M Gellatly
- Department of Pharmacy, Surrey Memorial Hospital, Surrey, BC, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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14
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Sim MMS, Shiferawe S, Wood JP. Novel strategies in antithrombotic therapy: targeting thrombosis while preserving hemostasis. Front Cardiovasc Med 2023; 10:1272971. [PMID: 37937289 PMCID: PMC10626538 DOI: 10.3389/fcvm.2023.1272971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/06/2023] [Indexed: 11/09/2023] Open
Abstract
Antithrombotic therapy is a delicate balance between the benefits of preventing a thrombotic event and the risks of inducing a major bleed. Traditional approaches have included antiplatelet and anticoagulant medications, require careful dosing and monitoring, and all carry some risk of bleeding. In recent years, several new targets have been identified, both in the platelet and coagulation systems, which may mitigate this bleeding risk. In this review, we briefly describe the current state of antithrombotic therapy, and then present a detailed discussion of the new generation of drugs that are being developed to target more safely existing or newly identified pathways, alongside the strategies to reverse direct oral anticoagulants, showcasing the breadth of approaches. Combined, these exciting advances in antithrombotic therapy bring us closer than we have ever been to the "holy grail" of the field, a treatment that separates the hemostatic and thrombotic systems, preventing clots without any concurrent bleeding risk.
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Affiliation(s)
- Martha M. S. Sim
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, KY, United States
- Saha Cardiovascular Research Center, University of Kentucky, Lexington, KY, United States
| | - Semekidus Shiferawe
- Saha Cardiovascular Research Center, University of Kentucky, Lexington, KY, United States
| | - Jeremy P. Wood
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, KY, United States
- Saha Cardiovascular Research Center, University of Kentucky, Lexington, KY, United States
- Division of Cardiovascular Medicine Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, United States
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15
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Roosendaal LC, van den Ancker W, Wiersema AM, Blankensteijn JD, Jongkind V. Unfractionated heparin and the activated clotting time in non-cardiac arterial procedures. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:488-494. [PMID: 37255497 DOI: 10.23736/s0021-9509.23.12723-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
INTRODUCTION Unfractionated heparin is administered during non-cardiac arterial procedures (NCAP) to prevent thromboembolic complications. In order to achieve a safe level of anticoagulation, the effect of heparin can be measured. The aim of this review was to provide an overview on what is known about heparin, suggested tests to monitor the effect of heparin, including the activated clotting time (ACT), and the factors that could influence that ACT. EVIDENCE ACQUISITION A literature search in PubMed was performed. Articles reporting on heparin, clotting time tests (including thrombin time, activated partial thromboplastin time, anti-activated factor X and ACT), and ACT measurement devices were selected. EVIDENCE SYNTHESIS Heparin has a non-predictable effect in the individual patient, which could be measured using the ACT. However, ACT values can be influenced by many factors, such as hemodilution, hypothermia and thrombocytopenia. In addition, a high variation in ACT outcomes is found between measurement devices of different brands. In the sparse literature on the role of ACT during NCAP, no consensus has been reached on optimal target ACT values. An ACT >250 seconds leads to more bleeding complications. Females have a longer ACT after heparin administration, with a higher risk of bleeding complications. CONCLUSIONS The effect of heparin is unpredictable. ACT can be used to monitor the effect of heparin and achieve individualized anticoagulation, tailored to the patient and the specifics of the operative procedure. However, the ACT itself can be affected by several factors and caution must be present, as measured ACT values differ between measurement devices.
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Affiliation(s)
- Liliane C Roosendaal
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, the Netherlands
| | | | - Arno M Wiersema
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, the Netherlands
| | - Jan D Blankensteijn
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, the Netherlands
| | - Vincent Jongkind
- Department of Vascular Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands -
- Amsterdam Cardiovascular Sciences, Microcirculation, Amsterdam, the Netherlands
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16
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Gkiouliava A, Argiriadou H, Antonitsis P, Goulas A, Papapostolou E, Sarridou D, Karapanagiotidis GT, Anastasiadis K. Individualized heparin monitoring and management reduces protamine requirements in cardiac surgery on minimal invasive extracorporeal circulation; A prospective randomized study. Perfusion 2023:2676591231204284. [PMID: 37776194 DOI: 10.1177/02676591231204284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
INTRODUCTION Individualized heparin and protamine management is increasingly used as a strategy to reduce coagulation activation and bleeding complications. While it is associated with increased heparin requirements during Cardiopulmonary Bypass (CPB), the impact on protamine administration remains controversial. We aim to investigate the effect of heparin level-guided monitoring on protamine dosing during cardiac surgery where low-anticoagulation protocols are implemented. METHODS This is a prospective, randomized, controlled trial. A total of 132 patients undergoing elective full-spectrum cardiac surgery with Minimal Invasive Extracorporeal Circulation (MiECC) were recruited. All patients were managed by the same anaesthetic, surgical and perfusion team. Patients were randomly allocated in two groups; the individualized heparin-protamine titration (IHPT) group and the conventional heparinization and reversal group by using ACT (cACT) with a 0.75:1, protamine: heparin ratio. Titration was accomplished with the Hepcon HMS Plus (Medtronic, Minneapolis, MN) system. The primary outcome of the study was the total protamine dose used. Secondary outcomes comprised of the total heparin dose, the percentage of patients achieving target ACT, 24-h transfusion requirements, postoperative bleeding, duration of mechanical ventilation, major morbidity and length of hospital stay. Patients in each group were divided in two subgroups according to the target ACT; those operated for coronary artery bypass grafting (CABG) using a target ACT >300 s and the rest (non-CABG) patients operated with a target ACT >400 s, respectively. RESULTS Protamine requirements were significantly reduced when IHPT was implemented; CABG (118 ± 24 mg vs 163 ± 61 mg; p < 0.001) and non-CABG cases (151 ± 46 mg vs 197 ± 45 mg; p < 0.001). Moreover, heparin requirements were significantly higher in the non-CABG subgroup managed with IHPT (34,539 ± 7658 IU vs 29,893 ± 9037 IU; p = 0.02). In overall, no significant differences were detected with respect to postoperative bleeding, transfusion of RBC or other blood products. CONCLUSIONS Individualized heparin monitoring and management reduces protamine requirements in cardiac surgery with MiECC implementing reduced anticoagulation strategy. TRIAL REGISTRATION clinicaltrials.gov; NCT04215588.
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Affiliation(s)
- Anna Gkiouliava
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Helena Argiriadou
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Polychronis Antonitsis
- Cardiothoracic Department, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Antonis Goulas
- First Laboratory of Pharmacology, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Evangelia Papapostolou
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Despoina Sarridou
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Georgios T Karapanagiotidis
- Cardiothoracic Department, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Kyriakos Anastasiadis
- Cardiothoracic Department, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
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17
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Rijpkema M, Vlot EA, Stehouwer MC, Bruins P. Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass? Perfusion 2023:2676591231199218. [PMID: 37734336 DOI: 10.1177/02676591231199218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND Heparin rebound is a common observed phenomenon after cardiac surgery with CPB and is associated with increased postoperative blood loss. However, the administration of extra protamine may lead to increased blood loss as well. Therefore, we want to investigate the relation between heparin rebound and postoperative blood loss and the necessity to provide extra protamine to reverse heparin rebound. METHODS We searched PubMed, Cochrane, EMBASE, Google Scholar and Web of Science to review the question: "Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass." Combination of search words were framed within four major categories: heparin rebound, blood loss, cardiac surgery and cardiopulmonary bypass. All studies that met our question were included. Quality assessment was performed using the Cochrane risk of bias (RoB2) tool for randomized controlled trials and the risk of bias in non-randomized studies of intervention (ROBINS-I) for non-randomised trials. RESULTS 4 randomized and 17 non-randomized studies were included. The mean incidence of heparin rebound was 40%. The postoperative heparin levels, due to heparin rebound, were often below or equal to 0.2 IU/mL. We could not demonstrate an association between heparin rebound and postoperative blood loss or transfusion requirements. However the quality of evidence was poor due to a broad variety of definitions of heparin rebound, measured by various coagulation tests and studies with small sample sizes. CONCLUSION The influence of heparin rebound on postoperative bleeding seems to be negligible, but might get significant in conjunction with incomplete heparin reversal or other coagulopathies. For that reason, it might be useful to get a picture of the entire coagulation spectrum after cardiac surgery, as can be done by the use of a viscoelastic test in conjunction with an aggregometry test.
