1
|
Reardon B, Pasalic L, Favaloro EJ. The Role of Viscoelastic Testing in Assessing Hemostasis: A Challenge to Standard Laboratory Assays? J Clin Med 2024; 13:3612. [PMID: 38930139 PMCID: PMC11205135 DOI: 10.3390/jcm13123612] [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: 05/01/2024] [Revised: 06/18/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Viscoelastic testing is increasingly being used in clinical and research settings to assess hemostasis. Indeed, there are potential situations in which viscoelastic testing is reportedly superior to standard routine laboratory testing for hemostasis. We report the current testing platforms and terminology, as well as providing a concise narrative review of the published evidence to guide its use in various clinical settings. Notably, there is increasing evidence of the potential utility of viscoelastic testing for assessment of direct oral anticoagulants, and bleeding associated with chronic liver disease, orthotopic liver transplantation, cardiac surgery, trauma, obstetrics and pediatrics.
Collapse
Affiliation(s)
- Benjamin Reardon
- School of Medicine and Public Health, Joint Medical Program, University of Newcastle, Callaghan, NSW 2145, Australia;
- Haematology Department, Calvary Mater Hospital Newcastle, Waratah, NSW 2298, Australia
| | - Leonardo Pasalic
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW 2145, Australia;
- Westmead Clinical School, University of Sydney, Westmead, NSW 2145, Australia
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Emmanuel J. Favaloro
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW 2145, Australia;
- Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Westmead, NSW 2145, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW 2650, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia
| |
Collapse
|
2
|
Westfall KM, Ramcharan RN, Shulkosky MM, Wahl WL, Hecht JP. The Effect of Antiplatelet Agents on Thromboelastography. Am Surg 2023; 89:4598-4603. [PMID: 36039607 DOI: 10.1177/00031348221124327] [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: 11/17/2022]
Abstract
BACKGROUND Thomboelastography (TEG) is a point of care viscoelastic test that provides an assessment of clot formation and kinetics. Antiplatelet agents are commonly used but there is limited literature evaluating their possible effects on overall clot kinetics. We aimed to evaluate the relationship between antiplatelet agents and clot kinetics as defined by TEG. METHODS This is a retrospective study of adult patients who underwent TEG from February 2018 to July 2020. Patients who received anticoagulants or blood transfusions within 72 hours, had an incomplete TEG, were diagnosed with COVID-19, or had liver failure were excluded. Patients were stratified based on antiplatelet status. RESULTS Of 1060 patients, 119 were included (50 controls, 69 antiplatelet agents-37 aspirin monotherapy, 26 dual antiplatelet therapy). Between the control and antiplatelet therapy groups, there was no significant difference in clot time, maximal clot strength, or fibrinogen level. When compared to control patients, patients on dual antiplatelets had significantly higher fibrinogen levels (408.1 mg/dL vs 481.5 mg/dL, P = .013) but no significant differences in clot time or maximal clot strength. In our subgroup analysis, patients on dual antiplatelets had increased maximal clot strength (58.8° vs 63°, P = .005) and fibrinogen levels (384.1 mg/dL vs 481.5 mg/dL, P = .005) compared to those on aspirin alone. DISCUSSION Compared to control patients and those on aspirin alone, patients on dual antiplatelets have increased maximal clot strength and increased fibrinogen levels. These results can help physicians better target product resuscitation in patients who are on antiplatelet agents.
Collapse
Affiliation(s)
| | - Roger N Ramcharan
- Department of Surgery, St. Joseph Mercy Ann Arbor, Ann Arbor, MI, USA
| | | | - Wendy L Wahl
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jason P Hecht
- Department of Surgery, St. Joseph Mercy Ann Arbor, Ann Arbor, MI, USA
| |
Collapse
|
3
|
Ramanujam V, DiMaria S, Varma V. Thromboelastography in the Perioperative Period: A Literature Review. Cureus 2023; 15:e39407. [PMID: 37362492 PMCID: PMC10287184 DOI: 10.7759/cureus.39407] [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] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.
Collapse
Affiliation(s)
- Vendhan Ramanujam
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Stephen DiMaria
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Vivek Varma
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| |
Collapse
|
4
|
Davidson S. Monitoring of Antiplatelet Therapy. Methods Mol Biol 2023; 2663:381-402. [PMID: 37204725 DOI: 10.1007/978-1-0716-3175-1_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
In the late 1990s, the antithrombotic antiplatelet agent, clopidogrel, a P2Y12 inhibitor, was introduced. Around the same time, there was an increase in a number of new methods to measure platelet function (e.g., PFA-100 in 1995), and this has continued. It became evident that not all patients responded to clopidogrel in the same way and that some patients had a relative "resistance" to therapy, termed "high on-treatment platelet reactivity." This then led to some publications to advocate platelet function testing being used for patients on antiplatelet therapy. Platelet function testing was also suggested for use in patients awaiting cardiac surgery after stopping their antiplatelet therapy as a way of balancing thrombotic risk pre-surgery and bleeding risk perioperatively. This chapter will discuss some of the commonly used platelet function tests used in these settings, particularly those that are sometimes referred to as point-of-care tests or that require minimal laboratory sample manipulation. The latest guidance and recommendations for platelet function testing will be discussed following several clinical trials looking at the usefulness of platelet function testing in these clinical settings.
Collapse
Affiliation(s)
- Simon Davidson
- Division of Medicine, University College London, London, UK.
| |
Collapse
|
5
|
Hartmann J, Curzen N. Modified Thromboelastography for Peri-interventional Assessment of Platelet Function in Cardiology Patients: A Narrative Review. Semin Thromb Hemost 2022; 49:192-200. [PMID: 36252602 PMCID: PMC9894686 DOI: 10.1055/s-0042-1757545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Viscoelastic testing (VET), such as thromboelastography, can measure whole blood coagulation dynamics in real time and is used across a range of clinical settings, including cardiac surgery, liver transplant, and trauma. The use of modified thromboelastography with platelet function assessment (TEG(R) PlateletMapping(R) Assay) can provide an analysis of platelet contribution to hemostasis, including the contribution of the P2Y12 receptor and thromboxane pathway to platelet function. The TEG PlateletMapping Assay has shown high correlation with the current gold standard test of platelet function, light transmission aggregometry, to measure arachidonic acid and adenosine diphosphate agonist-induced platelet activation. Studies have also shown comparable results with other whole blood platelet function tests. In this review, we explore the clinical applications of modified thromboelastography with platelet function assessment. This includes guiding dual antiplatelet therapy in relation to cardiac procedures, such as percutaneous coronary interventions, transcatheter aortic valve replacement, and left atrial appendage closure. We also explore the developing use of thromboelastography in the emergency care setting of coronavirus disease 2019, which is commonly associated with a hypercoagulable and hypofibrinolytic state. Despite a general lack of high-quality, grade 1 evidence regarding the use of modified thromboelastography with platelet function assessment in these disease areas, the ability of the TEG PlateletMapping Assay to measure global hemostasis and platelet reactivity rapidly and to view and evaluate results at the point of care makes it a promising area for further study for managing patient treatment and optimizing hemostatic therapy.
