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Scherlinger M, Guillotin V, Truchetet ME, Contin-Bordes C, Sisirak V, Duffau P, Lazaro E, Richez C, Blanco P. Systemic lupus erythematosus and systemic sclerosis: All roads lead to platelets. Autoimmun Rev 2018; 17:625-635. [PMID: 29635077 DOI: 10.1016/j.autrev.2018.01.012] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 01/18/2018] [Indexed: 01/13/2023]
Abstract
Systemic lupus erythematosus (SLE) and systemic sclerosis (SSc) are two phenotypically distincts inflammatory systemic diseases. However, SLE and SSc share pathogenic features such as interferon signature, loss of tolerance against self-nuclear antigens and increased tissue damage such as fibrosis. Recently, platelets have emerged as a major actor in immunity including auto-immune diseases. Both SLE and SSc are characterized by strong platelet system activation, which is likely to be both the witness and culprit in their pathogenesis. Platelet activation pathways are multiple and sometimes redundant. They include immune complexes, Toll-like receptors activation, antiphospholipid antibodies and ischemia-reperfusion associated with Raynaud phenomenon. Once activated, platelet promote immune dysregulation by priming interferon production by immune cells, providing CD40L supporting B lymphocyte functions and providing a source of autoantigens. Platelets are actively implicated in SLE and SSc end-organ damage such as cardiovascular and renal disease and in the promotion of tissue fibrosis. Finally, after understanding the main pathogenic implications of platelet activation in both diseases, we discuss potential therapeutics targeting platelets.
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Affiliation(s)
- Marc Scherlinger
- Service de Rhumatologie, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Vivien Guillotin
- Service de médecine interne, FHU ACRONIM, Hôpital Saint André, Centre Hospitalier Universitaire, 1 rue Jean Burguet, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Marie-Elise Truchetet
- Service de Rhumatologie, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Cécile Contin-Bordes
- Laboratoire d'Immunologie et Immunogénétique, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Vanja Sisirak
- Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Pierre Duffau
- Service de médecine interne, FHU ACRONIM, Hôpital Saint André, Centre Hospitalier Universitaire, 1 rue Jean Burguet, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Estibaliz Lazaro
- Laboratoire d'Immunologie et Immunogénétique, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Christophe Richez
- Service de Rhumatologie, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France
| | - Patrick Blanco
- Laboratoire d'Immunologie et Immunogénétique, FHU ACRONIM, Hôpital Pellegrin, Centre Hospitalier Universitaire, Place Amélie Raba Léon, 33076 Bordeaux, France; Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France; CNRS-UMR 5164, ImmunoConcept, Université de Bordeaux, 146 rue Léo Saignat, 33076 Bordeaux, France.
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Mellgren K, Friberg L, Hedner T, Mellgren G, Wadenvik H. Blood Platelet Activation and Membrane Glycoprotein Changes during Extracorporeal Life Support (Ecls). In Vitro Studies. Int J Artif Organs 2018. [DOI: 10.1177/039139889501800604] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to evaluate an in vitro model for investigation of platelet function parameters in an extracorporeal system. Two different perfusion pumps were compared, a roller pump (Polystan) and a centrifugal pump (Biomedicus). A continuous increase in glycoprotein (GP)1b-negative platelets was observed in both circuits. A marked increase of plasma β-thromboglobulin thromboglobulin concentration and a decrease of the intracellular pool of serotonin was observed, indicating a marked release of alpha as well as of dense granules. The plasma concentration of glycocalicin increased in parallel with a reduced platelet surface expression of GP1b, suggesting that the loss of GP1b is caused by proteolysis rather than by a downregulation of this receptor protein. It is concluded that ECLS results in a pronounced platelet degranulation and causes changes of important membrane receptors which might explain some of the bleeding problems observed in patients treated with ECLS. No significant difference was noted between the roller pump and the centrifugal pump. Trial of strategies, e.g. protease inhibitors and nitric oxide to revert this untoward effect of ECLS are highly warranted.