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Affiliation(s)
- Marije Rijpkema
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Eline A Vlot
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Marco C Stehouwer
- Department of extracorporeal circulation, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter Bruins
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
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18
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Lee MH, Beck M, Shann K. Protamine dose to neutralize heparin at the completion of cardiopulmonary bypass can be reduced significantly without affecting post-operative bleeding. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:105-111. [PMID: 37682208 PMCID: PMC10487347 DOI: 10.1051/ject/2023026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 07/05/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Systemic anticoagulation with heparin during cardiopulmonary bypass (CPB) should be neutralized by protamine administration to restore normal hemostasis. Our previous study showed the protamine-to-heparin ratio (P-to-H) of 1:1 (1 mg protamine:100 IU circulating heparin; 1.0 Ratio) is likely an overestimation. Thus, we reduced the P-to-H in the HMS Plus Hemostasis Management System to 0.9:1 (0.9 Ratio) for 5 months and then to 0.8:1 (0.8 Ratio). We monitored post-operative (post-op) bleeding in the setting of reduced protamine dose (PD). METHODS We performed a retrospective study of 632 patients (209 for the 1.0 Ratio, 211 for 0.9 Ratio, 212 for 0.8 Ratio group) who underwent cardiac surgery to measure the reduction of PD and how it affects 24-hour (24 h) post-op chest tube output. We also analyzed the entire data set to explore whether further reduction of P-to-H is warranted. RESULTS While there was no difference in the indexed heparin dose among the three groups, we achieved a significant reduction in the indexed actual protamine dose (APDi) by 24% (0.9 Ratio) and 31% (0.8 Ratio) reductions compared to the 1.0 Ratio group. On average, APDi was 88 ± 22, 67 ± 18, and 61 ± 15 mg/m2 in the 1.0, 0.9, and 0.8 Ratio groups, respectively. We found no significant difference in 24 h post-op bleeding among the three groups. CONCLUSION 1.0 Ratio at the completion of CPB is likely an excessive administration of protamine. With the stepwise reduction of PD, we observed no increase in post-op bleeding, which may indicate that no meaningful increase in heparin rebound occurred. In addition, further analysis of the entire data set demonstrates that a 0.75 Ratio is likely sufficient to neutralize the heparin completely.
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Affiliation(s)
- Min-Ho Lee
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Perfusion Team, Massachusetts General Hospital 55 Fruit Street Boston MA 02114 USA
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Perfusion Services, Children’s Hospital of Philadelphia 3401 Civic Center Blvd. Philadelphia PA 19104 USA
| | - Matthew Beck
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Perfusion Team, Massachusetts General Hospital 55 Fruit Street Boston MA 02114 USA
| | - Kenneth Shann
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Perfusion Team, Massachusetts General Hospital 55 Fruit Street Boston MA 02114 USA
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19
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Smiley RM, Chen CJ. Use of protamine to reverse therapeutic heparin infusion in a post-cesarean patient with postoperative hemorrhage. Int J Obstet Anesth 2023; 55:103879. [PMID: 37024394 DOI: 10.1016/j.ijoa.2023.103879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/01/2023] [Accepted: 03/16/2023] [Indexed: 03/28/2023]
Affiliation(s)
- R M Smiley
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
| | - C-J Chen
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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20
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Vespe MW, Stone ME, Lin HM, Ouyang Y. Accurate protamine:heparin matching (not just smaller protamine doses) decreases postoperative bleeding in cardiac surgery; results from a high-volume academic medical center. Perfusion 2023:2676591231190739. [PMID: 37493300 DOI: 10.1177/02676591231190739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND A multidisciplinary Quality Assurance/Performance Improvement study to identify the incidence of "heparin rebound" in our adult cardiac surgical population instead detected a thromboelastometry pattern suggestive of initial protamine overdose in 34% despite Hepcon-guided anticoagulation management. Analysis of our practice led to an intervention that made an additional lower-range Hepcon cartridge available to the perfusionists. METHODS One year later, an IRB-approved retrospective study was conducted in >500 patients to analyze the effects of the intervention, specifically focusing on the impact of the initial protamine dose accuracy and 18-h mediastinal chest tube drainage (MCTd). RESULTS No differences were observed between group demographics, surgical procedures, duration of CPB or perioperative blood product transfusion. Both groups were managed using the same perfusion and anesthesia equipment, strategies, and protocols. The median initial protamine dose decreased by 19% (p < .001) in the intervention group (170 [IQR 140-220] mg; n = 295) versus the control group (210 [180-250] mg; n = 257). Mean 18-h MCTd decreased by 13% (p < .001) in the intervention group (405.15 ± 231.54 mL; n = 295) versus the control group (466.13 ± 286.73 mL; n = 257). Covariate-adjusted mixed effects model showed a significant reduction of MCTd in the intervention group, starting from hour 11 after surgery (group by time interaction p = .002). CONCLUSION Though previous investigators have associated lower protamine doses with less MCTd, this study demonstrates that more accurately matching the initial protamine dose to the remaining circulating heparin concentration reduces postoperative bleeding.
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Affiliation(s)
| | - Marc E Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hung-Mo Lin
- Department of Anesthesiology and Yale Center for Analytical Science, Yale Schoold of Medicine, New Haven, CT, USA
| | - Yuxia Ouyang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Struck MF, Werdehausen R, Kirsten H, Gössmann H, Veelken R, van Bömmel F, Stehr S, Denecke T, Ebel S. Prognostic Factors for Postoperative Bleeding Complications and Prolonged Intensive Care after Percutaneous Hepatic Chemosaturation Procedures with Melphalan. Cancers (Basel) 2023; 15:3776. [PMID: 37568592 PMCID: PMC10417144 DOI: 10.3390/cancers15153776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/21/2023] [Accepted: 07/23/2023] [Indexed: 08/13/2023] Open
Abstract
Percutaneous hepatic melphalan perfusion (chemosaturation) in patients with liver metastases is known to be associated with procedure-related hemodynamic depression and coagulation impairment, which may cause bleeding complications and/or a prolonged intensive care unit length of stay (ICU LOS). We retrospectively analyzed possible predictive factors for bleeding complications and an ICU LOS > 1 d in a cohort of 31 patients undergoing 90 chemosaturation procedures. Using a multivariable mixed-model approach, we identified the amount of perioperative fluid volume (OR 12.0, 95% CI 2.3-60.0, p = 0.003) and protamine (OR 0.065, 95% CI 0.007-0.55, p = 0.012) to be associated with bleeding complications. Furthermore, the amount of perioperative fluid volume was associated with an ICU LOS > 1 d (OR 5.2, 95% CI 1.4-19.0, p = 0.011). Heparin dosage, melphalan dosage, extracorporeal circulation time, and noradrenaline dosage had no significant effects on outcomes. Protamine use was not associated with anaphylactic or thromboembolic complications. Despite the limited sample size, these results suggest a restrictive perioperative fluid regime to be beneficial, and support the use of protamine for heparin reversal after chemosaturation procedures. Further prospective randomized trials are needed to confirm these findings.
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Affiliation(s)
- Manuel Florian Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (R.W.); (S.S.)
| | - Robert Werdehausen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (R.W.); (S.S.)
| | - Holger Kirsten
- Institute for Medical Statistics, Informatics and Epidemiology, Medical Faculty, University of Leipzig, 04107 Leipzig, Germany;
| | - Holger Gössmann
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (H.G.); (T.D.); (S.E.)
| | - Rhea Veelken
- Division of Hepatology, Department of Gastroenterology, University Hospital Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (R.V.); (F.v.B.)
| | - Florian van Bömmel
- Division of Hepatology, Department of Gastroenterology, University Hospital Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (R.V.); (F.v.B.)
| | - Sebastian Stehr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (R.W.); (S.S.)