Collapse
Affiliation(s)
- Jan Hartmann
- Haemonetics Corp., Boston, Massachusetts,Address for correspondence Jan Hartmann, MD Haemonetics Corp, 125 Summer Street, Boston, MA 02110
| | - Nick Curzen
- Faculty of Medicine, University of Southampton & Cardiothoracic Department, University Hospital Southampton, United Kingdom
| |
Collapse
|
6
|
Application of a TEG-Platelet Mapping Algorithm to Guide Reversal of Antiplatelet Agents in Adults with Mild-to-Moderate Traumatic Brain Injury: An Observational Pilot Study. Neurocrit Care 2022; 37:638-648. [PMID: 35705826 DOI: 10.1007/s12028-022-01535-x] [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] [Received: 09/27/2021] [Accepted: 05/13/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Traumatic intracranial hemorrhages expand in one third of cases, and antiplatelet medications may exacerbate hematoma expansion. However, the reversal of an antiplatelet effect with platelet transfusion has been associated with harm. We sought to determine whether a thromboelastography platelet mapping (TEG-PM)-guided algorithm could limit platelet transfusion in patients with hemorrhagic traumatic brain injury (TBI) prescribed antiplatelet medications without a resultant clinically significant increase in hemorrhage volume, late hemostatic treatments, or delayed operative intervention. METHODS A total of 175 consecutive patients with TBI were admitted to our university-affiliated, level I trauma center between March 2016 and December 2019: 54 preintervention patients (control) and 121 patients with TEG-PM (study). After exclusion for anticoagulant administration, availability of neuroimaging and emergent neurosurgery, 62 study patients and 37 control patients remained. Intervention consisted of administration of desmopressin (DDAVP) for nonsurgical patients with significant inhibition at the arachidonic acid or adenosine diphosphate receptor sites. For surgical patients with significant inhibition, dual therapy with DDAVP and platelet transfusion was employed. Study patients were compared with a group of historical controls, which were identified from a prospectively maintained registry and typically treated with empiric platelet transfusion. RESULTS Median age was 75 years (interquartile range 85-67) and 77 years (interquartile range 81-65) in the TEG-PM and control patient groups, respectively. Admission hemorrhage volumes were similar (10.7 cm3 [20.1] in patients with TEG-PM vs. 14.1 cm3 [19.7] in controls; p = 0.41). There were no significant differences in admission Glasgow Coma Scale, mechanism of trauma, or baseline comorbidities. A total of 57% of controls versus 10% of patients with TEG-PM (p < 0.001) were transfused platelets; 52% of intervention patients and 0% controls were treated with DDAVP. Expansion hemorrhage volumes were not significantly different (14.0 cm3 [20.2] patients with TEG-PM versus 13.6 cm3 [23.7] controls; p = 0.93). There was no significant difference in rates of clinical deterioration, delayed neurosurgical intervention, or late platelet transfusion between groups. CONCLUSIONS Among patients with hemorrhagic TBI prescribed preinjury antiplatelet therapy, our study suggests that the use of a TEG-PM algorithm may reduce platelet transfusions without a concurrent increase in clinically significant hematoma expansion. Further study is required to prove a causative relationship.
Collapse
|
7
|
Wang Z, Zou Y, Xia L, Li X, Yao Y, Ye Y, Lv Q. Does thromboelastography predict bleeding in patients treated with clopidogrel or ticagrelor in off-pump coronary artery bypass grafting? Thromb Res 2022; 213:145-153. [DOI: 10.1016/j.thromres.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
|
8
|
Yousuf MS, Samad K, Ahmed SS, Siddiqui KM, Ullah H. Cardiac Surgery and Blood-Saving Techniques: An Update. Cureus 2022; 14:e21222. [PMID: 35186524 PMCID: PMC8844256 DOI: 10.7759/cureus.21222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/12/2022] Open
Abstract
Cardiac surgery is typically attributed with a significant risk of intraoperative blood loss and allogeneic blood transfusions. Intraoperative blood loss, allogenic blood transfusions, high dose anticoagulation requirement, and interactions with cardiopulmonary bypass (CPB) have all been linked to cardiac surgeries. To reduce unnecessary transfusions and their negative effects, it is recommended to follow evidence-based multidisciplinary strategies, which are collectively termed patient blood management (PBM). This review highlights the most recent blood conservation strategies in adult cardiac surgery, which can be employed pre-operatively, intra-operatively, and postoperatively, to enhance red cell mass and attenuate the utilization of packed red blood cells (PRBCs) and other blood products.
Collapse
|
9
|
Racine-Brzostek SE, Asmis LM. Assessment of platelet function utilizing viscoelastic testing. Transfusion 2021; 60 Suppl 6:S10-S20. [PMID: 33089932 DOI: 10.1111/trf.16081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/29/2020] [Accepted: 08/29/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Sabrina E Racine-Brzostek
- Department of Pathology and Laboratory Medicine, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
| |
Collapse
|
10
|
Modern methods for monitoring hemorrhagic resuscitation in the United States: Why the delay? J Trauma Acute Care Surg 2021; 89:1018-1022. [PMID: 33048910 DOI: 10.1097/ta.0000000000002977] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
11
|
Datta SS, De D, Bose S. Thromboelastography Platelet Mapping—A Useful Preoperative Tool to Reduce Transfusion Requirement by Determining Timing of Coronary Artery Bypass Graft Surgery in Patients taking Dual Antiplatelet Medication: A Pilot Study from Eastern India. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1723622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractIn this pilot study, we proposed an algorithm to use thromboelastography platelet mapping (TEG-PM) as an effective preoperative platelet function assessment tool in coronary artery bypass graft surgery (CABG) to reduce the transfusion requirement by determining timing of surgery in patients who are on dual antiplatelet therapy (DAPT). Total 15 elective CABG patients who were receiving DAPT were tested by TEG-PM assay after 72 hours’ stoppage of both medications. Four patients who had < 50% inhibition with agonists (arachidonic acid [AA] and adenosine diphosphate [ADP]) were operated within 24 hours of assay. Eight patients who had > 70% inhibition with AA/ADP, surgery was deterred till 48 hours, and 3 patients with > 50% but < 70% inhibition were operated within 24 hours after preoperative prophylactic platelet transfusion. Transfusion requirement was recorded and compared with the previous transfusion data for CABG cases operated without TEG-PM. Distribution of ADP inhibition was 67.54 ± 30.03% and AA inhibition was 60.69 ± 30.14%, showing a variable offset of the effect of both medications starting after 72 hours of cessation. Overall transfusion requirement was decreased by using TEG-PM algorithm. Preoperative platelet function testing to determine the timing of surgery by TEG-PM assay in DAPT-treated patients may be a useful strategy to reduce transfusion requirement in CABG.
Collapse
Affiliation(s)
- Suvro Sankha Datta
- Department of Transfusion Medicine, The Mission Hospital, Durgapur, West Bengal, India
| | - Dibyendu De
- Department of Clinical Hematology, The Mission Hospital, Durgapur, West Bengal, India
| | - Satyajit Bose
- Department of Cardio-Vascular Surgery, The Mission Hospital, Durgapur, West Bengal, India
| |
Collapse
|
12
|
Viscoelastic Hemostatic Assays and Platelet Function Testing in Patients with Atherosclerotic Vascular Diseases. Diagnostics (Basel) 2021; 11:diagnostics11010143. [PMID: 33478051 PMCID: PMC7835760 DOI: 10.3390/diagnostics11010143] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
Platelets play crucial role in acute vascular atherosclerotic diseases, including myocardial infarction and stroke. Additionally, platelet aggregation is a key target of antiplatelet agents, forming the keystone of pharmacotherapy of various atherosclerotic cardiovascular diseases. Thromboelastography and thromboelastometry, representing currently available viscoelastic hemostatic assays (VHA), are designed as whole blood, real-time analyzers of clot formation and clot resolution. These assays could, in theory, overcome some limitations of currently available platelet function testing assays. This article reviews the current experience with the use of VHA for platelet function testing and for monitoring of the response to antiplatelet therapy.
Collapse
|
13
|
Alvitigala BY, Gooneratne LV, Constantine GR, Wijesinghe RANK, Arawwawala LDAM. Pharmacokinetic, pharmacodynamic, and pharmacogenetic assays to monitor clopidogrel therapy. Pharmacol Res Perspect 2020; 8:e00686. [PMID: 33200888 PMCID: PMC7670852 DOI: 10.1002/prp2.686] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022] Open
Abstract
Clopidogrel is the most common and widely used antiplatelet agent for patients with coronary artery disease following confirmation by electrocardiographic studies. The nonresponsiveness of patients to clopidogrel and the possibility of testing for clopidogrel resistance by platelet function assays (PFA) are contentious issues. Light transmission aggregometry (LTA) is considered as the gold standard test among all PFA. In this review, the most commonly used PFA used for monitoring the effect of clopidogrel, LTA, vasodilator-stimulated phosphoprotein assay phosphorylation, rotational thromboelastometry (ROTEM) delta and ROTEM platelet, thromboelastography, PFA-100, VerifyNow P2Y12 assay, Multiplate analyzer, Plateletworks assay and pharmacogenetic studies, are comparatively discussed including their principles of action, advantages, and disadvantages. VerifyNow P2Y12 assay can be accepted as the ideal point of care test out of the discussed assays. However, modified assays are required which could overcome the limitations associated with currently available assays.