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Affiliation(s)
- K. Mellgren
- Department of Pediatric Surgery, Östra Hospital, University of Göteborg, Göteborg - Sweden
| | - L.G. Friberg
- Department of Pediatric Surgery, Östra Hospital, University of Göteborg, Göteborg - Sweden
| | - T. Hedner
- Department of Clinical Pharmacology, University of Göteborg, Göteborg - Sweden
| | - G. Mellgren
- Department of Pediatric Surgery, Östra Hospital, University of Göteborg, Göteborg - Sweden
| | - H. Wadenvik
- Department of Medicine, Sahlgrenska Hospital, University of Göteborg, Göteborg - Sweden
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Abstract
Heparin's anticoagulation effect makes it the principal component in the immediate treatment of all thrombotic diseases. After hemorrhage, the most important complication of heparin is thrombocytopenia, the decrease in the number of blood platelets. Ten cases of "heparin-induced thrombocytopenia" are described, and guidelines for diagnosing heparin-induced thrombocytopenia in patients who present for cardiac and vascular surgery are given. Methods of treating patients with heparin-induced thrombocytopenia, including use of arachidonic acid derivatives, antiplatelet agents, other anticoagulants, heparinoids, natural and synthetic thrombin inhibitors, hirudin, and defibrinogenation with ancrod, are discussed.
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Affiliation(s)
- David Cummins
- Departments of Haematology and Anaesthesia, Harefield Hospital, Harefield, Middlesex, United Kingdom
| | - Elaine Hill
- Departments of Haematology and Anaesthesia, Harefield Hospital, Harefield, Middlesex, United Kingdom
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Walenga JM, Fareed J, Bick RL, Pifarré R. New Anticoagulants for the Cardiovascular Patient. Clin Appl Thromb Hemost 2016. [DOI: 10.1177/107602969500100104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Manuscript received May 9, 1994; accepted July 7, 1994. Address correspondence and reprint requests to Dr. Jeanine M. Walenga, Department of Pathology, Loyola University Med ical Center, 2160 South First Avenue, Maywood, IL 60153, U.S.A. Summary: Invasive cardiac procedures and cardiac sur gery, which have become a significant component of health care, provide a particular case scenario where there are special considerations given to control bleeding and to have available alternative anticoagulants for pa tients unable to tolerate heparin (e.g., heparin-induced thrombocytopenia). We describe a comprehensive proto col for blood preservation in cardiac surgery incorporat ing the patient's medical history, autologous transfusions, and intraoperative techniques of heparin and protamine titration and dosing. Furthermore, various new anticoag ulants under clinical development are discussed, particu larly hirudin, hirulog, iloprost, ancrod, Lomoparan, low- molecular-weight heparins, 1-deamino-8-D-arginine- vasopressin (DDAVP), and aprotinin. These approaches should benefit the patient with difficult to control periop erative bleeding, heparin-induced thrombocytopenia, al lergic reactions to protamine, platelet dysfunction, and poor response to heparin (e.g., due to antithrombin III deficiency).
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Affiliation(s)
- Jeanine M. Walenga
- Department of Pathology, Loyola University Medical Center, Department of Thoracic and Cardiovascular Surgery, Hemostasis and Thrombosis Research Laboratories, Loyola University Medical Center, Maywood, Illinois
| | - Jawed Fareed
- Department of Pathology, Loyola University Medical Center
| | - Rodger L. Bick
- Department of Oncology,Presbyterian Hospital of Dallas, Dallas, Texas, U.S.A
| | - Roque Pifarré
- Department of Thoracic and Cardiovascular Surgery, Hemostasis and Thrombosis Research Laboratories, Loyola University Medical Center, Maywood, Illinois
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Palatianos G, Michalis A, Alivizatos P, Lacoumenda S, Geroulanos S, Karabinis A, Iliopoulou E, Soufla G, Kanthou C, Khoury M, Sfyrakis P, Stavridis G, Astras G, Vassili M, Antzaka C, Marathias K, Kriaras I, Tasouli A, Papadopoulos K, Katafygioti M, Matoula N, Angelidis A, Melissari E. Perioperative use of iloprost in cardiac surgery patients diagnosed with heparin-induced thrombocytopenia-reactive antibodies or with true HIT (HIT-reactive antibodies plus thrombocytopenia): An 11-year experience. Am J Hematol 2015; 90:608-17. [PMID: 25808486 DOI: 10.1002/ajh.24017] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 03/16/2015] [Accepted: 03/16/2015] [Indexed: 11/09/2022]
Abstract
Thrombocytopenia and thromboembolism(s) may develop in heparin immune-mediated thrombocytopenia (HIT) patients after reexposure to heparin. At the Onassis Cardiac Surgery Center, 530 out of 17,000 patients requiring heart surgery over an 11-year period underwent preoperative HIT assessment by ELISA and a three-point heparin-induced platelet aggregation assay (HIPAG). The screening identified 110 patients with HIT-reactive antibodies, out of which 46 were also thrombocytopenic (true HIT). Cardiac surgery was performed in HIT-positive patients under heparin anticoagulation and iloprost infusion. A control group of 118 HIT-negative patients received heparin but no iloprost during surgery. For the first 20 patients, the dose of iloprost diminishing the HIPAG test to ≤5% was determined prior to surgery by in vitro titration using the patients' own plasma and donor platelets. In parallel, the iloprost "target dose" was also established for each patient intraoperatively, but before heparin administration. Iloprost was infused initially at 3 ng/kg/mL and further adjusted intraoperatively, until ex vivo aggregation reached ≤5%. As a close correlation was observed between the "target dose" identified before surgery and that established intraoperatively, the remaining 90 patients were administered iloprost starting at the presurgery identified "target dose." This process significantly reduced the number of intraoperative HIPAG reassessments needed to determine the iloprost target dose, and reduced surgical time, while maintaining similar primary clinical outcomes to controls. Therefore, infusion of iloprost throughout surgery, under continuous titration, allows cardiac surgery to be undertaken safely using heparin, while avoiding life-threatening iloprost-induced hypotension in patients diagnosed with HIT-reactive antibodies or true HIT.