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (H.G.); (T.D.); (S.E.)
| | - Sebastian Ebel
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr. 20, 04103 Leipzig, Germany; (H.G.); (T.D.); (S.E.)
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Facchetti N, Hinrichs JB, Becker LS, Schneider MA, Brüning R, Rademacher J, Lenz J, Kudrass K, Vogel A, Wacker FK, Dewald CLA. Heparin reversal with protamine sulfate after Percutaneous Hepatic Perfusion (PHP): is less more? Cancer Imaging 2023; 23:68. [PMID: 37452405 PMCID: PMC10349410 DOI: 10.1186/s40644-023-00590-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Abstract
PURPOSE Percutaneous hepatic perfusion (PHP) is a palliative intraarterial therapy for unresectable hepatic malignancies. During PHP, high-dose melphalan is infused via the hepatic artery to saturate tumor in the liver with the chemotherapeutic substance. The venous hepatic blood is filtered by an extracorporeal melphalan specific filtration system. Blood clotting in the extracorporeal filter system is prevented by administering unfractionated heparin (UFH) in high doses, which might be reversed with protamine sulfate after the procedure. Aim of this retrospective two-center-study was to analyze the potential effect of UFH reversal with protamine sulfate on complication rates following PHP. MATERIALS AND METHODS All patients receiving PHP treatment between 10/2014 and 04/2021 were classified according to their intraprocedural coagulation management: 92 patients/192 PHP received full UFH reversal with protamine (groupPROTAMINE); 13 patients/21 PHP in groupREDUCED_PROTAMINE received a reduced amount of protamine, and 28 patients/43 PHP did not receive UFH reversal with protamine (groupNO_PROTAMINE). Periinterventional clinical reports, findings and laboratory values were retrospectively evaluated. Complications and adverse events were classified according to Common Terminology Criteria for Adverse Events (CTCAEv5.0). RESULTS Thromboembolic events were recorded after 10 PHP procedures (5%) in groupPROTAMINE, six of which (3%) were major events (CTCAE grade 3-5). No (0%) thromboembolic events were recorded in groupREDUCED_PROTAMINE and groupNO_PROTAMINE. Hemorrhagic events were registered after 24 PHP (13%) in groupPROTAMINE, two of which (1%) were major (CTCAE grade 3-4). In groupREDUCED_PROTAMINE, only minor bleeding events were recorded, and one major hemorrhagic event was documented in groupNO_PROTAMINE (2%). There was a significant difference between the percentage of post-interventional thrombopenia in groupPROTAMINE (39%) and groupREDUCED_PROTAMINE (14%) versus groupNO_PROTAMINE (23%) (p=.00024). In groupPROTAMINE one patient suffered from a severe anaphylactic shock after the administration of protamine. CONCLUSION Our retrospective study implies that there might be a link between the practice of protamine sulfate administration to reverse the full hemodilutive effect of UFH after PHP and the post-interventional risk of thromboembolic events as well as clinically significant thrombopenia. Our data suggest that the standard use of protamine sulfate after PHP in low-risk patients without clinical signs of active bleeding should be critically re-evaluated.
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Affiliation(s)
- Nadia Facchetti
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Jan B. Hinrichs
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Lena S. Becker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Martin A. Schneider
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Roland Brüning
- Department of Radiology and Neuroradiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Jan Rademacher
- Department of Anesthesiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Jochen Lenz
- Department of Anesthesiology, Asklepios Clinic Hamburg-Barmbek, Hamburg, Germany
| | - Kirsten Kudrass
- Department of Anesthesiology, Hannover Medical School, Hannover, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Frank K. Wacker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Cornelia L. A. Dewald
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
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23
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Gorai S, Mula S, Jonnalgadda PN, Patro BS, Chakraborty G. In house synthesized novel distyryl-BODIPY dye and polymer assembly as deep-red emitting probe for protamine detection. Talanta 2023; 265:124915. [PMID: 37442005 DOI: 10.1016/j.talanta.2023.124915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023]
Abstract
In this contribution, we designed and synthesized a deep-red emitting distyryl-BODIPY dye (dye 3) which is non-fluorescent in aqueous solution due to the formation of non-emissive aggregates. However, in presence of an amphiphilic polymer (polystyrene sulfonate, PSS), the aggregated dye molecules de-aggregate and form dye 3-PSS complex, which significantly modulates the optical features of the bound dye. Interestingly, the dye 3-PSS complex shows turn-on fluorescence response in deep-red region in presence of protamine (Pr) due to the formation of dye 3-PSS-Pr ternary complex. Such enhancement follows a linear trend in the dynamic range of 0-8.75 μM of Pr which has been utilized to determine Pr with limit of detection (LOD) of 15.04(±0.5) nM in phosphate buffer. Furthermore, excellent selectivity of the dye 3-PSS system towards Pr allows us to determine Pr even in complex biological matrix like 1% human serum. Thus, dye 3-PSS system can be applied as a very effective tool for the detection and quantification of Pr in deep-red region, overcoming several limitations encountered with the probes in the shorter wavelength region. This is the first report on BODIPY dye based supramolecular assembly for sensing and quantification of protamine.
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Affiliation(s)
- Sudip Gorai
- Bio-Organic Division, Bhabha Atomic Research Centre, Mumbai, 400085, India; Homi Bhabha National Institute, Anushakti Nagar, Mumbai, 400094, India
| | - Soumyaditya Mula
- Bio-Organic Division, Bhabha Atomic Research Centre, Mumbai, 400085, India; Homi Bhabha National Institute, Anushakti Nagar, Mumbai, 400094, India.
| | - Padma Nilaya Jonnalgadda
- Homi Bhabha National Institute, Anushakti Nagar, Mumbai, 400094, India; Laser and Plasma Technology Division, Bhabha Atomic Research Centre, Mumbai, 400085, India
| | - Birija S Patro
- Bio-Organic Division, Bhabha Atomic Research Centre, Mumbai, 400085, India; Homi Bhabha National Institute, Anushakti Nagar, Mumbai, 400094, India
| | - Goutam Chakraborty
- Laser and Plasma Technology Division, Bhabha Atomic Research Centre, Mumbai, 400085, India.
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24
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Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost 2023; 21:1714-1723. [PMID: 37062523 DOI: 10.1016/j.jtha.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
Protamine, a highly basic protein isolated from salmon sperm, is the only clinically available agent to reverse the anticoagulation of unfractionated heparin. Following intravenous administration, protamine binds to heparin in a nonspecific electrostatic interaction to reverse its anticoagulant effects. In clinical use, protamine is routinely administered to reverse high-dose heparin anticoagulation in cardiovascular procedures, including cardiac surgery with cardiopulmonary bypass. Despite the lack of supportive evidence regarding protamine's effectiveness to reverse low-molecular-weight heparin, it is recommended in guidelines with low-quality evidence. Different dosing strategies have been reported for reversing heparin in cardiac surgical patients based on empiric dosing, pharmacokinetics, or point-of-care measurements of heparin levels. Protamine administration is associated with a spectrum of adverse reactions that range from vasodilation to life-threatening cardiopulmonary dysfunction and shock. The life-threatening responses appear to be hypersensitivity reactions due to immunoglobulin E and/or immunoglobulin G antibodies. However, protamine and heparin-protamine complexes can activate complement inflammatory pathways and inhibit other coagulation factors. Although alternative agents for reversing heparin are not currently available for clinical use, additional research continues evaluating novel therapeutic approaches.