Collapse
Affiliation(s)
- Bhawani Yasassri Alvitigala
- Department of Medical Laboratory ScienceFaculty of Health SciencesThe Open University of Sri LankaNugegodaSri Lanka
| | | | | | | | | |
Collapse
|
14
|
Woźniak MJ, Abbasciano R, Monaghan A, Lai FY, Corazzari C, Tutino C, Kumar T, Whiting P, Murphy GJ. Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies Evaluating Point-of-Care Tests of Coagulopathy in Cardiac Surgery. Transfus Med Rev 2020; 35:7-15. [PMID: 33187808 DOI: 10.1016/j.tmrv.2020.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 09/08/2020] [Accepted: 09/19/2020] [Indexed: 02/01/2023]
Abstract
Treatment guidelines recommend the routine use of point-of-care diagnostic tests for coagulopathy in the management of cardiac surgery patients at risk of severe bleeding despite uncertainty as to their diagnostic accuracy. We performed a systematic review and meta-analysis of studies that evaluated the diagnostic accuracy of viscoelastometry, platelet function tests, and modified thromboelastography (TEG) tests, for coagulopathy in cardiac surgery patients. The reference standard included resternotomy for bleeding, transfusion of non-red cell components, or massive transfusion. We searched MEDLINE, EMBASE, CINAHL, and Clinical Trials.gov, from inception to June 2019. Study quality was assessed using QUADAS-2. Bivariate models were used to estimate summary sensitivity and specificity with (95% confidence intervals). All 29 studies (7440 participants) included in the data synthesis evaluated the tests as predictors of bleeding. No study evaluated their role in the management of bleeding. None was at low risk of bias. Four were judged as low concern regarding applicability. Pooled estimates of diagnostic accuracy were; Viscoelastic tests, 12 studies, sensitivity 0.61 (0.44, 0.76), specificity 0.83 (0.70, 0.91) with significant heterogeneity. Platelet function tests, 12 studies, sensitivity 0.63 (0.53, 0.72), specificity 0.75 (0.64, 0.84) with significant heterogeneity. TEG modification tests, 3 studies, sensitivity 0.80 (0.67, 0.89), specificity 0.76 (0.69, 0.82) with no evidence of heterogeneity. Studies reporting the highest values for sensitivity and specificity had important methodological limitations. In conclusion, we did not demonstrate predictive accuracy for commonly used point-of-care devices for coagulopathic bleeding in cardiac surgery. However, the certainty of the evidence was low.
Collapse
Affiliation(s)
- Marcin J Woźniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK.
| | - Riccardo Abbasciano
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Alexandra Monaghan
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Florence Y Lai
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Claudio Corazzari
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK; Cardiac Surgery Unit, Insubria University, Varese, Italy
| | | | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Penny Whiting
- Centre for Research Synthesis and Decision Analysis (CReSyDA), Bristol Medical School, University of Bristol, Bristol, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| |
Collapse
|
15
|
Agarwal S, Abdelmotieleb M. Viscoelastic testing in cardiac surgery. Transfusion 2020; 60 Suppl 6:S52-S60. [PMID: 32955756 DOI: 10.1111/trf.16075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
Bleeding complications are common in cardiac surgery and lead to an increase in morbidity and mortality. This is multifactorial in aetiology including the effects of cardiopulmonary bypass, the drugs given to manipulate the coagulation system and the vascular nature of the surgery itself. Viscoelastic tests provide a point of care, rapid assessment of coagulation which offer the advantage of faster turnaround times and a nuanced view of the elements of the coagulation system allowing targeted therapy to be delivered quickly. Both thomboelastography (TEG)and thromboelastometry (ROTEM) have been recommended for use in cardiac surgery, both have shown a reduction in transfusion and bleeding when used as part of a testing algorithm. They are particularly useful in assessing residual heparinisation and fibrinogen levels. Additionally, TEG allows the evaluation of the effects of anti-platelet agents on platelet function. This review discusses the mechanisms by which bleeding occurs in cardiac surgery and explores three uses of viscoelastic testing in cardiac surgery: to predict bleeding, to assess platelet function and peri-operative testing to reduce transfusion.
Collapse
Affiliation(s)
- Seema Agarwal
- Department of Cardiothoracic Anaesthesia and ICM, Manchester University Foundation Trust, Manchester, UK
| | - Mohamed Abdelmotieleb
- Department of Cardiothoracic Anaesthesia and ICM, Manchester University Foundation Trust, Manchester, UK
| |
Collapse
|
16
|
Tian L, Gao X, Yang J, Yao Y, Ji H. Association of Adenosine Diphosphate-Induced Platelet Maximum Amplitude With Postoperative Bleeding and Blood Transfusions in Patients Undergoing Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2020; 35:421-428. [PMID: 32758409 DOI: 10.1053/j.jvca.2020.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To investigate the association of adenosine diphosphate (ADP)-induced platelet maximum amplitude (MAADP) with postoperative bleeding and blood product transfusions in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). DESIGN This single-center observational study recruited 200 patients who underwent elective, first-time, isolated CABG with CPB. A rapid thromboelastography with platelet mapping test was conducted for all patients before the surgery. Patients were categorized by the preoperative MAADP into ≤50 mm (MAADP ≤50 group [n = 87]) and MAADP >50 mm (MAADP >50 group [n = 113]). The primary outcome was postoperative bleeding at 6 and 24 hours as measured by chest tube drainage volume. The perioperative blood product transfusions, postoperative complications, postoperative time course, and in-hospital mortality also were evaluated. SETTING University hospital. PARTICIPANTS Adult patients scheduled to undergo isolated primary CABG with CPB. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The study included 200 patients who underwent CABG with CPB. MAADP was >50 mm in 113 (56.5%) patients (MAADP >50 group). Compared with the MAADP >50 group, the postoperative chest tube drainage volume at 6 and 24 hours was significantly greater in the patients with MAADP ≤50 mm (476.90 ± 156.36 mL v 403.36 ± 133.24 mL; p < 0.001 and 935.86 ± 318.43 mL v 667.21 ± 222.75 mL; p < 0.001, respectively). The consumption of blood products in patients with MAADP ≤50 mm was significantly more than those with MAADP >50 mm. The durations of intensive care unit stay and length of postoperative hospital stay were markedly longer in the MAADP ≤50 group than in the MAADP >50 group (p = 0.001 and p = 0.005; respectively). There were no significant differences in adverse outcomes between the 2 groups except for the postoperative atrial fibrillation, which occurred more in the MAADP ≤50 group than in the MAADP >50 group (8.05% v 1.77%; p = 0.043). MAADP (area under the receiver operating characteristic curve of 0.767; p < 0.001) was demonstrated to have significant ability to predict bleeding tendency, with a sensitivity of 76.2% and a specificity of 69.0%. CONCLUSIONS Preoperative MAADP may play a potential role in the prediction of postoperative bleeding and allogeneic blood transfusions and guide clinicians in perioperative management of patients undergoing CABG with CPB.