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Affiliation(s)
- George Palatianos
- 3rd Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - Alkiviadis Michalis
- 2nd Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - Petros Alivizatos
- 1st Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | | | | | | | - Eugenia Iliopoulou
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
| | - Giannoula Soufla
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
| | - Chryso Kanthou
- Department of Oncology, School of Medicine; University of Sheffield; Sheffield United Kingdom
| | - Mazen Khoury
- 2nd Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - Petros Sfyrakis
- 1st Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - George Stavridis
- 1st Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - George Astras
- 3rd Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - Maria Vassili
- Department of Anaesthesiology; Onassis Cardiac Surgery Center; Athens Greece
| | - Christina Antzaka
- Department of Anaesthesiology; Onassis Cardiac Surgery Center; Athens Greece
| | | | - Ioannis Kriaras
- Intensive Care Unit, Onassis Cardiac Surgery Center; Athens Greece
| | | | | | - Marina Katafygioti
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
| | - Nikoletta Matoula
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
| | - Antonios Angelidis
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
| | - Euthemia Melissari
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
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6
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Beirne C, Hynes N, Sultan S. Six Years' Experience with Prostaglandin I2 Infusion in Elective Open Repair of Abdominal Aortic Aneurysm: A Parallel Group Observational Study in a Tertiary Referral Vascular Center. Ann Vasc Surg 2008; 22:750-5. [DOI: 10.1016/j.avsg.2008.08.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Revised: 08/28/2008] [Accepted: 08/29/2008] [Indexed: 10/21/2022]
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7
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Greinacher A, Warkentin TE. Treatment of Heparin-Induced Thrombocytopenia: An Overview. HEPARIN-INDUCED THROMBOCYTOPENIA 2007. [DOI: 10.3109/9781420045093.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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8
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Hsu HH, Rubin LJ. Iloprost inhalation solution for the treatment of pulmonary arterial hypertension. Expert Opin Pharmacother 2006; 6:1921-30. [PMID: 16144511 DOI: 10.1517/14656566.6.11.1921] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a condition that is characterised by increased pulmonary arterial pressure and vascular resistance that can lead to right ventricular failure and death. A variety of disturbances in pulmonary vascular endothelial and smooth muscle function are present in PAH, including reduced production of vasodilator and antiproliferative substances, such as nitric oxide and prostacyclin, and an overproduction of mitogens, such as endothelin. As a result of these observations, therapies have been developed for PAH that specifically target these pathogenic processes, including prostacyclin analogues and endothelin receptor antagonists. This article reviews iloprost inhalation solution, the most recently approved form of prostacyclin therapy that is delivered directly to the lungs by inhalation.