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Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina, USA.
| | - Kamrouz Ghadimi
- Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, The School of Biomedical Engineering, The University of British Columbia, Vancouver, British Colombia, Canada
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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25
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Kneizeh K, Milzi A, Vogt F, Witte K, Marx N, Lehrke M, Almalla M, Schröder J. Efficacy and Safety of Low-Dose Protamine in Reducing Bleeding Complications during TAVI: A Propensity-Matched Comparison. J Clin Med 2023; 12:4243. [PMID: 37445282 DOI: 10.3390/jcm12134243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVES We aimed to evaluate the efficacy and safety of low-dose protamine in reducing access site-related complications during Transcatheter Aortic Valve Implantation (TAVI) as compared to full-dose protamine. BACKGROUND Access site-related complications represent an independent predictor of poor outcomes of TAVI. Data regarding heparin reversal with protamine and the dosage needed to prevent bleeding complications are scarce among patients undergoing TAVI. METHODS A total of 897 patients were retrospectively included in the study. Patients who underwent percutaneous coronary intervention within 4 weeks before or concomitantly with TAVI (n = 191) were given 0.5 mg protamine for each 100 units of unfractionated heparin. All other patients (n = 706) were considered as a control group and 1 mg protamine for each 100 units of heparin was administered. RESULTS The combined intra-hospital endpoint of death, life-threatening major bleeding, and major vascular complications were significantly more frequent in patients receiving low-dose protamine [29 (15.2%) vs. 50 (7.1%), p < 0.001]. After propensity matching (n = 130 for each group) for relevant clinical characteristics including anti-platelet therapy [19 (14.6%) vs. 6 (4.6%), p = 0.006], low-dose protamine predicted the combined endpoint (OR 3.54, 95%-CI 1.36-9.17, p = 0.009), and even in multivariable analysis, low-dose protamine continued to be a predictor of the combined endpoint in the matched model (OR 3.07, 95%-CI 1.17-8.08, p = 0.023) alongside baseline hemoglobin. CONCLUSIONS In this propensity-matched retrospective analysis, a low-dose protamine regime is associated with a higher rate of major adverse events compared to a full-dose protamine regime following transfemoral TAVI.
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Affiliation(s)
- Kinan Kneizeh
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Andrea Milzi
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Felix Vogt
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Klaus Witte
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Michael Lehrke
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Mohammad Almalla
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Jörg Schröder
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
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Nisi F, Carenzo L, Ruggieri N, Reda A, Pascucci MG, Pignataro A, Civilini E, Piccioni F, Giustiniano E. The anesthesiologist's perspective on emergency aortic surgery: Preoperative optimization, intraoperative management, and postoperative surveillance. Semin Vasc Surg 2023; 36:363-379. [PMID: 37330248 DOI: 10.1053/j.semvascsurg.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
The management of emergencies related to the aorta requires a multidisciplinary approach involving various health care professionals. Despite technological advancements in treatment methods, the risks and mortality rates associated with surgery remain high. In the emergency department, definitive diagnosis is usually obtained through computed tomography angiography, and management focuses on controlling blood pressure and treating symptoms to prevent further deterioration. Preoperative resuscitation is the main focus, followed by intraoperative management aimed at stabilizing the patient's hemodynamics, controlling bleeding, and protecting vital organs. After the operation, factors such as organ protection, transfusion management, pain control, and overall patient care must be taken into account. Endovascular techniques are becoming more common in surgical treatment, but they also present new challenges in terms of complications and outcomes. It is recommended that patients with suspected ruptured abdominal aortic aneurysms be transferred to facilities with both open and endovascular treatment options and a track record of successful outcomes to ensure the best patient care and long-term results. To achieve optimal patient outcomes, close collaboration and regular case discussions between health care professionals are necessary, as well as participation in educational programs to promote a culture of teamwork and continuous improvement.
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Affiliation(s)
- Fulvio Nisi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Nadia Ruggieri
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Antonio Reda
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | | | - Arianna Pignataro
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Efrem Civilini
- Vascular Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan Italy
| | - Federico Piccioni
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Enrico Giustiniano
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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27
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Danek BA, Kearney KE, Chung CJ, Steinberg Z, Lombardi WL, McCabe JM, Azzalini L. The contemporary role of protamine in the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2023. [PMID: 37172213 DOI: 10.1002/ccd.30679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/06/2023] [Accepted: 04/28/2023] [Indexed: 05/14/2023]
Abstract
Access to the arterial circulation and full anticoagulation carries a risk of serious bleeding during and after percutaneous coronary intervention. Important sources of bleeding include the arterial access site and coronary artery perforation. Prompt and effective management of hemorrhagic complications is an essential interventional skill. Protamine sulfate is well-known as a heparin reversal agent. Despite this, there is heterogeneity in the use of protamine during interventional procedures. While protamine is generally well-tolerated, it is associated with a risk of hypersensitivity reaction, including anaphylaxis, among others. The purpose of this review is to summarize the existing evidence about and experience with the use of protamine sulfate in the setting of percutaneous coronary and structural interventional procedures.
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Affiliation(s)
- Barbara A Danek
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kathleen E Kearney
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Christine J Chung
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Zachary Steinberg
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - William L Lombardi
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - James M McCabe
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Lorenzo Azzalini
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
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28
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Sunada T, Takeshita J, Tachibana K. New intra-conduit thrombus detected using transesophageal echocardiography immediately after weaning from cardiopulmonary bypass during the Fontan procedure: a case report. J Anesth 2023; 37:482-486. [PMID: 37085673 DOI: 10.1007/s00540-023-03195-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/13/2023] [Indexed: 04/23/2023]
Abstract
This study reports a case wherein a new thrombus was detected by transesophageal echocardiography in the conduit during extracardiac conduit Fontan procedure. Immediately after weaning from the cardiopulmonary bypass and administration of protamine, a thrombus was noted in the conduit by transesophageal echocardiography. Since the patient was hemodynamically stable, anticoagulation therapy was initiated after admission to the intensive care unit. One week post-surgery, imaging results showed residual thrombus, but the patient was safely discharged. Even during Fontan procedure, careful observation with transesophageal echocardiography is important because of the possibility of thrombus formation in the conduit.
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Affiliation(s)
- Taiga Sunada
- Osaka Women's and Children's Hospital, 840 Murodocho, Izumi, Osaka, Japan.
- Kobe City Medical Center General Hospital, Kobe, Japan.
| | - Jun Takeshita
- Osaka Women's and Children's Hospital, 840 Murodocho, Izumi, Osaka, Japan
| | - Kazuya Tachibana
- Osaka Women's and Children's Hospital, 840 Murodocho, Izumi, Osaka, Japan
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29
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Kanitra JJ, Bjorklund RL, Clausen DJ, Hayward RD, Paxton RA, Haouilou JC. Protamine use in transcarotid arterial revascularization. Vascular 2023; 31:312-316. [PMID: 35040739 DOI: 10.1177/17085381211067047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The literature suggests that heparin reversal with protamine in transcarotid arterial revascularization (TCAR) decreases postoperative bleeding complications without an increase in stroke or death. However, the dosing of protamine in TCAR has not yet been evaluated. We aimed to evaluate our experience with intraoperative heparin reversal with protamine. METHODS This was a single-center, retrospective, observational study that evaluated the heparin and protamine doses used during TCAR. All adult patients who underwent TCAR between 9/1/2019 and 4/2/2021 were included. Demographic data was obtained from the Vascular Quality Initiative and protamine/heparin doses were obtained from a chart review. Multivariate logistic regression models were used to assess the association between the protamine/heparin dose ratio and other variables. RESULTS Sixty-two patients were included. The average protamine/heparin dose ratio used was 0.96 ± 0.12 mg/U; seven had a ratio less than 0.8 mg/U, and one was greater than 1.2 mg/U. Two patients experienced bleeding complications, which were managed non-operatively. No patient with a protamine/heparin ratio greater than 0.8 mg/U had postoperative bleeding. Postoperative bradycardia was observed in 32.3% of patients and hypotension in 35%, with 19% requiring vasopressors. No relationship was identified between the protamine/heparin ratio and bleeding, bradycardia, or hypotension. No 30-day myocardial infarction, stroke or death occurred. CONCLUSIONS We identified a near 1:1 ratio of a protamine/heparin dosing regimen for the reversal of heparin during TCAR, with postoperative bleeding complications similar to those reported in the literature. However, patients who received a lower protamine/heparin ratio did not experience bleeding complications. In the era of protamine shortages, a future larger-scale study is needed to evaluate the impact of a lower protamine dose on postoperative complications.
