1
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Hollis IB, Jennings DL, Krim S, Ton VK, Ducharme A, Cowger J, Looby M, Eulert-Green JJ, Bansal N, Horn E, Byku M, Katz J, Michaud CJ, Rajapreyar I, Campbell P, Vale C, Cosgrove R, Hernandez-Montfort J, Otero J, Ingemi A, Raj S, Weeks P, Agarwal R, Martinez ES, Tops LF, Ahmed MM, Kiskaddon A, Kremer J, Keebler M, Ratnagiri RK. An ISHLT consensus statement on strategies to prevent and manage hemocompatibility related adverse events in patients with a durable, continuous-flow ventricular assist device. J Heart Lung Transplant 2024; 43:1199-1234. [PMID: 38878021 DOI: 10.1016/j.healun.2024.04.065] [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: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 07/15/2024] Open
Abstract
Life expectancy of patients with a durable, continuous-flow left ventricular assist device (CF-LVAD) continues to increase. Despite significant improvements in the delivery of care for patients with these devices, hemocompatability-related adverse events (HRAEs) are still a concern and contribute to significant morbility and mortality when they occur. As such, dissemination of current best evidence and practices is of critical importance. This ISHLT Consensus Statement is a summative assessment of the current literature on prevention and management of HRAEs through optimal management of oral anticoagulant and antiplatelet medications, parenteral anticoagulant medications, management of patients at high risk for HRAEs and those experiencing thrombotic or bleeding events, and device management outside of antithrombotic medications. This document is intended to assist clinicians caring for patients with a CF-LVAD provide the best care possible with respect to prevention and management of these events.
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Affiliation(s)
- Ian B Hollis
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina; University of North Carolina Medical Center, Chapel Hill, North Carolina.
| | - Douglas L Jennings
- New York Presbyterian Columbia Irving Medical Center/Long Island University College of Pharmacy, New York, New York
| | - Selim Krim
- John Ochsner Heart and Vascular Institute, New Orleans, Louisiana
| | - Van-Khue Ton
- Massachusetts General Hospital, Boston, Massachusetts
| | - Anique Ducharme
- Montreal Heart Institute/Université de Montréal, Montreal, Quebec, Canada
| | | | - Mary Looby
- Inova Fairfax Medical Campus, Falls Church, Virginia
| | | | - Neha Bansal
- Mount Sinai Kravis Children's Hospital, New York, New York
| | - Ed Horn
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mirnela Byku
- University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Jason Katz
- Division of Cardiology, NYU Grossman School of Medicine & Bellevue Hospital, New York, New York
| | | | | | | | - Cassandra Vale
- The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Richard Cosgrove
- Cornerstone Specialty Hospital/University of Arizona College of Pharmacy, Tucson, Arizona
| | | | - Jessica Otero
- AdventHealth Littleton Hospital, Littleton, Colorado
| | | | | | - Phillip Weeks
- Memorial Hermann-Texas Medical Center, Houston, Texas
| | - Richa Agarwal
- Duke University Medical Center, Durham, North Carolina
| | | | - Laurens F Tops
- Leiden University Medical Center, Leiden, the Netherlands
| | | | - Amy Kiskaddon
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Mary Keebler
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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2
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Brandewie K, Lorts A, Luchtman-Jones L, Gao Z, Geer B, Villa C, Perry T. Impact of inflammation and steroids on anti-coagulation in children supported on a ventricular assist device. J Artif Organs 2024:10.1007/s10047-024-01442-2. [PMID: 38581568 DOI: 10.1007/s10047-024-01442-2] [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: 11/14/2023] [Accepted: 03/06/2024] [Indexed: 04/08/2024]
Abstract
Critically ill pediatric patients supported on ventricular assist devices (VADs) are increasingly being anticoagulated on bivalirudin, but with difficulty monitoring anticoagulation. Activated partial thromboplastin time (aPTT) has recently been shown to poorly correlate with bivalirudin plasma concentrations, while dTT had excellent correlation. However, aPTT is the more common monitoring test and dTT testing is rarely used. In addition, effects of frequent clinical VAD scenarios (such as inflammation) on the accuracy of aPTT and dTT testing remains uncertain. We reviewed the effects of clinical scenarios (infection/inflammation, chylothorax, and steroids administration) on anticoagulation monitoring in 10 pediatric VAD patients less than 3 years at Cincinnati Children's Hospital Medical Center from 10/27/2020 to 5/6/2022 using bivalirudin for anticoagulation. There were 16 inflammation/infection, 3 chylothorax, and 6 steroids events. Correlation between dTT and aPTT was significantly lower after infection/inflammation, with dTT increasing prior to inflammation/infection while aPTT remained unchanged. In addition, steroids are administered to VAD patients to reduce inflammation and thus additionally stabilize anticoagulation. However, this anticoagulation stabilization effect was reflected more accurately by dTT compared to aPTT. In children requiring VAD support utilizing bivalirudin anticoagulation, inflammation/infection is a common occurrence resulting in anticoagulation changes that may be more accurately reflected by dTT as opposed to aPTT.
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Affiliation(s)
- Katie Brandewie
- Cincinnati Children's Hospital Medical Center, Main Street, Cincinnati, OH, 77030, USA.
| | - Angela Lorts
- Cincinnati Children's Hospital Medical Center, Main Street, Cincinnati, OH, 77030, USA
| | - Lori Luchtman-Jones
- Cincinnati Children's Hospital Medical Center, Main Street, Cincinnati, OH, 77030, USA
| | - Zhiqian Gao
- Cincinnati Children's Hospital Medical Center, Main Street, Cincinnati, OH, 77030, USA
| | - Becca Geer
- Cincinnati Children's Hospital Medical Center, Main Street, Cincinnati, OH, 77030, USA
| | - Chet Villa
- Cincinnati Children's Hospital Medical Center, Main Street, Cincinnati, OH, 77030, USA
| | - Tanya Perry
- Cincinnati Children's Hospital Medical Center, Main Street, Cincinnati, OH, 77030, USA.
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3
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Scott EJ, Rotar E, Dahl JJ, Beller JP, Money DT, Chancellor WZ, Mehaffey JH, Morisette M, Yarboro LT, Teman NR. Discordance among assays for monitoring? Anticoagulation during extracorporeal life support. Perfusion 2023; 38:1714-1721. [PMID: 36167522 DOI: 10.1177/02676591221129741] [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
OBJECTIVES The optimal method for monitoring of anticoagulation in patients on extracorporeal life support (ECLS) is unknown. The objective of this study was to assess the relationship between anti-factor Xa level (anti-Xa; IU/mL) and activated partial thromboplastin time (aPTT; seconds) for monitoring intravenous unfractionated heparin anticoagulation in adult ECLS patients. METHODS Charts of all adult patients cannulated for ECLS from 2015 through 2017 were reviewed and laboratory and heparin infusion data were extracted for analysis. Time matched pairs of anti-Xa and aPTT were considered concordant if both laboratory values were within the same clinically utilized range. A hierarchical logistic regression model was used to determine factors associated with discordance while accounting for patient level effects. RESULTS A total of 1016 paired anti-Xa and aPTT values from 65 patients were evaluated. 500 (49.2%) paired samples were discordant with a degree of variability on linear regression (r2 = 0.315). The aPTT fell into a higher therapeutic range compared to the anti-Xa in 31.6% and lower in 17.3%. Logistic regression demonstrated that discordance was independently associated with time from initiation of ECLS (OR 1.17 per day, p < 0.001), average heparin infusion rate (OR 1.25 per U/kg/hr, p < 0.001), and INR (OR 3.22, p < 0.001). CONCLUSIONS Nearly half of all aPTT and anti-Xa values were in discordant ranges and discordance is more likely as the time on ECLS and the INR level increase. The use of either assay in isolation to guide heparin anticoagulation may lead to misestimation of the degree of anticoagulation in complex ECLS patients.