Collapse
Affiliation(s)
- Lijuan Tian
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xurong Gao
- Department of Transfusion Medicine, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Yang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuntai Yao
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwen Ji
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Transfusion Medicine, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|
17
|
Godier A, Garrigue D, Lasne D, Fontana P, Bonhomme F, Collet JP, de Maistre E, Ickx B, Gruel Y, Mazighi M, Nguyen P, Vincentelli A, Albaladejo P, Lecompte T. Management of antiplatelet therapy for non elective invasive procedures of bleeding complications: proposals from the French working group on perioperative haemostasis (GIHP), in collaboration with the French Society of Anaesthesia and Intensive Care Medicine (SFAR). Anaesth Crit Care Pain Med 2019; 38:289-302. [DOI: 10.1016/j.accpm.2018.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/07/2018] [Indexed: 12/12/2022]
|
18
|
Godier A, Garrigue D, Lasne D, Fontana P, Bonhomme F, Collet JP, de Maistre E, Ickx B, Gruel Y, Mazighi M, Nguyen P, Vincentelli A, Albaladejo P, Lecompte T. Management of antiplatelet therapy for non-elective invasive procedures or bleeding complications: Proposals from the French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Thrombosis and Haemostasis (GFHT), in collaboration with the French Society for Anaesthesia and Intensive Care (SFAR). Arch Cardiovasc Dis 2019; 112:199-216. [DOI: 10.1016/j.acvd.2018.10.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/09/2018] [Indexed: 12/21/2022]
|
19
|
Azarfarin R, Noohi F, Kiavar M, Totonchi Z, Heidarpour A, Hendiani A, Koleini ZS, Rahimi S. Relationship between maximum clot firmness in ROTEM ® and postoperative bleeding after coronary artery bypass graft surgery in patients using clopidogrel. Ann Card Anaesth 2018; 21:175-180. [PMID: 29652280 PMCID: PMC5914219 DOI: 10.4103/aca.aca_139_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: The aim of the present study was to investigate the relationship between maximum clot firmness (MCF) in rotational thromboelastometry (ROTEM®) and postoperative bleeding in patients on clopidogrel after emergency coronary artery bypass graft surgery (CABG). Methods: This observational study recruited 60 patients posted for emergency CABG following unsuccessful primary percutaneous coronary intervention (PCI) while on 600 mg of clopidogrel. The study population was divided into 2 groups on the basis of their MCF in the extrinsically activated thromboelastometric (EXTEM) component of the (preoperative) ROTEM® test: patients with MCF <50 mm (n = 16) and those with MCF ≥50 mm (n = 44). Postoperative chest tube drainage amount, need for blood product transfusion, postoperative complications, and duration of mechanical ventilation after CABG were recorded. Results: No significant differences were observed between the two groups regarding duration of surgery, cardiopulmonary bypass, and aortic cross-clamp time. Chest tube drainage at 6, 12, and 24 h after Intensive Care Unit admission were significantly higher in the patients with MCF below 50 mm. The need for blood product transfusion was higher in the group with MCF <50 mm. In patients who experienced postoperative bleeding of 1000 mL or more, the ROTEM® parameters of INTEM (Intrinsically activated thromboelastomery) α and MCF, EXTEM α and MCF, and HEPTEM (INTEM assay performed in the presence of heparinase) MCF (but not FIBTEM (Thromboelastometric assay for the fibrin part of the clot) values) were significantly lower than those with postoperative bleeding <1000 mL (P ≤ 0.05). Conclusions: When platelet aggregometry is not available, the ROTEM® test could be useful for the prediction of increased risk bleeding after emergency CABG in patients who have received a loading dose of clopidogrel.
Collapse
Affiliation(s)
- Rasoul Azarfarin
- Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, University of Medical Sciences, Tehran, Iran
| | - Fereidoon Noohi
- Cardiac Intervention Research Center, Rajaie Cardiovascular Medical And Research Center, University of Medical Sciences, Tehran, Iran
| | - Majid Kiavar
- Cardiac Intervention Research Center, Rajaie Cardiovascular Medical And Research Center, University of Medical Sciences, Tehran, Iran
| | - Ziae Totonchi
- Rajaie Cardiovascular Medical and Research Center, University of Medical Sciences, Tehran, Iran
| | - Avaz Heidarpour
- Rajaie Cardiovascular Medical and Research Center, University of Medical Sciences, Tehran, Iran
| | - Amir Hendiani
- Faculty of Medicine, University of Medical Sciences, Tehran, Iran
| | | | - Saeid Rahimi
- Faculty of Medicine, University of Medical Sciences, Tehran, Iran
| |
Collapse
|
20
|
Kim JS, Kaufman J, Patel SS, Manco-Johnson M, Di Paola J, da Cruz EM. Antiplatelet Effect of Ketorolac in Children After Congenital Cardiac Surgery. World J Pediatr Congenit Heart Surg 2018; 9:651-658. [DOI: 10.1177/2150135118799041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Ketorolac is used for pediatric analgesia after surgery despite its known platelet inhibition via the arachidonic acid (AA) pathway. The degree of platelet inhibitory effect after cardiac surgery is not well characterized. Thromboelastography with platelet mapping (TEG-PM) is emerging as a frequently used test to evaluate platelet inhibition via the AA pathway. Methods: Post hoc analysis of a data set collected in a prospective observational cohort study evaluating platelet inhibition in children after congenital heart surgery with cardiopulmonary bypass (CPB). Categorization into two groups: (1) received ketorolac and (2) did not receive ketorolac for analgesia after surgery. The TEG-PM was evaluated at two time points (prior to surgery and 12-48 hours after CPB). Results: Fifty-three children were studied; mean age was 6.6 (range: 0.07-16.7) years and 45% (n = 24) were female. Participants were distributed into two groups by ketorolac use, 41 within the ketorolac group and 12 in the no ketorolac group. All 41 participants who received ketorolac had platelet inhibition and 11 (91.7%) of 12 participants who did not receive ketorolac had normal platelet function after surgery ( P < .0001). There was no difference in patient characteristics or clinical data between the two groups. Conclusions: Ketorolac use in a cohort of children after congenital cardiac surgery was associated with platelet inhibition via the AA pathway when evaluated by TEG-PM.
Collapse
Affiliation(s)
- John S. Kim
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Jon Kaufman
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Sonali S. Patel
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Marilyn Manco-Johnson
- Department of Pediatrics, Hemophilia and Thrombosis Center, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Jorge Di Paola
- Department of Pediatrics, Hemophilia and Thrombosis Center, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Eduardo M. da Cruz
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| |
Collapse
|
21
|
Korpallová B, Samoš M, Bolek T, Škorňová I, Kovář F, Kubisz P, Staško J, Mokáň M. Role of Thromboelastography and Rotational Thromboelastometry in the Management of Cardiovascular Diseases. Clin Appl Thromb Hemost 2018; 24:1199-1207. [PMID: 30041546 PMCID: PMC6714776 DOI: 10.1177/1076029618790092] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The monitoring of coagulation by viscoelastometric methods—thromboelastography and rotational thromboelastometry—may detect the contributions of cellular and plasma components of hemostasis. These methods might overcome some of the serious limitations of conventional laboratory tests. Viscoelastic testing can be repeatedly performed during and after surgery and thus provides a dynamic picture of the coagulation process during these periods. Several experiences with the use of these methods in cardiovascular surgery have been reported, but there is perspective for more frequent use of these assays in the assessment of platelet response to antiplatelet therapy and in the assessment of coagulation in patients on long-term dabigatran therapy. This article reviews the current role and future perspectives of thromboelastography and thromboelastometry in the management of cardiovascular diseases.
Collapse
Affiliation(s)
- Barbora Korpallová
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Matej Samoš
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Tomáš Bolek
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ingrid Škorňová
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - František Kovář
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Kubisz
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Ján Staško
- 2 Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Marián Mokáň
- 1 Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| |
Collapse
|
22
|
|
23
|
Labruyère C, Reny JL, Chapelle C, Piot M, Fontana P, Gris JC, Delavenne X, Mismetti P, Laporte S, Mallouk N. Prevalence of poor biological response to clopidogrel. Thromb Haemost 2017; 107:494-506. [DOI: 10.1160/th11-03-0202] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 12/14/2011] [Indexed: 12/28/2022]
Abstract
SummaryThe existence of poor biological response to clopidogrel has been shown in some patients. Despite the increasing number of studies, this phenomenon remains difficult to quantify. We performed a systematic review to estimate the prevalence of poor biological response to clopidogrel and investigate the factors known to modulate this. An exhaustive search was performed. Altogether 171 publications were identified, providing data for a total of 45,664 subjects. The estimated prevalence of poor biological response to clopidogrel ranged from 15.9% to 49.5% according to the platelet function assay employed. The assays most frequently used were light transmittance aggregometry (LTA), the vasodilator-stimulated phosphoprotein (VASP) assay and the Verify -now® assay. For all these assays, higher cut-off values were associated with a lower prevalence of poor biological response to clopidogrel. However, when choosing a fixed cut-off point for each assay, the prevalence of poor biological response to clopidogrel was highly variable suggesting that other factors could modulate poor biological response to clopidogrel. Finally, none of the studied factors could apparently explain the variability of poor biological response to clopidogrel. This meta-analysis shows that the prevalence of poor biological response depends on the assay employed, the cut-off value and on various unidentified additional factors.