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Affiliation(s)
- John J Kanitra
- Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA
| | | | - David J Clausen
- Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA
| | - R David Hayward
- Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA
| | - Renee A Paxton
- Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA
| | - Jimmy C Haouilou
- Department of Surgery, 21928Ascension St John Hospital, Detroit, MI, USA
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Bhavsar R, Tang M, Greisen J, Jakobsen CJ. Increasing obesity is associated with lower postoperative bleeding in coronary bypass patients. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00181-7. [PMID: 37062665 DOI: 10.1053/j.jvca.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/02/2023] [Accepted: 03/08/2023] [Indexed: 04/18/2023]
Abstract
OBJECTIVE Despite inherent comorbidities, obese cardiac surgical patients paradoxically had shown lower morbidity and mortality, although the nature of this association is still unclear. Thus, the authors intended in this large registry-based study to investigate the impact of obesity on short- and long-term postoperative outcomes, focusing on bleeding and transfusion requirements. DESIGN Retrospective registry study. SETTING Three university hospitals. PARTICIPANTS A cohort of 12,330 prospectively compiled data from coronary bypass grafting patients undergoing surgery between 2007 to 2020 were retrieved from the Western Denmark Heart Registry. INTERVENTIONS The parameters were analyzed to assess the association between body mass index (BMI) and the selected outcome parameters. MEASUREMENTS AND MAIN RESULTS The crude data showed a clear statistically significant association in postoperative drainage from 637 (418-1108) mL in underweight patients with BMI <18.5 kg/m2 to 427 (295-620) mL in severely obese patients with BMI ≥40 kg/m2 (p < 0.0001, Kruskal-Wallis). Further, 50.0% of patients with BMI <18.5 received an average of 451 mL/m2 in red blood cell transfusions, compared to 16.7% of patients with BMI >40 receiving 84 mL/m2. The obese groups were less often submitted to reexploration due to bleeding, and fewer received perioperative hemostatics, inotropes, and vasoconstrictors. The crude data showed increasing 30-day and 6-month mortality with lower BMI, whereas the one-year mortality showed a V-shaped pattern, but BMI had no independent impact on mortality in logistic regression analysis. CONCLUSION Patients with high BMI may carry protection against postoperative bleeding after cardiac surgery, probably secondary to an inherent hypercoagulable state, whereas underweight patients carry a higher risk of bleeding and worse outcomes.
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Affiliation(s)
- Rajesh Bhavsar
- Heart, Lung, and Vascular, Aarhus University Hospital, Aarhus, Denmark
| | - Mariann Tang
- Heart, Lung, and Vascular, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob Greisen
- Heart, Lung, and Vascular, Aarhus University Hospital, Aarhus, Denmark
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Cartwright B, Mundell N. Anticoagulation for cardiopulmonary bypass: part one. BJA Educ 2023; 23:110-116. [PMID: 36844440 PMCID: PMC9947996 DOI: 10.1016/j.bjae.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/25/2023] Open
Affiliation(s)
- B. Cartwright
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- University of Sydney, Sydney, NSW, Australia
| | - N. Mundell
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Yamada Y, Iemura J, Kambara A, Tateishi N, Kozaki Y, Yamada M, Maruyama J, Azuma E. Association of postoperative atrial fibrillation with higher dosing ratios of protamine-to-heparin. THE JOURNAL OF EXTRACORPOREAL TECHNOLOGY 2023; 55:23-29. [PMID: 37034101 PMCID: PMC10071503 DOI: 10.1051/ject/2023003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 12/29/2022] [Indexed: 03/29/2023]
Abstract
Background: Postoperative atrial fibrillation (POAF) is defined as new-onset AF in the immediate postoperative period. The relatively high incidence of POAF after cardiac surgery is well described, but pathophysiological mechanisms underlying the initiation, maintenance, and progression of POAF may be multifactorial and have not yet been comprehensively characterized. One of the mechanisms includes altered Ca2+ kinetics. Accumulating evidence has suggested that altered atrial cytosolic calcium handling contributes to the development of POAF, protamine reversibly modulates the calcium release channel/ryanodine receptor 2 (RyR2) and voltage-dependent cardiac RyR2. However, it is currently unknown whether such abnormalities contribute to the arrhythmogenic substrate predisposing patients to the development of POAF. Methods: We have retrospectively analyzed 147 patients who underwent cardiac surgery with cardiopulmonary bypass support. Of these, 40 patients were excluded from the analysis because of pre-existing AF. All patients received heparin followed by protamine at different dosing ratios of protamine-to-heparin, depending on the periods studied. Results: The dosing ratio of protamine-to-heparin = 1.0 was compared with higher dosing ratios of protamine-to-heparin >1.0 up to 1.7. POAF developed in 15 patients (15/107 = 14%), of these, 5 out of 57 patients (33.3%) in the dosing ratio of protamine-to-heparin = 1.0 and 10 out of 35 patients (66.7%) in the higher dosing ratios of protamine-to-heparin. Statistical significance was observed in patients with higher dosing ratios of protamine-to-heparin, compared with the dosing ratio of protamine-to-heparin = 1.0 (odds ratio = 3.890, 95% CI = 1.130–13.300, p-value = 0.031). When types of diseases were analyzed in terms of higher dosing ratios of protamine-to-heparin, only valvular disorders were significantly associated with POAF (p = 0.04). Conclusions: Protamine is clinically utilized to reverse heparin overdose and has been shown to display immunological and inflammatory alterations. However, its association with POAF has not been reported. Our results provide evidence that higher dosing ratios of protamine-to-heparin may increase the incidence of POAF.
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Affiliation(s)
- Yasuharu Yamada
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Department of Clinical Engineering, Faculty of Medical Engineering, Suzuka University of Medical Science Mie 513-8670 Japan
- Corresponding author:
| | - Junzo Iemura
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Department of Cardiovascular Surgery, Okanami General Hospital Mie 518-0121 Japan
| | - Atushi Kambara
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Department of Cardiovascular Surgery, Okanami General Hospital Mie 518-0121 Japan
| | - Noboru Tateishi
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Division of Clinical Engineering, Okanami General Hospital Mie 518-0121 Japan
| | - Yuji Kozaki
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Division of Clinical Engineering, Okanami General Hospital Mie 518-0121 Japan
| | - Masako Yamada
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Department of Clinical Engineering, Mie University Hospital Mie 514-0001 Japan
| | - Junko Maruyama
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Department of Clinical Engineering, Faculty of Medical Engineering, Suzuka University of Medical Science Mie 513-8670 Japan
| | - Eiichi Azuma
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Department of Clinical Engineering, Faculty of Medical Engineering, Suzuka University of Medical Science Mie 513-8670 Japan
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Transcaval Access and Closure Best Practices. JACC Cardiovasc Interv 2023; 16:371-395. [PMID: 36858658 PMCID: PMC9989507 DOI: 10.1016/j.jcin.2022.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 03/02/2023]
Abstract
Transcaval aortic access is a versatile electrosurgical technique for large-bore arterial access through the wall of the abdominal aorta from the adjoining inferior vena cava. Although counterintuitive, its relative safety derives from the recognition that interstitial hydraulic pressure exceeds venous pressure, so arterial bleeding harmlessly decompresses into the nearby caval venous hole. Transcaval access has been performed in thousands of patients for transcatheter aortic valve replacement and endovascular thoracic aneurysm repair and to avoid limb ischemia in percutaneous mechanical circulatory support. Transcaval access may have value compared with transaxillary or subclavian access and with surgical transcarotid access when standard transfemoral access is not optimal. The dissemination of transcaval access and closure techniques has been hampered by the unavailability of commercially marketed devices. This state-of-the-art review details exemplary transcaval technique, patient selection, computed tomographic planning, step-by-step access and closure, management of complications, and procedural troubleshooting in special situations. These contemporary best practices can help operators gain or maintain proficiency.