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Affiliation(s)
- Erik J Scott
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Evan Rotar
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Jolian J Dahl
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Jared P Beller
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | | | - W Z Chancellor
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - J H Mehaffey
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | | | - Leora T Yarboro
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Nicholas R Teman
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
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4
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Trachtenberg B, Cowger J. HFSA Expert Consensus Statement on the Medical Management of Patients on Durable Mechanical Circulatory Support. J Card Fail 2023; 29:479-502. [PMID: 36828256 DOI: 10.1016/j.cardfail.2023.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/24/2023]
Abstract
The medical management of patients supported with durable continuous flow left ventricular assist device (LVAD) support encompasses pharmacologic therapies administered in the preoperative, intraoperative, postoperative and chronic LVAD support stages. As patients live longer on LVAD support, the risks of LVAD-related complications and progression of cardiovascular and other diseases increase. Using existing data from cohort studies, registries, randomized trials and expert opinion, this Heart Failure Society of America Consensus Document on the Medical Management of Patients on Durable Mechanical Circulatory Support offers best practices on the management of patients on durable MCS, focusing on pharmacological therapies administered to patients on continuous flow LVADs. While quality data in the LVAD population are few, the utilization of guideline directed heart failure medical therapies (GDMT) and the importance of blood pressure management, right ventricular preload and afterload optimization, and antiplatelet and anticoagulation regimens are discussed. Recommended pharmacologic regimens used to mitigate or treat common complications encountered during LVAD support, including arrhythmias, vasoplegia, mucocutaneous bleeding, and infectious complications are addressed. Finally, this document touches on important potential pharmacological interactions from anti-depressants, herbal and nutritional supplements of relevance to providers of patients on LVAD support.
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Affiliation(s)
- Barry Trachtenberg
- Houston Methodist Heart and Vascular Center, Methodist J.C. Walter Transplant Center.
| | - Jennifer Cowger
- Medical Director, Mechanical Circulatory Support Program, Codirector, Cardiac Critical Care, Henry Ford Advanced Heart Failure Program.
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5
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Weingarten N, Song C, Iyengar A, Herbst DA, Helmers M, Meldrum D, Guevara-Plunkett S, Dominic J, Atluri P. Antithrombotic therapy for durable left ventricular assist devices - current strategies and future directions. Indian J Thorac Cardiovasc Surg 2022; 38:628-636. [PMID: 36258825 PMCID: PMC9569275 DOI: 10.1007/s12055-022-01409-z] [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: 04/28/2022] [Revised: 07/31/2022] [Accepted: 08/21/2022] [Indexed: 10/14/2022] Open
Abstract
Left ventricular assist devices (LVADs) improve survival and quality of life for patients with advanced heart failure but are associated with high rates of thromboembolic and hemorrhagic complications. Antithrombotic therapy is required following LVAD implantation, though practices vary. Identifying a therapeutic strategy that minimizes the risks of thromboembolic and hemorrhagic complications is critical to optimizing patient outcomes and is an area of active investigation. This paper reviews strategies for initiating and maintaining antithrombotic therapy in durable LVAD recipients, focusing on those with centrifugal-flow devices.
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Affiliation(s)
- Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Cindy Song
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - David Alan Herbst
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Mark Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Danika Meldrum
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Sara Guevara-Plunkett
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Jessica Dominic
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
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Hayward C, Adachi I, Baudart S, Davis E, Feller ED, Kinugawa K, Klein L, Li S, Lorts A, Mahr C, Mathew J, Morshuis M, Müller M, Ono M, Pagani FD, Pappalardo F, Rich J, Robson D, Rosenthal DN, Saeed D, Salerno C, Sauer AJ, Schlöglhofer T, Tops L, VanderPluym C. Global Best Practices Consensus: Long-term Management of HeartWare Ventricular Assist Device Patients. J Thorac Cardiovasc Surg 2022; 164:1120-1137.e2. [DOI: 10.1016/j.jtcvs.2022.03.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/24/2022] [Accepted: 03/24/2022] [Indexed: 11/15/2022]
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Jenks CL, Landry LM, Garrison CF, Campbell JG, Weeks MF, Tramel SW, Knudson JD. Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Protocol Associated with a Decrease in Complications. ASAIO J 2022; 68:275-280. [PMID: 33883505 DOI: 10.1097/mat.0000000000001438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) in pediatrics has rapidly progressed in recent years; however, there continues to be considerable variation in anticoagulation practices. In 2016, we implemented a standardized anticoagulation protocol in effort to reduce clotting and bleeding complications. A single-center retrospective analysis of pediatric patients requiring ECMO between 2014 and 2018 was performed. One hundred one ECMO cases in 94 pediatric patients met eligibility criteria (preprotocol = 64 cases; postprotocol = 37 cases). Demographics, ECMO parameters, complications, laboratories, and blood product requirements were analyzed for differences between the two groups. There was a significant decrease in the incidence of hematologic (p < 0.022), neurologic (p < 0.001), and renal complications (p < 0.001) in the postprotocol era. Incidence of bleeding, cardiac/pulmonary complications, and circuit changes were similar between the groups. The postprotocol group required fewer transfusions of red blood cells and cryoprecipitate. Additionally, platelet counts and fibrinogen levels were maintained higher in the postprotocol era. In conclusion, implementation of a standardized anticoagulation protocol was associated with improved anticoagulation parameters and a decrease in hematologic and neurologic complications, coagulopathy, renal injury, and blood product administration. We attribute these findings to transitioning to anti-Xa as a measure of heparinization and maintaining higher platelet counts.
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Affiliation(s)
- Christopher L Jenks
- From the Department of Pediatrics, Division of Pediatric Critical Care, University of Mississippi Medical Center, Jackson, Mississippi
| | - Lily M Landry
- Department of Pediatrics, Division of Pediatric Cardiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Carrie F Garrison
- Department of Pediatrics, Division of Pediatric Critical Care, Studer Family Children's Hospital at Sacred Heart, Pensacola, Florida
| | - Joshua G Campbell
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Mary F Weeks
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Sarah W Tramel
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jarrod D Knudson
- From the Department of Pediatrics, Division of Pediatric Critical Care, University of Mississippi Medical Center, Jackson, Mississippi
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8
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Monteagudo-Vela M, Bowles C, Raj B, Robinson D, Simon A. Anticoagulation in syncardia total artificial heart recipients: anti-factor Xa or activated partial thromboplastin time? Interact Cardiovasc Thorac Surg 2021; 34:322-325. [PMID: 34849924 PMCID: PMC8766202 DOI: 10.1093/icvts/ivab251] [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: 03/09/2021] [Revised: 07/15/2021] [Accepted: 08/13/2021] [Indexed: 11/12/2022] Open
Abstract
Although the activated partial thromboplastin time (aPTT) has historically been the method of choice for anticoagulation monitoring in patients undergoing mechanical circulatory support with intravenous unfractionated heparin, it is being progressively superseded by the anti-factor Xa (anti-Xa) method. A retrospective single-arm, single-centre analysis of 20 patients who underwent total artificial heart implantation entailed simultaneous determinations of aPTT and anti-Xa. Agreement between these parameters was assessed using the Bland-Altman method. Despite a positive correlation between aPTT and anti-Xa, normal target ranges were poorly aligned: from 5th to 30th postoperative day, for anti-Xa values of 0.2 and 0.4 U/ml corresponding aPTT values were 52.1 and 65.2 s, 7.9 and 14.8 lower than predicted values, respectively. This was not associated with thromboembolic sequalae. It was not possible to demonstrate a significant relationship between the predictor variables (postoperative day; white blood cell count; C-reactive protein concentration; alanine transaminase and alkaline phosphatase level; bilirubin; haemoglobin; albumin and total protein concentration) and the agreement between aPTT and anti-Xa levels. In summary, when anti-Xa levels were used to guide anticoagulation therapy, corresponding aPTT levels were low with respect to target range. Methodology applied in this study is generalizable to other forms of mechanical circulatory support.