Collapse
|
24
|
Sivapalan P, Bäck AC, Ostrowski SR, Ravn HB, Johansson PI. Transfusion requirements in elective cardiopulmonary bypass surgery patients: predictive value of Multiplate and Thromboelastography (TEG) Platelet Mapping Assay. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:345-351. [PMID: 28537454 DOI: 10.1080/00365513.2017.1325000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Managing haemostasis in patients undergoing cardiopulmonary bypass (CPB) surgery remains a challenge. There is no established laboratory test to predict transfusion requirements in cardiac surgery. We investigated whether preoperative Thromboelastography (TEG) with Platelet Mapping Assay (PMA) or Multiple Electrode Aggrometry (MEA) could predict transfusion requirements in patients undergoing elective coronary artery bypass grafting (CABG) or combined CABG with aortic or mitral valve replacement. We prospectively investigated 199 patients undergoing elective CABG or combined procedures. PMA and MEA were performed at baseline (after anaesthesia induction), upon arrival at the intensive care unit and on the first postoperative day. Patients receiving fresh frozen plasma and/or platelets (FFP/PLT) had a lower PMA maximum amplitude (MA) for adenosine diphosphate (PMA-ADP) and arachidonic acid (PMA-AA) at baseline, at arrival in the intensive care unit and the first postoperative day compared to non-transfused patients. Receiver operating characteristic curves on PMA showed that lower values predicted FFP/PLT transfusion: PMA-ActF 0.64 (p = 0.04), PMA-ADP 0.69 (p = 0.01) and PMA-AA 0.71 (p = 0.002). In contrast, MEA values were not able to predict FFP/PLT transfusions. This study shows that preoperative PMA potentially is a better screening tool for platelet inhibition associated with transfusion requirements in patients undergoing CABG or combined procedures.
Collapse
Affiliation(s)
- Praleene Sivapalan
- a Department of Cardiothoracic Anaesthesiology , Copenhagen University Hospital , Copenhagen , Denmark
| | - Anne Caroline Bäck
- b Department of Cardiothoracic Surgery , Copenhagen University Hospital , Copenhagen , Denmark
| | - Sisse Rye Ostrowski
- c Section for Transfusion Medicine, Capital Region Blood Bank , Copenhagen University Hospital , Copenhagen , Denmark
| | - Hanne Berg Ravn
- a Department of Cardiothoracic Anaesthesiology , Copenhagen University Hospital , Copenhagen , Denmark
| | - Pär Ingemar Johansson
- d Department of Surgery , University of Texas Health Medical School , Houston , TX , USA.,e Center for Systems Biology, The School of Engineering and Natural Sciences , University of Iceland , Reykjavik , Iceland
| |
Collapse
|
25
|
Elbadawi A, Saad M, Nairooz R. Aspirin Use Prior to Coronary Artery Bypass Grafting Surgery: a Systematic Review. Curr Cardiol Rep 2017; 19:18. [DOI: 10.1007/s11886-017-0822-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
26
|
Samoš M, Stančiaková L, Duraj L, Kovář F, Fedor M, Šimonová R, Bolek T, Galajda P, Staško J, Kubisz P, Mokáň M. Monitoring the hemostasis with rotation thromboelastometry in patients with acute STEMI on dual antiplatelet therapy: First experiences. Medicine (Baltimore) 2017; 96:e6045. [PMID: 28178148 PMCID: PMC5313005 DOI: 10.1097/md.0000000000006045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Rotation thromboelastometry (ROTEM) is a viscoelastometric point-of-care-test for the complex evaluation of changes in hemostasis, performed in whole blood. However, no prospective study evaluating the efficacy of the antiplatelet therapy using ROTEM was performed.Fifty-six patients (34 men, 22 women, mean age 67.75 years, and age range 34-88 years) with acute ST-elevation myocardial infarction (STEMI), treated with dual antiplatelet therapy, undergoing urgent coronary angiography and percutaneous coronary intervention (PCI) of culprit coronary lesion were included. Three blood samples were taken (sample 1 taken before the urgent coronary angiography, sample 2 in 24 hours after the admission, and sample 3 in 30 days after acute STEMI). Twenty-one healthy blood donors (17 men, 4 women, mean age 50.38 years, and age range 40-74 years) were recruited as the control group. Blood samples were tested with ROTEM Gamma (Pentapharm GmbH, Munich, Germany) and light transmission aggregometry (LTA).Clotting time (CT) was significantly prolonged and maximum clot firmness (MCF) was significantly higher in patients compared to controls. Mean platelet aggregation after the induction with arachidonic acid (33.2% vs 74.6% in sample 1 and 21.1% vs 74.6% in sample 2), as well as adenosine diphosphate (51.4% vs 72.7% in sample 1 and 37.1% vs 72.7% in sample 2), were significantly lower in patients with acute STEMI.Significantly prolonged CT and increased MCF was found in patients with acute STEMI. This study confirmed the ability of ROTEM to identify changes in hemostasis in ACS patients on antithrombotic therapy.
Collapse
Affiliation(s)
| | - Lucia Stančiaková
- National Centre of Haemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin, Slovak Republic
| | - Lukáš Duraj
- National Centre of Haemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin, Slovak Republic
| | | | - Marián Fedor
- National Centre of Haemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin, Slovak Republic
| | - Radoslava Šimonová
- National Centre of Haemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin, Slovak Republic
| | | | | | - Ján Staško
- National Centre of Haemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin, Slovak Republic
| | - Peter Kubisz
- National Centre of Haemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin, Martin, Slovak Republic
| | | |
Collapse
|
27
|
Bonhomme F. Tests d’évaluation de la fonction plaquettaire délocalisés : un guide pour la transfusion de plaquettes ? Transfus Clin Biol 2016; 23:202-204. [DOI: 10.1016/j.tracli.2016.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/01/2016] [Indexed: 11/28/2022]
|
28
|
Agarwal S. Platelet function testing in cardiac surgery. Transfus Med 2016; 26:319-329. [PMID: 27535575 DOI: 10.1111/tme.12335] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/12/2016] [Accepted: 07/24/2016] [Indexed: 12/17/2022]
Abstract
Bleeding in cardiac surgery is known to cause increased morbidity and mortality. The rise in the use of anti-platelet medication has led to an increase in the number of patients presenting for cardiac surgery with platelet dysfunction, who are at a heightened risk of bleeding. However, the extent of platelet inhibition is well known to differ among individuals. In the past few years, a number of point-of-care platelet function testing devices, which may be able to assess platelet reactivity, have entered the market. This review will examine the devices most commonly studied and the evidence surrounding their use in cardiac surgery and their effect on blood loss.