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Erdem S, An SY, McAlister CA, Basra SS. Suicide left ventricle following protamine: A case report. Catheter Cardiovasc Interv 2023; 101:592-595. [PMID: 36626268 DOI: 10.1002/ccd.30528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/31/2022] [Accepted: 12/10/2022] [Indexed: 01/11/2023]
Abstract
A patient with severe aortic stenosis and left ventricular hypertrophy underwent a transcatheter aortic valve replacement. The patient's blood pressure significantly dropped after protamine administration. A diagnosis of suicide left ventricle post-valve replacement was made. The diagnosis and management of the protamine reaction are detailed. This case highlights the need to slowly infuse protamine sulfate and monitor for adverse events.
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Affiliation(s)
- Saliha Erdem
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sin Y An
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Courtney A McAlister
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sukhdeep S Basra
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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Taneja R, Szoke DJ, Hynes Z, Jones PM. Minimum protamine dose required to neutralize heparin in cardiac surgery: a single-centre, prospective, observational cohort study. Can J Anaesth 2023; 70:219-227. [PMID: 36471142 DOI: 10.1007/s12630-022-02364-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Excess protamine contributes to coagulopathy following cardiopulmonary bypass (CPB) and may increase blood loss and transfusion requirements. The primary aim of this study was to find the least amount of protamine necessary to neutralize residual heparin following CPB using the gold standard assays of anti-IIa and anti-Xa activity. Secondary objectives were to evaluate whether the post-CPB activated clotting time could be used as a surrogate marker for quantifying heparin neutralization. METHODS Twenty-eight consecutive patients undergoing elective cardiac surgery were enrolled. Protamine administration was standardized through an infusion pump at 25 mg·min-1. Blood samples were withdrawn prior to and following administration of 150, 200, 250, and 300 mg protamine and analyzed for activated clotting time and anti-IIa and -Xa activity. RESULTS Following a mean (standard deviation) cumulative heparin dose of 67,700 (19,400) units and a CPB duration of 113 (71) min, protamine requirements varied widely. Eight out of 25 (32%) patients showed complete neutralization of anti-IIa and -Xa activity at the first sampling point (150 mg protamine; protamine:heparin ratio, 0.3 [0.1]). A protamine:heparin ratio of 0.5 (0.2) was sufficient for heparin neutralization in > 90% of patients. After CPB, a low to mid-range activated clotting time correlated well with anti-IIa and -Xa activity. CONCLUSIONS The protamine:heparin ratio required to neutralize residual unfractionated heparin (UFH) following CPB is variable. A protamine:heparin ratio of 0.3 was sufficient to neutralize UFH in some patients, while a ratio of 0.5 is sufficient to neutralize both residual anti-IIa and -Xa activity in most patients. Larger studies are necessary to confirm these findings and evaluate their clinical implications. STUDY REGISTRATION ClinicalTrials.gov (NCT03787641); registered 26 December 2018.
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Affiliation(s)
- Ravi Taneja
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada.
- Division of Critical Care, Department of Medicine, London Health Sciences Centre, University Hospital, B2-223, 339 Windermere Road, London, ON, N6A 5A5, Canada.
| | - Daniel J Szoke
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
| | - Zachary Hynes
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
| | - Philip M Jones
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
- Department of Epidemiology & Biostatistics, University of Western Ontario, London, ON, Canada
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Chen M, ShangGuan J, Jiang J, Jiang J, Li F, Dong Q, Diao H, Liu X. Durably antibacterial cotton fabrics coated by protamine via Schiff base linkages. Int J Biol Macromol 2023; 227:1078-1088. [PMID: 36464182 DOI: 10.1016/j.ijbiomac.2022.11.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/01/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
Abstract
The development of antibacterial cotton fabrics with an overall performance is critical but remains challenging. In this study, we propose a facile method to prepare durable antibacterial cotton fabric without significant sacrifices of wearing comfortability. Cotton fabric is firstly oxidated to obtain dialdehyde groups, then treated with PM molecules to establish a PM coating on the fiber surfaces via Schiff base linkages. The resultant cotton fabrics show durably antibacterial activity, realizing high bacterial reduction rates against both E. coli and S. aureus higher than 99.99 %, and offering remarkable durabilities tolerable 50 washing cycles and 500 rubbing times. These fabrics also show reliable safety for human skin that proofed by a series of cytotoxicity tests with positive results. This work demonstrates an example of versatile strategy to impart effective antibacterial function with durable activity to cotton textiles, showing great potential for practical applications in functional textile fields.
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Affiliation(s)
- Maoshuang Chen
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Jianan ShangGuan
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Junyi Jiang
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Jingjing Jiang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Fengjuan Li
- School of Mechanical and Electrical Engineering, Xinjiang Institute of Technology, Aksu 843100, China
| | - Qingqi Dong
- Zhe Jiang Hengyi High-Tech Materials Co. Ltd., No. 11268, Red 15th Line, Qiantang New Area, Hangzhou 311228, China.
| | - Hongyan Diao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China.
| | - Xiangdong Liu
- School of Materials Science and Engineering, Zhejiang Sci-Tech University, Hangzhou 310018, China.
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Boucher N, Dreksler H, Hooper J, Nagpal S, MirGhassemi A, Miller E. Anaesthesia for vascular emergencies - a state of the art review. Anaesthesia 2023; 78:236-246. [PMID: 36308289 DOI: 10.1111/anae.15899] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 01/11/2023]
Abstract
In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at a vascular surgical centre, patients may present to any emergency department and may require both immediate management and safe transport to a vascular centre. We describe the surgical and anaesthetic considerations for management of aortic dissection, aortic rupture, carotid endarterectomy, acute limb ischaemia and mesenteric ischaemia. Important issues to consider in aortic dissection are extent of the dissection and surgical need for bypasses in addition to endovascular repair. From an anaesthetist's perspective, aortic dissection requires infrastructure for massive transfusion, smooth management should an endovascular procedure require conversion to an open procedure, haemodynamic manipulation during stent deployment and prevention of spinal cord ischaemia. Principles in management of aortic rupture, whether open or endovascular treatment is chosen, include immediate transfer to a vascular care centre; minimising haemodynamic changes to reduce aortic shear stress; permissive hypotension in the pre-operative period; and initiation of massive transfusion protocol. Carotid endarterectomy for carotid stenosis is managed with general or regional techniques, and anaesthetists must be prepared to manage haemodynamic, neurological and airway issues peri-operatively. Acute limb ischaemia is a result of embolism, thrombosis, dissection or trauma, and may be treated with open repair or embolectomy, under either general or local anaesthesia. Due to hypercoagulability, there may be higher numbers of acutely ischaemic limbs among patients with COVID-19, which is important to consider in the current pandemic. Mesenteric ischaemia is a rare vascular emergency, but it is challenging to diagnose and associated with high morbidity and mortality. Several peri-operative issues are common to all vascular emergencies: acute renal injury; management of transfusion; need for heparinisation and reversal; and challenging postoperative care. Finally, the important development of endovascular techniques for repair in many vascular emergencies has improved care, and the availability of transoesophageal echocardiography has improved monitoring as well as aids in surgical placement of endovascular grafts and for post-procedural evaluation.
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Affiliation(s)
- N Boucher
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - H Dreksler
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, ON, Canada
| | - J Hooper
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,Department of Critical Care, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - S Nagpal
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, ON, Canada
| | - A MirGhassemi
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - E Miller
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
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Revelly E, Scala E, Rosner L, Rancati V, Gunga Z, Kirsch M, Ltaief Z, Rusca M, Bechtold X, Alberio L, Marcucci C. How to Solve the Conundrum of Heparin-Induced Thrombocytopenia during Cardiopulmonary Bypass. J Clin Med 2023; 12:jcm12030786. [PMID: 36769435 PMCID: PMC9918281 DOI: 10.3390/jcm12030786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a major issue in cardiac surgery requiring cardiopulmonary bypass (CPB). HIT represents a severe adverse drug reaction after heparin administration. It consists of immune-mediated thrombocytopenia paradoxically leading to thrombotic events. Detection of antibodies against platelets factor 4/heparin (anti-PF4/H) and aggregation of platelets in the presence of heparin in functional in vitro tests confirm the diagnosis. Patients suffering from HIT and requiring cardiac surgery are at high risk of lethal complications and present specific challenges. Four distinct phases are described in the usual HIT timeline, and the anticoagulation strategy chosen for CPB depends on the phase in which the patient is categorized. In this sense, we developed an institutional protocol covering each phase. It consisted of the use of a non-heparin anticoagulant such as bivalirudin, or the association of unfractionated heparin (UFH) with a potent antiplatelet drug such as tirofiban or cangrelor. Temporary reduction of anti-PF4 with intravenous immunoglobulins (IvIg) has recently been described as a complementary strategy. In this article, we briefly described the pathophysiology of HIT and focused on the various strategies that can be applied to safely manage CPB in these patients.