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Affiliation(s)
- María Monteagudo-Vela
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher Bowles
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Binu Raj
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Derek Robinson
- Department of Mathematics, 3A20 Pevensey 2 Building, University of Sussex, Falmer Campus, Brighton, UK
| | - Andre Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
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9
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Lund M, Macwan AS, Tunströmer K, Lindahl TL, Boknäs N. Effects of Heparin and Bivalirudin on Thrombin-Induced Platelet Activation: Differential Modulation of PAR Signaling Drives Divergent Prothrombotic Responses. Front Cardiovasc Med 2021; 8:717835. [PMID: 34660719 PMCID: PMC8511449 DOI: 10.3389/fcvm.2021.717835] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022] Open
Abstract
Heparin and bivalirudin are widely used as anticoagulants in the setting of acute thrombosis. In this study, we investigated how these drugs affect the ability of thrombin to generate a prothrombotic platelet response via activation of the protease-activated receptors (PARs) 1 and 4. We examined the effects of heparin/antithrombin and bivalirudin on PAR1- and PAR4-mediated intracellular calcium mobilization, aggregation, α-granule release, and procoagulant membrane exposure in platelets exposed to thrombin concentrations likely to be encountered in the thrombus microenvironment during thrombosis. At physiological antithrombin levels, heparin treatment resulted in complete and sustained inhibition of thrombin-induced PAR4-mediated platelet activation, but transient PAR1 signaling was sufficient to elicit significant α-granule release and platelet aggregation. In contrast, bivalirudin treatment resulted in rapid and profound inhibition of signaling from both PAR receptors, followed by a delayed phase of PAR4-mediated platelet activation, resulting in a robust prothrombotic response. Combination treatment with bivalirudin and subtherapeutic concentrations of heparin completely inhibited the residual platelet activation observed with single drug treatment at all time-points. Our results show that heparin and bivalirudin have different and complementary inhibitory effects on the activation of PAR1 and PAR4 by thrombin.
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Affiliation(s)
- Mikael Lund
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ankit S Macwan
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Kjersti Tunströmer
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Tomas L Lindahl
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Clinical Chemistry and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Niklas Boknäs
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Hematology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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10
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Gustafsson F, Ben Avraham B, Chioncel O, Hasin T, Grupper A, Shaul A, Nalbantgil S, Hammer Y, Mullens W, Tops LF, Elliston J, Tsui S, Milicic D, Altenberger J, Abuhazira M, Winnik S, Lavee J, Piepoli MF, Hill L, Hamdan R, Ruhparwar A, Anker S, Crespo-Leiro MG, Coats AJS, Filippatos G, Metra M, Rosano G, Seferovic P, Ruschitzka F, Adamopoulos S, Barac Y, De Jonge N, Frigerio M, Goncalvesova E, Gotsman I, Itzhaki Ben Zadok O, Ponikowski P, Potena L, Ristic A, Jaarsma T, Ben Gal T. HFA of the ESC position paper on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider Part 3: at the hospital and discharge. ESC Heart Fail 2021; 8:4425-4443. [PMID: 34585525 PMCID: PMC8712918 DOI: 10.1002/ehf2.13590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/22/2021] [Accepted: 08/19/2021] [Indexed: 12/28/2022] Open
Abstract
The growing population of left ventricular assist device (LVAD)‐supported patients increases the probability of an LVAD‐ supported patient hospitalized in the internal or surgical wards with certain expected device related, and patient‐device interaction complication as well as with any other comorbidities requiring hospitalization. In this third part of the trilogy on the management of LVAD‐supported patients for the non‐LVAD specialist healthcare provider, definitions and structured approach to the hospitalized LVAD‐supported patient are presented including blood pressure assessment, medical therapy of the LVAD supported patient, and challenges related to anaesthesia and non‐cardiac surgical interventions. Finally, important aspects to consider when discharging an LVAD patient home and palliative and end‐of‐life approaches are described.
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Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Binyamin Ben Avraham
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C., Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Tal Hasin
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Avishai Grupper
- Heart Failure Institute, Lev Leviev Heart Center, Chaim Sheba Medical Center, Tel-Hashomer, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aviv Shaul
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Yoav Hammer
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, University Hasselt, Hasselt, Belgium
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeremy Elliston
- Anesthesiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Steven Tsui
- Transplant Unit, Royal Papworth Hospital, Cambridge, UK
| | - Davor Milicic
- Department for Cardiovascular Diseases, Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Johann Altenberger
- SKA-Rehabilitationszentrum Großgmain, Salzburger, Straße 520, Großgmain, 5084, Austria
| | - Miriam Abuhazira
- Department of Cardiothoracic Surgery, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Stephan Winnik
- Department of Cardiology, University Heart Center, University Hospital Zurich, Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Jacob Lavee
- Heart Transplantation Unit, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Lorrena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Righab Hamdan
- Department of Cardiology, Beirut Cardiac Institute, Beirut, Lebanon
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Stefan Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marisa Generosa Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), CIBERCV, Instituto de Investigacion Biomedica A Coruña (INIBIC), Universidad de a Coruña (UDC), A Coruña, Spain
| | | | - Gerasimos Filippatos
- Heart Failure Unit, Attikon University Hospital, National and Kapodistrian University of Athens, Greece. School of Medicine, University of Cyprus, Nicosia, Cyprus
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Rosano
- Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK.,RCCS San Raffaele Pisana, Rome, Italy
| | - Petar Seferovic
- Serbian Academy of Sciences and Arts, Heart Failure Center, Faculty of Medicine, Belgrade University Medical Center, Belgrade, Serbia
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Stamatis Adamopoulos
- Heart Failure and Heart Transplantation Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Yaron Barac
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nicolaas De Jonge
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria Frigerio
- Transplant Center and De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | | | - Israel Gotsman
- Heart Institute, Hadassah University Hospital, Jerusalem, Israel
| | - Osnat Itzhaki Ben Zadok
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Piotr Ponikowski
- Centre for Heart Diseases, University Hospital, Wroclaw, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Luciano Potena
- Heart and Lung Transplant Program, Bologna University Hospital, Bologna, Italy
| | - Arsen Ristic
- Department of Cardiology of the Clinical Center of Serbia, Belgrade University School of Medicine, Belgrade, Serbia
| | - Tiny Jaarsma
- Department of Nursing, Faculty of Medicine and Health Sciences, University of Linköping, Linköping, Sweden
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Li T, Meng Z, Zhu X, Gan H, Gu R, Wu Z, Liu T, Han P, Gao J, Han S, Dou G. In vitro and in vivo safety studies indicate that R15, a synthetic polyarginine peptide, could safely reverse the effects of unfractionated heparin. FEBS Open Bio 2021; 11:2468-2489. [PMID: 34184429 PMCID: PMC8409304 DOI: 10.1002/2211-5463.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/03/2021] [Accepted: 06/28/2021] [Indexed: 11/09/2022] Open
Abstract
Unfractionated heparin (UFH) is an anionic glycosaminoglycan that is widely used to prevent blood clotting. However, in certain cases, unwanted side effects can require it to be neutralized. Protamine sulfate (PS), a basic peptide rich in arginine, is the only approved antagonist for UFH neutralization. Many adverse reactions occur with the clinical application of PS, including systemic hypotension, pulmonary hypertension, and anaphylaxis. We previously described R15, a linear peptide composed of 15 arginine molecules, as a potential UFH antagonist. In this study, the in-depth safety of R15 was explored to reveal its merits and associated risks in comparison with PS. In vitro safety studies investigated the interactions of R15 with erythrocytes, fibrin, complement, and rat plasma. In vivo safety studies explored potential toxicity and immunogenicity of R15 and the UFH-R15 complex. Results showed that both PS and R15 can induce erythrocyte aggregation, thicken fibrin fibers, activate complement, and cause anticoagulation in a concentration-dependent manner. However, those influences weakened in whole blood or in live animals and were avoided when R15 was in a complex with UFH. We found dramatically enhanced complement activation when there was excess UFH in analyses involving UFH-PS complexes, and a slight increase in those involving UFH-R15 complexes. Within 2 h, R15 was degraded in rat plasma in vitro, whereas PS was not. Enhanced creatinine was found after a single intravenous injection of PS or R15 (900 U·kg-1 , body weight), suggesting possible abnormal renal function. The UFH-PS complex, but not the UFH-R15 complex, exhibited obvious immunogenicity. In conclusion, R15 is nonimmunogenic and potentially safe at a therapeutic dose to reverse the effects of UFH.