Collapse
Affiliation(s)
- S Agarwal
- Department of Anaesthesia and Critical Care, Liverpool Heart and Chest Hospital, Liverpool, UK.
| |
Collapse
|
29
|
Ellis J, Valencia O, Crerar-Gilbert A, Phillips S, Meeran H, Sharma V. Point-of-care platelet function testing to predict blood loss after coronary artery bypass grafting surgery: a prospective observational pilot study. Perfusion 2016; 31:676-682. [DOI: 10.1177/0267659116656774] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aim: With an increase in the number of patients who are on antiplatelet medications until the day of surgery, we undertook a prospective observational study to assess the ability of thromboelastography, thromboelastography platelet mapping and aggregometry via multiplate to detect platelet dysfunction and predict blood loss following coronary artery bypass grafting (CABG) surgery. Methods: Platelet function was evaluated pre- and post-cardiopulmonary bypass via thromboelastography, thromboelastography platelet mapping and aggregometry via multiplate in 52 patients undergoing coronary artery bypass grafting surgery. The median chest tube drainage of all patients in the study was ascertained to stratify patients into two groups: patients with and those without evidence of excessive blood loss after cardiac surgery. Results: Although all modalities could detect a decrease in platelet function following cardiopulmonary bypass, univariate and multivariate regression analysis identified preoperative arachidonic acid and adenosine diphosphate testing via multiplate as independent predictors of bleeding after cardiac surgery. Receiver operating curves on these multiplate parameters showed an area under the curve of 0.68 (p=0.03) and 0.66 (p=0.01) for arachidonic acid and adenosine diphosphate assays, respectively. Conclusion: This pilot study shows that preoperative multiplate testing may be a better predictor of platelet dysfunction and the resultant blood loss following cardiac surgery.
Collapse
Affiliation(s)
- James Ellis
- Department of Clinical Perfusion, St George’s Hospital, London, UK
| | | | | | - Simon Phillips
- Department of Clinical Perfusion, St George’s Hospital, London, UK
| | - Hanif Meeran
- Department of Anaesthesia, St George’s Hospital, London, UK
| | - Vivek Sharma
- Department of Anaesthesia, St George’s Hospital, London, UK
| |
Collapse
|
30
|
Viola F, Lin-Schmidt X, Bhamidipati C, Haverstick DM, Walker WF, Ailawadi G, Lawrence MB. Sonorheometry assessment of platelet function in cardiopulmonary bypass patients: Correlation of blood clot stiffness with platelet integrin α IIb β 3 activity, aspirin usage, and transfusion risk. Thromb Res 2016; 138:96-102. [DOI: 10.1016/j.thromres.2015.11.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
|
31
|
Leunissen TC, Janssen PW, ten Berg JM, Moll FL, Korporaal SJ, de Borst GJ, Pasterkamp G, Urbanus RT. The use of platelet reactivity testing in patients on antiplatelet therapy for prediction of bleeding events after cardiac surgery. Vascul Pharmacol 2016; 77:19-27. [DOI: 10.1016/j.vph.2015.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/07/2015] [Accepted: 12/21/2015] [Indexed: 02/07/2023]
|
32
|
Corredor C, Wasowicz M, Karkouti K, Sharma V. The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis. Anaesthesia 2015; 70:715-31. [PMID: 25916344 DOI: 10.1111/anae.13083] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 12/23/2022]
Abstract
This systematic review and meta-analysis appraises the utility of point-of-care platelet function tests for predicting blood loss and transfusion requirements in cardiac surgical patients, and analyses whether their use within a transfusion management algorithm is associated with improved patient outcomes. We included 30 observational studies incorporating 3044 patients in the qualitative assessment, and nine randomised controlled trials including 1057 patients in the meta-analysis. Platelet function tests demonstrated significant variability in their ability to predict blood loss and transfusion requirements. Their use within a blood transfusion algorithm demonstrated a reduction in blood loss at longest follow-up (mean difference -102.9 ml (95% CI -149.9 to -56.1 ml), p < 0.001), and transfusion of packed red cells (RR 0.86 (95% CI 0.78-0.94), p = 0.001) and fresh frozen plasma (RR 0.42 (95% CI 0.30-0.59), p < 0.001). Viscoelastic methods used in combination with other platelet function tests achieved greater reduction in blood loss (mean difference -111.8 ml (95% CI -174.9 to -49.1 ml), p = 0.0005) compared with their use alone (mean difference -90.6 ml (95% CI 166.1-15.0 ml), p = 0.02). We conclude that incorporation of point-of-care platelet function tests into transfusion management algorithms is associated with a reduction in blood loss and transfusion requirements in cardiac surgery patients.
Collapse
Affiliation(s)
- C Corredor
- Department of Anaesthesia, St. George's Hospital, London, UK
| | - M Wasowicz
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - V Sharma
- Department of Anaesthesia, St. George's Hospital, London, UK
| |
Collapse
|
33
|
Agarwal S, Johnson RI, Shaw M. Preoperative Point-of-Care Platelet Function Testing in Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:333-41. [DOI: 10.1053/j.jvca.2014.06.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Indexed: 11/11/2022]
|
34
|
Chowdhury M, Shore-Lesserson L, Mais AM, Leyvi G. Thromboelastograph with Platelet Mapping(TM) predicts postoperative chest tube drainage in patients undergoing coronary artery bypass grafting. J Cardiothorac Vasc Anesth 2014; 28:217-23. [PMID: 24630471 DOI: 10.1053/j.jvca.2013.12.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The goal of this study was to evaluate the ability of Thromboelastograph with Platelet Mapping (TEG-PM(TM)) to predict postoperative bleeding tendency in patients with a history of recent anti-platelet therapy undergoing coronary artery bypass grafting (CABG). DESIGN A retrospective analysis. Association between predictor variables (MAADP [maximum amplitude produced by adenosine diphosphate], MAAA [maximum amplitude produced by arachidonic acid], percent of platelets inhibited by clopidogrel, percent of platelets inhibited by aspirin) and the outcomes as elevated chest tube drainage (CTD) and blood transfusion were investigated by logistic regression model. CTD was considered elevated if it was ≥ 600 mL within 12 hours after surgery. SETTING A university hospital. PARTICIPANTS Patients on antiplatelet therapy scheduled to undergo CABG that had TEG-PM(TM) done as a point-of-care test. INTERVENTIONS None. RESULTS A total of 78 patients had preoperative TEG-PM(TM) test and on-pump CABG surgeries performed on the same day. Among them, 20 patients (25.6%) had elevated CTD. Decreased MAADP (odds ratio [OR] 0.94), increased percent inhibition of platelets by clopidogrel (OR 1.03), and lower body mass index (BMI) (OR 0.78) were significantly associated with elevated CTD. The same parameters were also associated with platelets transfusion: MAADP (OR 0.94), percent of inhibition of platelets by clopidogrel (OR 1.03) and BMI (OR 0.77). CONCLUSIONS TEG-PM(TM) parameters and BMI are predictive of elevated CTD and platelets transfusion. A 1 mm decrease in MAADP increases the likelihood of elevated CTD and the likelihood of platelets transfusion by 6% whereas 1 unit decrease in BMI is associated with an increased likelihood of elevated CTD and platelets transfusion by 22% and 23% respectively.
Collapse
Affiliation(s)
- Mohsin Chowdhury
- Department of Anesthesiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx.