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Affiliation(s)
- Etienne Revelly
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Correspondence:
| | - Emmanuelle Scala
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
| | - Lorenzo Rosner
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Valentina Rancati
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Ziyad Gunga
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Matthias Kirsch
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Zied Ltaief
- Department of Intensive Care Medicine, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Marco Rusca
- Department of Intensive Care Medicine, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Xavier Bechtold
- Department of Cardiac Surgery, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Lorenzo Alberio
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
| | - Carlo Marcucci
- Department of Anesthesiology, Lausanne University Hospital (CHUV), 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Rue du Bugnon 21, 1011 Lausanne, Switzerland
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Foubert R, Van Vaerenbergh G, Cammu G, Buys S, De Mey N, Lecomte P, Bouchez S, Rex S, Foubert L. Protamine titration to optimize heparin antagonization after cardiopulmonary bypass. Perfusion 2022:2676591221144702. [PMID: 36503295 DOI: 10.1177/02676591221144702] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
OBJECTIVES To optimize protamine titration for heparin antagonization after weaning from cardiopulmonary bypass (CPB). DESIGN A prospective, observational trial. SETTING Single-center, non-university teaching hospital. PARTICIPANTS Forty patients presenting for elective on-pump coronary artery bypass grafting with or without single valve surgery. INTERVENTIONS At the end of CPB, the residual amount of heparin in the patient was estimated using a Bull-curve. The total protamine dose was calculated as 1 unit of protamine for 1 unit of heparin. Protamine was administered as 5 aliquots containing 20% of the total protamine dose each, with 2-min intervals. MEASUREMENTS AND MAIN RESULTS Activated Clotting Time (ACT) values were measured 2 min after administration of each aliquot. ROTEM(®)-analysis was performed after the full dose of protamine had been administered. After 60% of the total protamine dose had been administered, ACT values were normalized in 86.5% of patients. After the complete dose of protamine had been administered, 61.1% of patients displayed signs of protamine overdose on ROTEM(®)-analysis. CONCLUSIONS In patients who present for on-pump coronary artery bypass grafting with or without single valve surgery, a 0.6-to-1 ratio of protamine-to-heparin to antagonize heparin may be sufficient and beneficial for patients.
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Affiliation(s)
- Ruben Foubert
- Department of Anesthesia, Intensive Care and Emergency Medicine, OLV Hospital Aalst, Aalst, Belgium
| | | | - Guy Cammu
- Department of Anesthesia, Intensive Care and Emergency Medicine, OLV Hospital Aalst, Aalst, Belgium
| | - Sara Buys
- Department of Anesthesia, Intensive Care and Emergency Medicine, OLV Hospital Aalst, Aalst, Belgium
| | - Nathalie De Mey
- Department of Anesthesia, Intensive Care and Emergency Medicine, OLV Hospital Aalst, Aalst, Belgium
| | - Patrick Lecomte
- Department of Anesthesia, Intensive Care and Emergency Medicine, OLV Hospital Aalst, Aalst, Belgium
| | - Stefaan Bouchez
- Department of Anesthesia, Intensive Care and Emergency Medicine, OLV Hospital Aalst, Aalst, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Luc Foubert
- Department of Anesthesia, Intensive Care and Emergency Medicine, OLV Hospital Aalst, Aalst, Belgium
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40
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Jiang Y, Liu Y, Jia X, Xin W, Wang H. The emerging role of adopting protamine for reducing the risk of bleeding complications during the percutaneous coronary intervention: A meta-analysis. J Card Surg 2022; 37:5341-5350. [PMID: 36352811 DOI: 10.1111/jocs.17139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The safety and the benefits of reducing the risk of bleeding complications via protamine administration during the percutaneous coronary intervention (PCI) remains unclear. This study aimed to systematically assessed the efficacy and safety of using protamine in PCI. METHOD Potential academic studies were identified from PubMed, Cochrane Library, EMBASE, and Web of Science. The time range we retrieved from was that from the inception of electronic databases to March 31, 2022. Gray studies were identified from the references of included literature reports. Stata version 12.0 statistical software (StataCorp LP) was used to analyze the pooled data. RESULTS A total of seven studies were involved in our study. The overall participants of the protamine group were 4983, whereas it was 1953 in the nonprotamine group. This meta-analysis indicated that protamine was preferable for PCI as its lower value of major bleeding (odds ratio [OR] = 0.489, 95% confidence interval [CI]: 0.362-0.661, p < .001) and minor bleeding (OR = 0.281, 95% CI: 0.123-0.643, p = .003). Additionally, the protamine did not tend to be related a higher incidence of mortality (p = .143), myocardial infarction (p = .990), and stent thrombosis (p = .698). CONCLUSIONS Based on available evidence, use of protamine may reduce the risk of bleeding complications without increasing the risk of mortality, myocardial infarction, and stent thrombosis. Given the relevant possible biases in our study, adequately powered and better-designed studies with long-term follow-up are required to reach a firmer conclusion.
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Affiliation(s)
- Yunshan Jiang
- Department of Cardiology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Yuzhi Liu
- Department of Cardiology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Xiaoli Jia
- Department of Pharmacy, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Wenqiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongyan Wang
- Department of Pharmacy, Liaocheng People's Hospital, Liaocheng, People's Republic of China
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41
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A Near Infra-red Emitting Supramolecular Dye-Polymer Assembly as Promising Platform for Protamine Sensing. J Mol Liq 2022. [DOI: 10.1016/j.molliq.2022.120928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Duceac IA, Coseri S. Biopolymers and their derivatives: Key components of advanced biomedical technologies. Biotechnol Adv 2022; 61:108056. [DOI: 10.1016/j.biotechadv.2022.108056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/26/2022] [Accepted: 10/23/2022] [Indexed: 11/02/2022]
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Gadly T, Patro BS, Chakraborty G. Fluorogenic gemcitabine based light up sensor for serum albumin detection in complex biological matrices. Colloids Surf B Biointerfaces 2022; 220:112865. [PMID: 36174489 DOI: 10.1016/j.colsurfb.2022.112865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/11/2022] [Accepted: 09/19/2022] [Indexed: 10/14/2022]
Abstract
Herein we report fluorogenic derivative of gemcitabine (GEM-DNS), synthesized from gemcitabine hydrochloride and dansyl chloride in a single step. Owing to its large stoke shift of ∼200 nm and intriguing photophysical properties, the said dye has been utilized to estimate albumin concentration in complex bio-media such as human urine and blood serum. High sensitivity and selectivity towards albumin make the aforementioned dye a powerful diagnostic tool to detect ailments such as liver cirrhosis, diabetes, hypertension etc.
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Affiliation(s)
- Trilochan Gadly
- Bio-Organic Division, Bhabha Atomic Research Centre, Mumbai 400085, India
| | - Birija S Patro
- Bio-Organic Division, Bhabha Atomic Research Centre, Mumbai 400085, India
| | - Goutam Chakraborty
- Laser & Plasma Technology Division, Bhabha Atomic Research Centre, Mumbai 400085, India.