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Affiliation(s)
- Tong Li
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Zhiyun Meng
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Xiaoxia Zhu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Hui Gan
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Ruolan Gu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Zhuona Wu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Taoyun Liu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Peng Han
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Jiarui Gao
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Su Han
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Guifang Dou
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
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12
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Moussa MD, Soquet J, Lamer A, Labreuche J, Gantois G, Dupont A, Abou-Arab O, Rousse N, Liu V, Brandt C, Foulon V, Leroy G, Schurtz G, Jeanpierre E, Duhamel A, Susen S, Vincentelli A, Robin E. Evaluation of Anti-Activated Factor X Activity and Activated Partial Thromboplastin Time Relations and Their Association with Bleeding and Thrombosis during Veno-Arterial ECMO Support: A Retrospective Study. J Clin Med 2021; 10:jcm10102158. [PMID: 34067573 PMCID: PMC8156165 DOI: 10.3390/jcm10102158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We aimed to investigate the relationship between anti-activated Factor X (anti-FXa) and activated Partial Thromboplastin Time (aPTT), and its modulation by other haemostasis co-variables during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. We further investigated their association with serious bleeding and thrombotic complications. METHODS This retrospective single-center study included 265 adults supported by VA-ECMO for refractory cardiogenic shock from January 2015 to June 2019. The concordance of anti-FXa and aPTT and their correlations were assessed in 1699 paired samples. Their independent associations with serious bleeding or thrombotic complications were also analysed in multivariate analysis. RESULTS The concordance rate of aPTT with anti-FXa values was 50.7%, with 39.3% subtherapeutic aPTT values. However, anti-FXa and aPTT remained associated (β = 0.43 (95% CI 0.4-0.45) 10-2 IU/mL, p < 0.001), with a significant modulation by several biological co-variables. There was no association between anti-FXa nor aPTT values with serious bleeding or with thrombotic complications. CONCLUSION During VA-ECMO, although anti-FXa and aPTT were significantly associated, their values were highly discordant with marked sub-therapeutic aPTT values. These results should favour the use of anti-FXa. The effect of biological co-variables and the failure of anti-FXa and aPTT to predict bleeding and thrombotic complications underline the complexity of VA-ECMO-related coagulopathy.
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Affiliation(s)
- Mouhamed Djahoum Moussa
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
- Correspondence: ; Tel.: +33-320-445-962
| | - Jérôme Soquet
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Antoine Lamer
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
- Univ. Lille, INSERM, CHU Lille, CIC-IT 1403, 59000 Lille, France
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
| | - Julien Labreuche
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
- CHU Lille, Department of Biostatistics, 59000 Lille, France
| | - Guillaume Gantois
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Annabelle Dupont
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 80054 Amiens, France;
- MP3CV, EA7517, CURS, Jules Verne University of Picardie, 80054 Amiens, France
| | - Natacha Rousse
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Vincent Liu
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Caroline Brandt
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Valentin Foulon
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Guillaume Leroy
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | | | - Emmanuel Jeanpierre
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - Alain Duhamel
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
- CHU Lille, Department of Biostatistics, 59000 Lille, France
| | - Sophie Susen
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - André Vincentelli
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Emmanuel Robin
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
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13
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Nykänen AI, Selby R, McRae KM, Zhao Y, Asghar UM, Donahoe L, Granton J, de Perrot M. Pseudo Heparin Resistance After Pulmonary Endarterectomy: Role of Thrombus Production of Factor VIII. Semin Thorac Cardiovasc Surg 2021; 34:315-323. [PMID: 33984481 DOI: 10.1053/j.semtcvs.2021.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 03/11/2021] [Indexed: 11/11/2022]
Abstract
Pulmonary endarterectomy (PEA) is the main treatment for chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative unfractionated heparin dosing can be monitored by activated partial thromboplastin time (APTT) or by anti-factor Xa activity (anti-Xa). In pseudo heparin resistance, APTT response to heparin is blunted due to elevated Factor VIII (FVIII) which can underestimate anticoagulation. We examined possible pseudo heparin resistance after PEA and assessed the impact of FVIII. APTT response to heparin before and after operation was determined in 13 PEA patients anticoagulated with unfractionated heparin. APTT and anti-Xa concordance was analyzed from paired postoperative samples, and antithrombin, fibrinogen and FVIII levels were measured. Single-cell RNA sequencing was used to characterize FVIII gene expression in PEA specimens of 5 patients. APTT response to heparin was blunted after PEA. APTT and anti-Xa were discordant in 36% of postoperative samples and most common discordant patterns were subtherapeutic APTT with therapeutic (16%) or supratherapeutic (11%) anti-Xa. Overall, APTT underestimated anticoagulation relative to anti-Xa in one-third of the samples. FVIII levels were elevated before surgery, increased substantially 1 and 3 days (median 4.32 IU/mL) after PEA, and were higher in discordant than concordant samples. Single-cell RNA sequencing showed FVIII gene expression in PEA specimen endothelial cells. Pseudo heparin resistance is common after PEA likely due to highly elevated postoperative FVIII levels indicating that anti-Xa reflects postoperative heparinization better than APTT in these patients. FVIII production by the pulmonary artery endothelium may participate in local prothrombotic processes important for CTEPH pathogenesis.