| | - Linda Shore-Lesserson
- Department of Anesthesiology, North Shore-Long Island Jewish Medical Center, New Hyde Park, NY
| | - Alec M Mais
- A.M.M. assisted with the article as a high school summer student
| | - Galina Leyvi
- Department of Anesthesiology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx
| |
Collapse
|
35
|
|
36
|
Gasparovic H, Petricevic M, Biocina B. Management of antiplatelet therapy resistance in cardiac surgery. J Thorac Cardiovasc Surg 2014; 147:855-62. [DOI: 10.1016/j.jtcvs.2013.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 09/24/2013] [Accepted: 10/06/2013] [Indexed: 12/01/2022]
|
37
|
Sun W, Jeleniowski K, Zhao X, Shen P, Li D, Hammond JA. Thromboelastography (TEG)-Based Algorithm Reduces Blood Product Utilization in Patients Undergoing VAD Implant. J Card Surg 2014; 29:238-43. [PMID: 24734284 DOI: 10.1111/jocs.12302] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Wenyu Sun
- Department of Cardiovascular Surgery; Qilu Hospital, Shandong University; Jinan P.R. China
| | - Ken Jeleniowski
- Department of Perfusion; Hartford Hospital; Hartford Connecticut
| | - Xin Zhao
- Department of Cardiovascular Surgery; Qilu Hospital, Shandong University; Jinan P.R. China
| | - Peter Shen
- Department of Cytopathology; Hartford Hospital; Hartford Connecticut
| | - Dadong Li
- Department of Research Administration; Hartford Hospital; Hartford Connecticut
| | | |
Collapse
|
38
|
Dalén M, van der Linden J, Holm M, Lindvall G, Ivert T. Adenosine diphosphate-induced single-platelet count aggregation and bleeding in clopidogrel-treated patients undergoing coronary artery bypass grafting. J Cardiothorac Vasc Anesth 2014; 28:230-4. [PMID: 24447500 DOI: 10.1053/j.jvca.2013.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To investigate the association between adenosine diphosphate (ADP)-induced platelet aggregation measured by single-platelet count testing and postoperative blood loss in clopidogrel-treated patients with acute coronary syndromes undergoing coronary artery bypass grafting (CABG). DESIGN Prospective observational study. SETTING Clinical study in one cardiac surgery center. PARTICIPANTS Eighty-eight patients treated with clopidogrel (300-600 mg loading dose followed by 75 mg daily) within 7 days before CABG. INTERVENTIONS Platelet function was assessed preoperatively by single-platelet count ADP-induced platelet aggregation. Postoperative blood loss and transfusion requirements were recorded. MEASUREMENTS AND MAIN RESULTS There was no significant association between ADP-induced platelet aggregation and blood loss 12 hours postoperatively (estimate -7.51; 95% confidence interval [CI]: -16.9-1.9; p = 0.12). ADP-induced platelet aggregation was associated significantly with the number of platelet concentrates administered within 24 hours after surgery (incidence rate ratio [IRR] 0.95; 95% CI: 0.92-0.98; p<0.01), but not to the number of packed red blood cells (IRR 0.98; 95% CI: 0.95-1.01; p = 0.14). CONCLUSIONS Preoperative ADP-induced platelet aggregation measured by single-platelet count testing in clopidogrel-treated patients with acute coronary syndromes undergoing CABG was not associated with postoperative blood loss or packed red blood cells transfused, but was associated significantly with number of platelet concentrates administered during the initial 24 postoperative hours.
Collapse
Affiliation(s)
- Magnus Dalén
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Jan van der Linden
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Manne Holm
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Gabriella Lindvall
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Torbjörn Ivert
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
39
|
Brainard BM, Goggs R, Mendez-Angulo JL, Mudge MC, Ralph AG, Wiinberg B. Systematic evaluation of evidence on veterinary viscoelastic testing Part 5: Nonstandard assays. J Vet Emerg Crit Care (San Antonio) 2014; 24:57-62. [DOI: 10.1111/vec.12146] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 11/15/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Benjamin M. Brainard
- Department of Small Animal Medicine and Surgery; College of Veterinary Medicine; University of Georgia; Athens GA 30602
| | - Robert Goggs
- Department of Clinical Sciences; College of Veterinary Medicine; Cornell University; Ithaca NY 14853
| | | | - Margaret C. Mudge
- College of Veterinary Medicine; Ohio State University; Columbus OH 43210
| | - Alan G. Ralph
- College of Veterinary Medicine; Department of Small Animal Clinical Sciences; Michigan State University; East Lansing MI 48823
| | | |
Collapse
|
40
|
Karathanos A, Geisler T. Monitoring aspirin and clopidogrel response: testing controversies and recommendations. Mol Diagn Ther 2013; 17:123-37. [PMID: 23588781 DOI: 10.1007/s40291-013-0022-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Antiplatelet therapy is the cornerstone of the treatment for patients with coronary artery disease (CAD). Dual therapy with clopidogrel and aspirin is currently the standard treatment after percutaneous coronary interventions. However, despite the use of clopidogrel, a considerable number of patients continue to suffer major adverse cardiac events. There is a growing degree of evidence supporting high on-treatment platelet reactivity (HPR) as a predictive factor for recurrent ischemic complications. Numerous studies have shown an interindividual variability of responsiveness to clopidogrel and aspirin, which is one of the reasons for HPR. There is yet to be established an assay for antiplatelet drug response as the gold standard. This paper provides a background to the current controversies surrounding the issue of testing for the effectiveness of antiplatelet therapy and reviews the various genetic and phenotype-based laboratory tests to measure aspirin and clopidogrel response and their correlation with clinical outcomes. On the basis of the current evidence and trying to be cost-effective, testing should be considered on a case-by-case basis, especially in patients who present with an acute coronary syndrome or stent thrombosis. In the case of stable CAD, we think that testing might be helpful in particular risk groups of patients to avoid ischemic or bleeding complications.
Collapse
Affiliation(s)
- Athanasios Karathanos
- Department of Cardiology and Cardiovascular Medicine, University Hospital Tübingen, Ottfried-Müller-Straße 10, 72076, Tübingen, Germany
| | | |
Collapse
|
41
|
Bitar A, Kreutz RP. Role of Thrombelastography (TEG) in Risk Assessment and Guidance of Antithrombotic Therapy in Patients with Coronary Artery Disease. Drug Dev Res 2013. [DOI: 10.1002/ddr.21112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Abbas Bitar
- Krannert Institute of Cardiology; Indiana University School of Medicine; Indianapolis IN USA
| | - Rolf P. Kreutz
- Krannert Institute of Cardiology; Indiana University School of Medicine; Indianapolis IN USA
| |
Collapse
|
42
|
Point of Care Testing in Cardiac Surgery: Diagnostic Modalities to Assess Coagulation and Platelet Function. Drug Dev Res 2013. [DOI: 10.1002/ddr.21099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
43
|
Cattano D, Altamirano AV, Kaynak HE, Seitan C, Paniccia R, Chen Z, Huang H, Prisco D, Hagberg CA, Pivalizza EG. Perioperative assessment of platelet function by Thromboelastograph Platelet Mapping in cardiovascular patients undergoing non-cardiac surgery. J Thromb Thrombolysis 2013; 35:23-30. [PMID: 22851059 DOI: 10.1007/s11239-012-0788-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
UNLABELLED Five percent of patients on dual antiplatelet therapy after coronary artery stent implantation will need non-cardiac surgery within the first year of therapy, and many more will need surgery later on. A function assay that evaluates platelet reactivity and inhibition by drug therapy is beneficial for such patients. Platelet Mapping assay (PM) using the TEG analyzer was tested in surgical patients. After IRB approval, 60 patients on combined aspirin and clopidogrel therapy were consented and enrolled. The TEG maximal amplitude (MA) and the percentage (%) platelet inhibition were recorded and analyzed. Fifty-seven patients (mean age 65.7 ± 10.9 years) had preoperative data only. Distribution of preoperative ADP (43.6 ± 24.4%) and AA inhibition (52.8 ± 30.2%) was determined, as well as for the preoperative MA ADP (43.1 ± 15.9 mm) and MA AA (37.2 ± 19.6 mm), showing an offset of the effect of both medications starting from day 3. Patients with complete pre- and postoperative data were stratified depending on duration off antiplatelet therapy (≤3 days, 3-7 days and >7 days): n = 27, ADP % preop inhibition (43.2 ± 21.6%), ADP % postop inhibition (32.3 ± 18.3%), p = 0.048. Distribution of immediate pre- and post- ADP and AA % inhibitions, showing a possible reduction in Δ of inhibition for clopidogrel at 3 days, were also assessed. CONCLUSION According to the findings, the TEG PM assay might be a feasible approach to objectively evaluate the effects of aspirin and clopidogrel during the perioperative period and potentially guide drug management.