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Dallan LRP, Dallan LAO, Lisboa LAF, Mejia OAV, Platania F, Rodrigues RDC, Dallan LAP, Jatene FB. Transit‐time flow measurement parameters after protamine infusion in CABG surgeries. J Card Surg 2022; 37:3492-3506. [DOI: 10.1111/jocs.16948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/03/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Luis Roberto P. Dallan
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Luis Alberto O. Dallan
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Luiz Augusto F. Lisboa
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Omar A. V. Mejia
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Fernando Platania
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Renan de Carvalho Rodrigues
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
| | - Luis Augusto P. Dallan
- Department of Cardiovascular Medicine, Harrington Heart and Vascular Institute University Hospitals Cleveland Medical Center Cleveland Ohio USA
| | - Fabio B. Jatene
- Department of Cardiovascular Surgery, Instituto do Coracao, Hospital das Clinicas, Faculdade de Medicina Universidade de Sao Paulo São Paulo Brazil
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van Ginkel DJ, Bor WL, Veenstra L, van 't Hof AWJ, Fabris E. Evolving concepts in the management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation. Eur J Intern Med 2022; 101:14-20. [PMID: 35623935 DOI: 10.1016/j.ejim.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/22/2022]
Abstract
Thromboembolic and bleeding complications negatively impact recovery and survival after transcatheter aortic valve implantation (TAVI). Particularly, there is a considerable risk of ischaemic stroke and vascular access related bleeding, as well as spontaneous gastro-intestinal bleeding. Therefore, benefit and harm of antithrombotic therapy should be carefully balanced. This review summarizes current evidence on peri- and post-procedural antithrombotic treatment. Indeed, in recent years, the management of antithrombotic therapy after TAVI has evolved from intensive, expert opinion-based strategies, towards a deescalated, evidence-based approach. Besides per procedural administration of unfractionated heparin, this encompasses single antiplatelet therapy in patients without a concomitant indication for oral anticoagulation (OAC); and OAC monotherapy in patients with such indication, mainly being atrial fibrillation. Combination therapy should generally be avoided to reduce bleeding risk, except after recent coronary stenting where a period of dual antiplatelet therapy (aspirin plus P2Y12-inhibitor) or P2Y12-inhibitor plus OAC (in patients with an independent indication for OAC) is recommended to prevent stent thrombosis. This new paradigm in which reduced antithrombotic intensity leads to improved patient safety, without a loss of efficacy, may be particularly suitable for elderly and fragile patients. Whether this holds in upcoming populations of younger and lower-risk patients and in specific populations as patients with subclinical valve thrombosis, is yet to be proven. Finally, whether less intensive or alternative approaches should be also applied for the periprocedural management of the antithrombotic therapy, has to be determined by ongoing and future studies.
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Affiliation(s)
- Dirk Jan van Ginkel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Willem L Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Leo Veenstra
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Arnoud W J van 't Hof
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Enrico Fabris
- Cardiothoracovascular Department, University of Trieste, Trieste, Italy.
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Falter F, Singh AA, Boyle JR. Reply to A Chaudhuri Protamine in carotid surgery: the advantages outweigh the disadvantages. Eur J Vasc Endovasc Surg 2022; 64:136-137. [PMID: 35589088 DOI: 10.1016/j.ejvs.2022.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/08/2022] [Indexed: 11/25/2022]
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47
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Safety and efficacy of immediate heparin reversal with protamine after complex percutaneous coronary intervention. BMC Cardiovasc Disord 2022; 22:207. [PMID: 35538419 PMCID: PMC9088099 DOI: 10.1186/s12872-022-02650-5] [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: 02/22/2022] [Accepted: 04/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background Compared to simple percutaneous coronary intervention (PCI), complex PCI is associated with higher bleeding and thrombotic risk. No previous study has evaluated the use of protamine after PCI with contemporary technologies. This study aimed to evaluate the safety and efficacy of manual compression with and without protamine after transfemoral complex PCI.
Methods We retrospectively analyzed 160 patients (protamine group, n = 92; non-protamine group, n = 68) who underwent complex PCI via the femoral artery. The primary outcome was a composite of in-hospital death, myocardial infarction, stent thrombosis, stroke/systemic embolism, bleeding requiring blood transfusion, and vascular access complications. Results The primary outcome was significantly lower in the protamine group than in the non-protamine group (4.3% vs. 17.6%; p = 0.006). This was driven mainly by the lower incidences of hematoma in the protamine group (3.3% vs. 13.2%, p = 0.020). Furthermore, the protamine group had a significantly shorter hospital stay than the non-protamine group (4.8 ± 3.7 days vs. 8.4 ± 8.3 days, p = 0.001). While > 90% of the patients had acute coronary syndrome, there were no incidences of myocardial infarction or stent thrombosis in either group. Conclusions Among patients who underwent complex PCI via transfemoral access, immediate protamine administration was associated with a significantly lower rate of vascular access complications, especially hematoma, and shorter hospital stay than no protamine administration.
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48
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Robinson KJ, Soda Y, Bakker E. Recent improvements to the selectivity of extraction-based optical ion sensors. Chem Commun (Camb) 2022; 58:4279-4287. [PMID: 35201251 PMCID: PMC8972301 DOI: 10.1039/d1cc06636f] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Optical sensors continue to demonstrate tremendous potential across a wide range of applications due to their high versatility and low cost. This feature article will focus on a number of recent advances made in improving the performance of extraction-based optical ion sensors within our group. This includes the progress of anchored solvatochromic transduction to provide pH and sample volume independent optical responses in nanoemulsion-based sensors. A recent breakthough is in polyion sensing in biological fluids that uses a novel indirect transduction mechanism that significantly improves the selectivity of dinonylnaphthalenesulfonate-based protamine sensors and its potential applications beyond polyion sensing. The role of particle stabilizers in relation to the response of emulsified sensors is shown to be important. Current challenges in the field and possible opportunities are also discussed. Selectivity remains a constant challenge in the development of optical extraction-based sensors. Fortunately, there are several mechanistic and compositional changes with the potential to improve selectivity without developing new ionophores.![]()
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Affiliation(s)
- Kye J Robinson
- Department of Inorganic, Analytical Chemistry University of Geneva Quai Ernest-Ansermet 30, 1211 Geneva, Switzerland.
| | - Yoshiki Soda
- Department of Inorganic, Analytical Chemistry University of Geneva Quai Ernest-Ansermet 30, 1211 Geneva, Switzerland.
| | - Eric Bakker
- Department of Inorganic, Analytical Chemistry University of Geneva Quai Ernest-Ansermet 30, 1211 Geneva, Switzerland.
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Wooten JM, Baldwin ST. Pharmacologic Agents Used to Reverse the Anticoagulant Effect of Common Anticoagulants. South Med J 2022; 115:220-226. [PMID: 35237842 DOI: 10.14423/smj.0000000000001372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Numerous oral and parenteral anticoagulant drugs are now available for clinical use. Understanding the precise pharmacologic properties of each anticoagulant is imperative for those practitioners who prescribe these drugs, including knowing the current recommendations for reversing the anticoagulant effect of each anticoagulant. This review provides a brief description of the various anticoagulants used today and also discusses the pharmacologic properties of those drugs used to reverse the anticoagulant action of specific anticoagulants.
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Affiliation(s)
- James M Wooten
- From the Department of Internal Medicine-Clinical Pharmacology, University of Missouri-Kansas City School of Medicine, Kansas City, and Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama (Retired)
| | - Steven T Baldwin
- From the Department of Internal Medicine-Clinical Pharmacology, University of Missouri-Kansas City School of Medicine, Kansas City, and Pediatric Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama (Retired)
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Abstract
Continuous renal replacement therapy is an important, yet challenging, treatment of critically ill patients with kidney dysfunction. Clotting within the dialysis filter or circuit leads to time off therapy and impaired delivery of prescribed treatment. Anticoagulation can be used to prevent this complication; however, doing so introduces risk for unintended complications such as bleeding or metabolic derangements in patients who are already critically ill. A thorough understanding of indications, therapeutic options, and monitoring principles is necessary for safe and effective use of this strategy. This review provides clinicians important information regarding when to anticoagulate, differences in pharmacologic agents, recommended doses, routes of drug delivery, and appropriate laboratory monitoring for patients receiving anticoagulation to support continuous renal replacement therapy.
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