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Affiliation(s)
- Antti I Nykänen
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Rita Selby
- Coagulation Laboratory, University Health Network, Toronto, Ontario, Canada
| | - Karen M McRae
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Yidan Zhao
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Usman M Asghar
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - John Granton
- Division of Respirology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada.
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14
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Rhoades R, Leong R, Kopenitz J, Thoma B, McDermott L, Dovidio J, Barletti S, Gong JZ, Massey HT, McKenzie SE, Rame JE, Al-Rawas N. Coagulopathy monitoring and anticoagulation management in COVID-19 patients on ECMO: Advantages of a heparin anti-Xa-based titration strategy. Thromb Res 2021; 203:1-4. [PMID: 33894473 PMCID: PMC8053597 DOI: 10.1016/j.thromres.2021.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/01/2021] [Accepted: 04/12/2021] [Indexed: 01/08/2023]
Affiliation(s)
- Ruben Rhoades
- Division of Hematology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA, United States of America.
| | - Ron Leong
- Critical Care Division, Department of Anesthesia, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Jason Kopenitz
- Critical Care Division, Department of Anesthesia, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Brandi Thoma
- Deparment of Pharmacy, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Lydia McDermott
- Critical Care Division, Department of Anesthesia, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Joseph Dovidio
- Critical Care Division, Department of Anesthesia, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Shannon Barletti
- Critical Care Division, Department of Anesthesia, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Jerald Z Gong
- Department of Pathology, Anatomy, & Cell Biology, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Howard T Massey
- Division of Cardiac Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Steven E McKenzie
- Division of Hematology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - J Eduardo Rame
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Nawar Al-Rawas
- Deparment of Pharmacy, Thomas Jefferson University, Philadelphia, PA, United States of America
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15
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Hollis IB, Doligalski CT, Jennings DJ. Pharmacotherapy for durable left ventricular assist devices. Pharmacotherapy 2021; 41:14-27. [PMID: 33278842 DOI: 10.1002/phar.2491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 12/12/2022]
Abstract
Left ventricular assist devices (LVADs) have revolutionized the care of patients with advanced heart failure, yet still require concomitant medications in order to achieve the best possible clinical outcomes. Since the outset of routine placement of durable, continuous-flow LVADs, much of the medication management of these patients to date has been based on International Society of Heart and Lung Transplantation (ISHLT) guidance, most recently published in 2013. Since 2013, numerous multidisciplinary pharmacotherapy publications have increased the LVAD community's understanding of best practices with respect to medications. We identified the major domains of LVAD medication management and conducted a comprehensive search of US National Library of Medicine MEDLINE® database using keywords chosen to identify medication-related publications of significance dated 2013 or later. Trials pertaining to the HeartMate II™ and the HeartMate™ 3 LVADs (Abbott, Chicago, IL) and the HeartWare™ HVAD™ System (Medtronic, Minneapolis, MN) were chosen for inclusion. Highest priority for inclusion was given to prospective, randomized, controlled studies. Absent these, controlled trials (retrospective or prospective observational) were given next-highest consideration, followed by retrospective uncontrolled studies, and finally case series. Reference lists of qualified publications were reviewed to find any other publications of interest that were not discovered on initial search. Case reports were generally excluded, except where the insight gained was deemed to be uniquely pertinent. This document serves to provide a comprehensive review of the current understanding of optimal medication management in patients with durable, continuous-flow LVADs.
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Affiliation(s)
- Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Christina T Doligalski
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Douglas J Jennings
- Department of Pharmacy Practice, Long Island University, New York-Presbyterian Hospital Columbia University Irving Medical Center, New York, New York, USA
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16
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Kirklin JK, Pagani FD, Goldstein DJ, John R, Rogers JG, Atluri P, Arabia FA, Cheung A, Holman W, Hoopes C, Jeevanandam V, John R, Jorde UP, Milano CA, Moazami N, Naka Y, Netuka I, Pagani FD, Pamboukian SV, Pinney S, Rogers JG, Selzman CH, Silverstry S, Slaughter M, Stulak J, Teuteberg J, Vierecke J, Schueler S, D'Alessandro DA. American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support. J Thorac Cardiovasc Surg 2020; 159:865-896. [DOI: 10.1016/j.jtcvs.2019.12.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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17
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Kirklin JK, Pagani FD, Goldstein DJ, John R, Rogers JG, Atluri P, Arabia FA, Cheung A, Holman W, Hoopes C, Jeevanandam V, John R, Jorde UP, Milano CA, Moazami N, Naka Y, Netuka I, Pagani FD, Pamboukian SV, Pinney S, Rogers JG, Selzman CH, Silverstry S, Slaughter M, Stulak J, Teuteberg J, Vierecke J, Schueler S, D'Alessandro DA. American Association for Thoracic Surgery/International Society for Heart and Lung Transplantation guidelines on selected topics in mechanical circulatory support. J Heart Lung Transplant 2020; 39:187-219. [PMID: 31983666 DOI: 10.1016/j.healun.2020.01.1329] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
| | - James K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala.
| | | | - Daniel J Goldstein
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | | | | | | | | | | | - Anson Cheung
- University of British Columbia, Vancouver, British Columbia, Canada
| | - William Holman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - Charles Hoopes
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | | | | | - Ulrich P Jorde
- Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | | | - Nader Moazami
- Langone Medical Center, New York University, New York, NY
| | - Yoshifumi Naka
- Columbia University College of Physicians & Surgeons, New York, NY
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Salpy V Pamboukian
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | | | | | | | | | | | - John Stulak
- Mayo Clinic College of Medicine and Science, Rochester, Minn
| | | | | | | | - Stephan Schueler
- Department for Cardiothoracic Surgery, Newcastle upon Tyne Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - David A D'Alessandro
- Department of Cardiothoracic Surgery, Massachusetts General Hospital, Boston, Mass
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18
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Sieg A, Pandya K, Winstead R, Evans R. Overview of Pharmacological Considerations in Extracorporeal Membrane Oxygenation. Crit Care Nurse 2019; 39:29-43. [PMID: 30936129 DOI: 10.4037/ccn2019236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Extracorporeal membrane oxygenation has become more widely used in recent years. Although this technology has proven to be lifesaving, it is not devoid of complications contributing to significant morbidity and mortality. Nurses who care for patients receiving extracorporeal membrane oxygenation should further their understanding of changes in medication profiles due to complex interactions with the extracorporeal membrane oxygenation circuitry. The aim of this comprehensive review is to give nurses a better understanding of analgesic, sedative, anti-infective, and anticoagulation medications that are frequently used to treat patients receiving extracorporeal membrane oxygenation.