Collapse
Affiliation(s)
- Davide Cattano
- Department of Anesthesiology, University of Texas Medical School at Houston, 6431 Fannin Street, MSB 5.020, Houston, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Castellino FJ, Liang Z, Davis PK, Balsara RD, Musunuru H, Donahue DL, Smith DL, Sandoval-Cooper MJ, Ploplis VA, Walsh M. Abnormal whole blood thrombi in humans with inherited platelet receptor defects. PLoS One 2012; 7:e52878. [PMID: 23300803 PMCID: PMC3532496 DOI: 10.1371/journal.pone.0052878] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 11/22/2012] [Indexed: 11/18/2022] Open
Abstract
To delineate the critical features of platelets required for formation and stability of thrombi, thromboelastography and platelet aggregation measurements were employed on whole blood of normal patients and of those with Bernard-Soulier Syndrome (BSS) and Glanzmann's Thrombasthenia (GT). We found that separation of platelet activation, as assessed by platelet aggregation, from that needed to form viscoelastic stable whole blood thrombi, occurred. In normal human blood, ristocetin and collagen aggregated platelets, but did not induce strong viscoelastic thrombi. However, ADP, arachidonic acid, thrombin, and protease-activated-receptor-1 and -4 agonists, stimulated both processes. During this study, we identified the genetic basis of a very rare double heterozygous GP1b deficiency in a BSS patient, along with a new homozygous GP1b inactivating mutation in another BSS patient. In BSS whole blood, ADP responsiveness, as measured by thrombus strength, was diminished, while ADP-induced platelet aggregation was normal. Further, the platelets of 3 additional GT patients showed very weak whole blood platelet aggregation toward the above agonists and provided whole blood thrombi of very low viscoelastic strength. These results indicate that measurements of platelet counts and platelet aggregability do not necessarily correlate with generation of stable thrombi, a potentially significant feature in patient clinical outcomes.
Collapse
Affiliation(s)
- Francis J Castellino
- W. M. Keck Center for Transgene Research, University of Notre Dame, Notre Dame, Indiana, United States of America.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
|
46
|
Součková L, Opatřilová R, Suk P, Čundrle I, Pavlík M, Zvoníček V, Hlinomaz O, Šrámek V. Impaired bioavailability and antiplatelet effect of high-dose clopidogrel in patients after cardiopulmonary resuscitation (CPR). Eur J Clin Pharmacol 2012; 69:309-17. [PMID: 22890586 DOI: 10.1007/s00228-012-1360-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 07/13/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Bioavailability of clopidogrel in the form of crushed tablets administered via nasogastric tube (NGT) has not been established in patients after cardiopulmonary resuscitation. Therefore, we performed a study comparing pharmacokinetic and pharmacodynamic response to high loading dose of clopidogrel in critically ill patients after cardiopulmonary resuscitation (CPR) with patients scheduled for elective coronary angiography with stent implantation. METHODS In the NGT group (nine patients, after cardiopulmonary resuscitation, mechanically ventilated, therapeutic hypothermia), clopidogrel was administered in the form of crushed tablets via NGT. Ten patients undergoing elective coronary artery stenting took clopidogrel per os (po) in the form of intact tablets. Pharmacokinetics of clopidogrel was measured with high-performance liquid chromatography (HPLC) before and at 0.5, 1, 6, 12, 24 h after administration of a loading dose of 600 mg. In five patients in each group, antiplatelet effect was measured with thrombelastography (TEG; Platelet Mapping) before and 24 h after administration. RESULTS The carboxylic acid metabolite of clopidogrel was detected in all patients in the po group. In eight patients, the maximum concentration was measured in the range of 0.5-1 h after the initial dose. In four patients in the of NGT group, the carboxylic acid metabolite of clopidogrel was undetectable and in the remaining patients was significantly delayed (peak values at 12 h). All patients in the po group reached clinically relevant (>50 %) inhibition of thrombocyte adenosine diphosphate (ADP) receptor after 24 h compared with only two in the NGT group (p = 0.012). There was a close correlation between peak of inactive clopidogrel metabolite plasmatic concentration and inhibition of the ADP receptor (r = 0.79; p < 0.001). CONCLUSION The bioavailability of clopidogrel in critically ill patients after cardiopulmonary resuscitation is significantly impaired compared with stable patients. Therefore, other drugs, preferentially administered intravenously, should be considered.
Collapse
Affiliation(s)
- L Součková
- Department of Anaesthesiology and Intensive Care, University Hospital St. Anne's Brno, Brno, Czech Republic
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Weitzel NS, Weitzel LB, Epperson LE, Karimpour-Ford A, Tran ZV, Seres T. Platelet mapping as part of modified thromboelastography (TEG®) in patients undergoing cardiac surgery and cardiopulmonary bypass. Anaesthesia 2012; 67:1158-65. [PMID: 22809250 DOI: 10.1111/j.1365-2044.2012.07231.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The platelet-mapping assay of the thromboelastograph was used to measure platelet aggregation and to examine the effect of cardiopulmonary bypass on multiple platelet receptors and the role of altered receptor activity in postoperative bleeding. The percentage platelet aggregation for collagen, adenosine diphosphate and arachidonic acid was measured in 40 patients divided post-hoc into high- or low-bleeding groups depending on postoperative 24-h chest tube output. Platelet aggregation was lower after cardiopulmonary bypass compared to before it using collagen (mean (SD) 45 (25) vs 19 (12)%, p<0.001), adenosine diphosphate (76 (23) vs 35 (24)%, p<0.001), and arachidonic acid (61 (33) vs 31 (35)%, p<0.001). Only platelet aggregation as measured using collagen pre- and post-cardiopulmonary bypass was significantly less in the high- compared to the low-bleeding group. This finding was significantly correlated with the 24-h chest tube drainage, and it predicted postoperative bleeding with a sensitivity of 83% and a specificity of 68%. Therefore, platelet aggregation is reduced following cardiopulmonary bypass, and this may play a role in predicting postoperative blood loss.
Collapse
Affiliation(s)
- N S Weitzel
- Department of Anesthesiology, University of Colorado, Denver, CO, USA.
| | | | | | | | | | | |
Collapse
|
48
|
Should more patients continue aspirin therapy perioperatively?: clinical impact of aspirin withdrawal syndrome. Ann Surg 2012; 255:811-9. [PMID: 22470078 DOI: 10.1097/sla.0b013e318250504e] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal. BACKGROUND For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned. METHODS We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion. RESULTS/CONCLUSIONS Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.
Collapse
|
49
|
Wohlauer MV, Moore EE, Thomas S, Sauaia A, Evans E, Harr J, Silliman CC, Ploplis V, Castellino FJ, Walsh M. Early platelet dysfunction: an unrecognized role in the acute coagulopathy of trauma. J Am Coll Surg 2012; 214:739-46. [PMID: 22520693 PMCID: PMC3348700 DOI: 10.1016/j.jamcollsurg.2012.01.050] [Citation(s) in RCA: 230] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 01/09/2012] [Accepted: 01/09/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Our aim was to determine the prevalence of platelet dysfunction using an end point of assembly into a stable thrombus after severe injury. Although the current debate on acute traumatic coagulopathy has focused on the consumption or inhibition of coagulation factors, the question of early platelet dysfunction in this setting remains unclear. STUDY DESIGN Prospective platelet function in assembly and stability of the thrombus was determined within 30 minutes of injury using whole blood samples from trauma patients at the point of care using thrombelastography-based platelet functional analysis. RESULTS There were 51 patients in the study. There were significant differences in the platelet response between trauma patients and healthy volunteers, such that there was impaired aggregation to these agonists. In trauma patients, the median ADP inhibition of platelet function was 86.1% (interquartile range [IQR] 38.6% to 97.7%) compared with 4.2 % (IQR 0 to 18.2%) in healthy volunteers. After trauma, the impairment of platelet function in response to arachidonic acid was 44.9% (IQR 26.6% to 59.3%) compared with 0.5% (IQR 0 to 3.02%) in volunteers (Wilcoxon nonparametric test, p < 0.0001 for both tests). CONCLUSIONS In this study, we show that platelet dysfunction is manifest after major trauma and before substantial fluid or blood administration. These data suggest a potential role for early platelet transfusion in severely injured patients at risk for postinjury coagulopathy.
Collapse
Affiliation(s)
- Max V Wohlauer
- Department of Surgery, University of Colorado Denver, Denver, CO, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Petricevic M, Biocina B, Konosic S, Kopjar T, Kunac N, Gasparovic H. Assessment of platelet function by whole blood impedance aggregometry in coronary artery bypass grafting patients on acetylsalicylic acid treatment may prompt a switch to dual antiplatelet therapy. Heart Vessels 2011; 28:57-65. [DOI: 10.1007/s00380-011-0216-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 11/04/2011] [Indexed: 11/24/2022]
|