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Affiliation(s)
- Adam Sieg
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support. .,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy. .,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia. .,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina.
| | - Komal Pandya
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
| | - Ryan Winstead
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
| | - Rickey Evans
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
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Adjusted calculation model of heparin management during cardiopulmonary bypass in obese patients: A randomised controlled trial. Eur J Anaesthesiol 2019. [PMID: 29521662 DOI: 10.1097/eja.0000000000000784] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anticoagulation during cardiopulmonary bypass (CPB) is usually adapted to total body weight (TBW). This may be inaccurate in obese patients and lead to heparin overdose with a risk of bleeding. OBJECTIVES To validate the efficacy and safety of an adjusted calculation model of heparin dosing based on ideal body weight (IBW) rather than TBW in obese CPB patients, with an expected target mean plasma heparin concentration of 4.5 IU ml after onset of CPB in the experimental group. DESIGN Randomised controlled study. SETTING University hospital. PATIENTS Sixty obese patients (BMI ≥ 30 kg m) scheduled for CPB were included from January to June 2016. INTERVENTIONS Patients received a bolus dose of unfractionated heparin of either 300 IU kg of TBW or 340 IU kg of IBW before onset of CPB. Additional adjusted boluses were injected to maintain an activated clotting time (ACT) of at least 400 s. MAIN OUTCOME MEASURES Plasma heparin concentration and ACT were measured at different time points. Total heparin doses and transfusion requirements were recorded. RESULTS The target heparin concentration of 4.5 IU ml was reached in the IBW group at the onset of CPB and maintained at all time points during CPB. Heparin concentrations were significantly higher in the TBW group after the bolus (6.52 ± 0.97 vs. 4.54 ± 1.13 IU ml, P < 0.001) and after cardioplegia (5.10 ± 1.03 vs. 4.31 ± 1.00 IU ml, P = 0.02). Total heparin doses were significantly higher in the TBW group. Mean ACT was significantly lower in the IBW group but remained over 400 s during CPB. The correlation between heparin and ACT was poor. Peri-operative bleeding and transfusion requirements were comparable. No thrombotic event occurred in the CPB circuit. CONCLUSION The current IBW-adjusted regimen of heparin administration may be used efficiently in obese CPB patients, thereby avoiding overdose which cannot be accurately assessed by ACT monitoring alone. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02675647.
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Luc JG, Tchantchaleishvili V, Phan K, Dunlay SM, Maltais S, Stulak JM. Medical Therapy As Compared To Surgical Device Exchange for Left Ventricular Assist Device Thrombosis: A Systematic Review and Meta-Analysis. ASAIO J 2019; 65:307-317. [DOI: 10.1097/mat.0000000000000833] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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21
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Adhikary SD, Prasad A, Soleimani B, Chin KJ. Continuous Erector Spinae Plane Block as an Effective Analgesic Option in Anticoagulated Patients After Left Ventricular Assist Device Implantation: A Case Series. J Cardiothorac Vasc Anesth 2019; 33:1063-1067. [DOI: 10.1053/j.jvca.2018.04.026] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Indexed: 11/11/2022]
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Bercovitz RS. An introduction to point-of-care testing in extracorporeal circulation and LVADs. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:516-521. [PMID: 30504352 PMCID: PMC6245959 DOI: 10.1182/asheducation-2018.1.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
There is a delicate balance between bleeding and clotting in patients on circuits such as ventricular assist devices or extracorporeal membrane oxygenation. Traditional coagulation tests, prothrombin time, activated partial thromboplastin time, and anti-factor Xa levels, are used to monitor patients on these devices. However, turnaround times and inability to assess global hemostasis, including platelets and fibrinogen have contributed to a recognition that faster, accurate, and more informative coagulation tests are needed. Activated clotting time is used to monitor heparin in patients on circuits and has the advantages of being a near-patient point-of-care test. However, its utility is limited to heparin monitoring. Viscoelastic tests (thromboelastometry and thromboelastography) are global, whole-blood coagulation tests, and whole-blood platelet aggregometry evaluates platelet function. Ideally, these tests can ensure that patients are within the therapeutic range of their antithrombotic medications, identify patients at risk for hemorrhagic or thrombotic complications, and guide management of acute bleeding complications. This ideal is currently hampered by a lack of studies that delineate clear ranges that are clinically relevant. Future research is needed to better understand the optimal use of point-of-care coagulation testing in patients on extracorporeal circuits and ventricular assist devices.
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Affiliation(s)
- Rachel Sara Bercovitz
- Division of Hematology/Oncology/Stem Cell Transplant, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL; and Ann & Robert H. Lurie Children's Hospital, Chicago, IL
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Wong SSM, Lau WY, Chan PK, Wan CK, Cheng YL. Correlation between activated partial thromboplastin time and anti-Xa activity in patients who received low-molecular weight heparin as anticoagulation for haemodialysis. Nephrology (Carlton) 2018; 22:921-924. [PMID: 28767200 DOI: 10.1111/nep.13122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2017] [Indexed: 11/27/2022]
Abstract
Plasma anti-Xa activity, the recommended test to monitor low-molecular weight heparin (LMWH) therapy, is not readily available in many laboratories. In our clinical trials on the use of LMWH as anticoagulation for haemodialysis, a consistent prolongation of APTT in addition to the elevated anti-Xa activity was observed in the patients after LMWH administration. Hence, the paired anti-Xa activity and APTT data were re-analyzed. The APTT ratio, which was the proportional change in APTT from the baseline value after LMWH administration, was found to have a strong correlation with anti-Xa activity (coefficient of determination, R 2 = 0.72, P < 0.001). In the receiver operating characteristic analysis, the APTT ratio was also found to be an excellent predictor of therapeutic anti-Xa activity ≧0.5 IU/mL (area under curve = 0.93, P < 0.001). The sensitivity was 88% and the specificity was 83.3% when an APTT ratio ≧1.4 was used as the cut point to predict the achievement of therapeutic anti-Xa activity. Our results illustrated that APTT is a potentially useful screening test to assess the degree of anticoagulation achieved by LMWH during haemodialysis, if the testing for plasma anti-Xa activity is not available.
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Affiliation(s)
- Steve Siu-Man Wong
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
| | - Wai-Yan Lau
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
| | - Ping-Kwan Chan
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
| | - Ching-Kit Wan
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
| | - Yuk-Lun Cheng
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong
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Nicholson JD, Kaakeh Y. Pharmacotherapy considerations for long-term management of patients with left ventricular assist devices. Am J Health Syst Pharm 2018; 75:755-766. [PMID: 29802111 DOI: 10.2146/ajhp170317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Yaman Kaakeh
- Purdue University College of Pharmacy, West Lafayette, IN
- Indiana University School of Medicine, West Lafayette, IN
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Increased Risk of Bleeding in Left Ventricular Assist Device Patients Treated with Enoxaparin as Bridge to Therapeutic International Normalized Ratio. ASAIO J 2018; 64:140-146. [DOI: 10.1097/mat.0000000000000612] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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McFarland CP, Lind SE. Thrombin Generation Biomarkers Decline With Parenteral Anticoagulation-An Overlooked Means of Anticoagulation Monitoring? Clin Appl Thromb Hemost 2018; 24:708-717. [PMID: 29439639 PMCID: PMC6714868 DOI: 10.1177/1076029617746506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Anticoagulation therapy is administered to patients to prevent or stop thrombin generation in vivo. Although plasma tests of in vivo thrombin generation have been available for more than 2 decades, they are not routinely used in clinical trials or practice to monitor anticoagulation therapy. We observed a fall in one such marker, the D-dimer antigen, in patients receiving anticoagulation therapy. We therefore conducted a systematic review of the medical literature to document the change in serum biomarkers of thrombin generation following the initiation of anticoagulation therapy. Using a defined search strategy, we screened PubMed and Embase citations and identified full-length articles published in English. Eighteen articles containing serial changes in 1 of 3 markers of thrombin generation (D-dimer antigen, thrombin–antithrombin complexes, and prothrombin fragment 1+2 antigen levels) in the 14 days following the initiation of anticoagulation were identified. Even though the assays used varied considerably, each of the 3 markers of thrombin generation declined in the initial period of anticoagulation therapy, with changes evident as early as 1 day after beginning therapy. These observations provide a rationale for further exploration of these markers as measures of the adequacy of anticoagulation using classic as well as novel anticoagulants. Particular patient groups that would benefit from additional means of monitoring anticoagulation therapy are discussed.
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Affiliation(s)
- Craig P McFarland
- 1 Department of Medicine, School of Medicine, University of Colorado, Aurora, CO, USA.,2 Division of Hospital Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Stuart E Lind
- 1 Department of Medicine, School of Medicine, University of Colorado, Aurora, CO, USA.,3 Department of Pathology, School of Medicine, University of Colorado, Aurora, CO, USA
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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Identifying optimal heparin management during cardiopulmonary bypass in obese patients: A prospective observational comparative study. Eur J Anaesthesiol 2018; 33:408-16. [PMID: 26886138 DOI: 10.1097/eja.0000000000000431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The heparin regimen providing anticoagulation during cardiopulmonary bypass (CPB) is usually adapted to total body weight (TBW), but may be inaccurate in obese patients in whom TBW exceeds their ideal body weight. OBJECTIVES The objective is to compare the effects of heparin injection based on TBW on haemostatic parameters between obese and nonobese patients during cardiac surgery and to calculate the optimal heparin regimen. DESIGN Prospective comparative study. SETTING University hospital. PATIENTS Two groups of 50 patients (BMI≥ or <30 kg m) were included in the study over a 9-month period in 2013. The study started on 27 February 2013. INTERVENTIONS An unfractionated heparin (UFH) bolus of 300 IU kg TBW was injected before initiation of CPB followed by additional doses (50 to 100 IU kg) to maintain a target activated coagulation time (ACT) of at least 400 s. MAIN OUTCOME MEASURES ACT and plasma heparin concentration were measured at different time points after initiation of, and weaning from CPB. RESULTS Obese patients received higher initial and total doses of heparin (P < 0.0001). Plasma heparin concentrations were significantly higher in obese patients at each time point (P < 0.001) and reached very high values after the initial bolus (5.90 vs. 4.48 IU ml, P < 0.0001). The relationship between plasma heparin concentration and ACT after the initial bolus was not linear and followed an asymptotic regression curve. Haemoglobin concentration decreased intraoperatively to a greater extent in the obese group (P < 0.001). No significant differences in postoperative bleeding or global transfusion requirements were observed. CONCLUSION The standard heparin regimen based on TBW in obese patients during CPB results in excessive plasma heparin concentrations and a significant intraoperative decrease in haemoglobin concentration. ACT monitoring was not accurate in identifying this excess dosage. An initial bolus of 340 IU kg ideal body weight would achieve a heparin concentration of 4.5 IU ml, similar to that observed in nonobese patients. Further investigations are warranted to confirm this heparin regimen.
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Arachchillage DRJ, Kamani F, Deplano S, Banya W, Laffan M. Should we abandon the APTT for monitoring unfractionated heparin? Thromb Res 2017; 157:157-161. [PMID: 28759760 DOI: 10.1016/j.thromres.2017.07.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 06/23/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The activated partial thromboplastin time (APTT) is commonly used to monitor unfractionated heparin (UFH) but may not accurately measure the amount of heparin present. The anti-Xa assay is less susceptible to confounding factors and may be a better assay for this purpose. MATERIALS AND METHODS The validity of the APTT for monitoring UFH was assessed by comparing with an anti-Xa assay on 3543 samples from 475 patients (infants [n=165], children 1-15years [n=60] and adults [n=250]) receiving treatment dose UFH. RESULTS Overall concordance was poor. The highest concordance (66%; 168/254) was seen in children. Concordance (51.8%) or discordance (48.4%) was almost equal in adult patients. Among adult patients whose anti-Xa level was within 0.3-0.7IU/mL, only 38% had an APTT in the therapeutic range whilst 56% were below and 6% were above therapeutic range. Children and adult patients with anti-Xa of 0.3-0.7IU/mL but sub- therapeutic APTT had significantly higher fibrinogen levels compared to those with therapeutic or supra-therapeutic APTT. CONCLUSIONS When the anti-Xa level was 0.3-0.7IU/mL, the majority of samples from infants demonstrated a supra-therapeutic APTT, whilst adults tended to have a sub-therapeutic APTT. This may lead to under anticoagulation in infants or over anticoagulation in adults with risk of bleeding if APTT is used to monitor UFH. These results further strengthen existing evidence of the limitation of APTT in monitoring UFH. Discordance of APTT and anti-Xa level in adults and children may be due to elevation of fibrinogen level.
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Affiliation(s)
- D R J Arachchillage
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK; Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, London, UK.
| | - F Kamani
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - S Deplano
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - W Banya
- Department of Haematology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - M Laffan
- Department of Haematology, Imperial College Healthcare NHS Trust and Imperial College London, London, UK
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Burcham PK, Rozycki AJ, Abel EE. Considerations for analgosedation and antithrombotic management during extracorporeal life support. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:69. [PMID: 28275614 PMCID: PMC5337214 DOI: 10.21037/atm.2016.11.45] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 10/17/2016] [Indexed: 11/08/2023]
Abstract
Despite the immense growth in extracorporeal life support (ECLS) technology and experience, opportunity remains to better characterize the pharmacotherapeutic considerations during ECLS. Analgosedation can be particularly challenging in the ECLS population due to in drug-circuit interactions that may lead to decreased systemic concentrations and pharmacodynamic effect. ECLS also requires the use of antithrombotic agents to mitigate the prothrombotic state created by the artificial surface in the ECLS circuit. There are a number of coagulation monitoring tests available. However, optimal monitoring and management in ECLS has not been established. Heparin continues to be the anticoagulant of choice for most ECLS centers, however, there is growing interest in the use of parenteral direct thrombin inhibitors (DTI) in this population. Advances in understanding pharmacotherapeutic management have not kept up with the technological advances in this population. More investigation is warranted to gain a greater understanding of the pharmacotherapeutic implications, facilitate standardized evidence-based practices, and improve patient centered outcomes.
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Affiliation(s)
- Pamela K Burcham
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio 43210, USA
| | - Alan J Rozycki
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio 43210, USA
| | - Erik E Abel
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio 43210, USA
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Harenberg J. Laboratory determination of old and new targeted anticoagulant agents for prevention of bleeding and thrombotic events in cancer patients. Thromb Res 2017; 140 Suppl 1:S165-7. [PMID: 27067972 DOI: 10.1016/s0049-3848(16)30117-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A two-fold prolongation of activated partial thromboplastin time (APTT) is established as therapeutic range for therapy with unfractionated heparin, hirudin and argatroban. The international normalized ratio (INR) of 2 to 3 is required to maintain anticoagulation in the therapeutic range of vitamin K antagonists. The therapeutic range of anti-factor Xa activity during therapy with low-molecular weight heparins and danaparoid are less well and of direct oral anticoagulants (DOAC) poorly defined. The relation of aPTT and INR values to thrombotic and bleeding events are well established despite a large variation of values in affected patients. The relation of coagulation values of the other anticoagulants to clinical events is open. The value of determination in cancer patients is higher because of the increased risk for thrombotic and bleeding events of this patient group. Several activities are currently undertaken to certify methods for in vitro diagnostic testing for DAOCs.
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Affiliation(s)
- Job Harenberg
- Medical Faculty Mannheim, University of Heidelberg, Maybachstrasse 14, 68169 Mannheim, Germany.
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New Challenges in the Treatment of Patients With Left Ventricular Support: LVAD Thrombosis. Curr Heart Fail Rep 2016; 13:302-309. [DOI: 10.1007/s11897-016-0310-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ton VK, Eisenberger A, Jennings D, Colombo PC, Topkara VK. Relationship of hemolysis with discordance in paired activated partial thromboplastin time and anti-Factor Xa measurements in continuous-flow left ventricular assist device patients. J Heart Lung Transplant 2016; 35:1365-1367. [PMID: 27836024 DOI: 10.1016/j.healun.2016.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/01/2016] [Accepted: 09/07/2016] [Indexed: 11/26/2022] Open
Affiliation(s)
- Van-Khue Ton
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Andrew Eisenberger
- Department of Medicine, Division of Hematology and Oncology, Columbia University Medical Center, New York, New York, USA
| | - Douglas Jennings
- Department of Pharmacy, Columbia University Medical Center, New York, New York, USA
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA
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Coagulation factor abnormalities related to discordance between anti-factor Xa and activated partial thromboplastin time in patients supported with continuous-flow left ventricular assist devices. J Heart Lung Transplant 2016; 35:1311-1320. [DOI: 10.1016/j.healun.2016.09.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/07/2016] [Accepted: 09/16/2016] [Indexed: 11/20/2022] Open
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Samuel S, Allison TA, Sharaf S, Yau G, Ranjbar G, Mckaig N, Nguyen A, Escobar M, Choi HA. Antifactor Xa levels vs. activated partial thromboplastin time for monitoring unfractionated heparin. A pilot study. J Clin Pharm Ther 2016; 41:499-502. [PMID: 27381025 DOI: 10.1111/jcpt.12415] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/09/2016] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES The two most common methods for monitoring unfractionated heparin (UFH) infusion are the activated partial thromboplastin time (aPTT) and the antifactor Xa heparin assay (anti-Xa). The purpose of this study is to compare the performance of an aPTT protocol vs. an anti-Xa protocol in adult patients as defined by the time to reach therapeutic range, the percentage of time the values were within the goal range and the number of times laboratory monitoring was conducted. We then analysed the discordance between paired values of anti-Xa and aPTT. METHODS This was a single-centre prospective cohort pilot study conducted from 1 September 2013 to 31 May 2014. RESULTS Eighty-five patients were treated with UFH infusion, aPTT monitoring (n = 48), anti-Xa monitoring (n = 37). The number of times aPTT and anti-Xa values were ordered was (median, IQR) 14 (2-34) vs 7 (2-76); P = 0·23. The time to reach therapeutic range in hours was (mean, SD) 22 (20) aPTT vs 15 (13) anti-Xa; P = 0·08. Therapeutic range (>50-100% of the time) was achieved in only 5 (10%) patients in the aPTT group vs. 21 (57%) in the anti-Xa group; P < 0·01. Supratherapeutic values (>50-100%) were observed in 38 (78%) patients in the aPTT group vs. 14 (38%) in the anti-Xa group; P < 0·01. The discordance between aPTT and anti-Xa was evaluated using 234 paired values from 37 patients. There was discordance between anti-Xa and aPTT values 57% of the time. Two patients had bleeding complications requiring blood transfusion or discontinuation of post-pilot protocol. WHAT IS NEW AND CONCLUSION Utilizing an anti-Xa protocol to monitor heparin infusion showed favourable results compared with utilizing an aPTT protocol by maintaining values within the therapeutic goal range. The most common discordant pattern in our study was a disproportionate prolongation of aPTT to anti-Xa values. Patients with discordant values presenting with high aPTT to normal anti-Xa values may have an increased risk of bleeding complications.
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Affiliation(s)
- S Samuel
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - T A Allison
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - S Sharaf
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - G Yau
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - G Ranjbar
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - N Mckaig
- Department of Pharmacy, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - A Nguyen
- Department of Pathology and Laboratory Medicine, The University of Texas Medical School at Houston, Houston, TX, USA
| | - M Escobar
- Department of Hematology, The University of Texas Medical School at Houston, Houston, TX, USA
| | - H A Choi
- Department of Neurosurgery and Neurology, The University of Texas Medical School at Houston, Houston, TX, USA
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Abstract
Heart failure continues to be a worldwide epidemic, effecting over 23 million persons. Despite advances in medical therapy, the disease is progressive and a significant proportion of patients will need advanced heart replacement therapy. Continuous flow assist devices have become a standard approach for many patients both as a bridge to cardiac transplantation and as destination therapy (DT). However, device related complications such as bleeding and thrombosis continue to hinder further advancements of this technology. The field is rapidly advancing and efforts to reduce pump complications are directed towards improving hemocompatibility and maximizing blood flow without clinically significant hemolysis, areas of stasis or turbulent flow.
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Affiliation(s)
- Sirtaz Adatya
- 1 Department of Medicine, Cardiology Division, University of Chicago, Chicago, Illinois, USA ; 2 Department of Medicine, Minneapolis Heart Institute at Abbott Northwestern, Minneapolis, MN, USA
| | - Mosi K Bennett
- 1 Department of Medicine, Cardiology Division, University of Chicago, Chicago, Illinois, USA ; 2 Department of Medicine, Minneapolis Heart Institute at Abbott Northwestern, Minneapolis, MN, USA
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Susen S, Rauch A, Van Belle E, Vincentelli A, Lenting PJ. Circulatory support devices: fundamental aspects and clinical management of bleeding and thrombosis. J Thromb Haemost 2015; 13:1757-67. [PMID: 26302994 DOI: 10.1111/jth.13120] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/02/2015] [Indexed: 12/01/2022]
Abstract
Circulatory support devices are increasingly being used to overcome cardiac or respiratory failure. Long-term devices are used either as a 'bridge to transplant' to support patients who are unable to wait any longer for a heart transplant, or, more recently, as 'destination therapy' for older patients suffering from end-stage heart failure and who have contraindications to heart transplantation. Short-term support devices for high-risk percutaneous coronary intervention, or as a 'bridge for decision' for patients suffering from refractory cardiogenic shock, have also been developed. The clinical benefit of such assist devices has been demonstrated in several important studies, but, unfortunately, thrombotic and bleeding complications are two major clinical issues in patients requiring these devices. Overcoming these issues is of major importance to allow the safe and broad use of these devices, and to consider them as true alternatives to heart transplantation. The present review focuses on thrombotic and bleeding complications, and describes how the risk of thrombosis and bleeding may vary according to the clinical indication, but also according to the type of device. We describe the current knowledge of the mechanisms underlying the occurrence of these complications, provide some guidance for choosing the most appropriate anticoagulation regimen to prevent their occurrence for each type of device and indication, and provide some recommendations for the management of patients when the complication occurs.
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Affiliation(s)
- S Susen
- Department of Hematology and Transfusion, Lille University Hospital, Lille, France
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
| | - A Rauch
- Department of Hematology and Transfusion, Lille University Hospital, Lille, France
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
| | - E Van Belle
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
- Department of Cardiology, Lille University Hospital, Lille, France
| | - A Vincentelli
- Institut Pasteur de Lille, EGID, INSERM UMR 1011, University of Lille 2, Lille, France
- Department of Cardiology, Lille University Hospital, Lille, France
- Department of Cardiac Surgery, Lille University Hospital, Lille, France
| | - P J Lenting
- Inserm U1176 & UMR_S 1176, University Paris-Sud, Le Kremlin Bicêtre, France
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