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Affiliation(s)
- Henry H Hsu
- CoTherix, Inc., 5000 Shoreline Court, San Francisco, CA 94080, USA
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9
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Palatianos GM, Foroulis CN, Vassili MI, Matsouka P, Astras GM, Kantidakis GH, Iliopoulou E, Melissari EN. Preoperative detection and management of immune heparin-induced thrombocytopenia in patients undergoing heart surgery with iloprost. J Thorac Cardiovasc Surg 2004; 127:548-54. [PMID: 14762367 DOI: 10.1016/j.jtcvs.2003.08.042] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate our protocol for the identification and management of patients with immune heparin-induced thrombocytopenia undergoing cardiac surgery. METHODS Among 1518 patients who underwent cardiac surgery between June 1998 and May 2001, 32 (2.1%) presented with platelet counts less than 150,000/mm3 preoperatively or a history of prolonged (>3 days) intravenous exposure to heparin or both. These 32 patients were evaluated with an enzyme-linked immunosorbent assay for antibodies against heparin-platelet factor 4 complex. Platelets of patients with detected antibodies were tested with the prostacyclin analog iloprost for inhibition of heparin aggregation and determination of the inhibiting concentration and corresponding intravenous infusion rate of iloprost. Patients with antibodies received heparin after complete platelet inhibition with iloprost infusion. Hypotension was prevented or treated with intravenous noradrenaline. Ten randomly selected patients with similar preoperative characteristics, no previous extended exposure to heparin, and normal platelet counts served as controls. RESULTS Ten of the 32 patients (group A, 31.3%) and none of the controls had antibodies against heparin-platelet factor 4 complex. Patients in group A underwent surgery with iloprost (6-24 ng.kg(-1).min(-1)) and had their blood pressure maintained at greater than 95 mm Hg with norepinephrine infusion (1-4 microg.kg(-1).min(-1)). Operative mortality was zero. There were no thrombotic complications or bleeding requiring exploration. One patient in group A bled 1310 mL/6 hours but did not need exploration. There was no difference in postoperative blood loss and morbidity between groups. Platelet counts were reduced by 12.5% +/- 8.7% (group A) and 38.1% +/- 15.2% (control) (P <.001) 1 hour postoperatively and reached preoperative values by the fifth postoperative day. CONCLUSIONS Immune heparin-induced thrombocytopenia can be detected preoperatively among patients with a low platelet count or a history of prolonged heparin exposure or both. Cardiac surgery can be safely undertaken using iloprost-induced platelet inhibition during heparinization.
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Affiliation(s)
- George M Palatianos
- Third Department of Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece.
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10
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Walenga JM, Frenkel EP, Bick RL. Heparin-induced thrombocytopenia, paradoxical thromboembolism, and other adverse effects of heparin-type therapy. Hematol Oncol Clin North Am 2003; 17:259-82, viii-ix. [PMID: 12627671 DOI: 10.1016/s0889-8588(02)00088-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article discusses the common and uncommon side effects of heparin and heparin-like therapy. Most attention is devoted to heparin-induced thrombocytopenia, as it is the most clinically aggressive adverse reaction. Additionally, less common and several newly reported side effects are discussed.
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Affiliation(s)
- Jeanine M Walenga
- Department of Thoracic-Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL 60153, USA.
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11
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Tanhehco EJ, Kilgore KS, Naylor KB, Park JL, Booth EA, Lucchesi BR. Reduction of myocardial infarct size after ischemia and reperfusion by the glycosaminoglycan pentosan polysulfate. J Cardiovasc Pharmacol 1999; 34:153-61. [PMID: 10413082 DOI: 10.1097/00005344-199907000-00024] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Activation of the complement system contributes to the tissue destruction associated with myocardial ischemia/reperfusion. Pentosan polysulfate (PPS), a negatively charged sulfated glycosaminoglycan (GAG) and an effective inhibitor of complement activation, was studied for its potential to decrease infarct size in an experimental model of myocardial ischemia/reperfusion injury. Open-chest rabbits were subjected to 30-min occlusion of the left coronary artery followed by 5 h of reperfusion. Vehicle (saline) or PPS (30 mg/kg/h) was administered intravenously immediately before the onset of reperfusion and every hour during the reperfusion period. Treatment with PPS significantly (p < 0.05) reduced infarct size as compared with vehicle-treated animals (27.5+/-2.9% vs. 13.34+/-2.6%). Analysis of tissue demonstrated decreased deposition of membrane-attack complex and neutrophil accumulation in the area at risk. The results indicate that, like heparin and related GAGs, PPS possesses the ability to decrease infarct size after an acute period of myocardial ischemia and reperfusion. The observations are consistent with the suggestion that PPS may mediate its cytoprotective effect through modulation of the complement cascade.
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Affiliation(s)
- E J Tanhehco
- Department of Pharmacology, University of Michigan Medical School, Ann Arbor 48109-0632, USA
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12
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Tardy/Poncet B, Mahul P, Beraud AM, Favre JP, Tardy B, Guyotat D. Failure of Orgaran therapy in a patient with a previous heparin-induced thrombocytopenia syndrome. Br J Haematol 1995; 90:969-70. [PMID: 7669684 DOI: 10.1111/j.1365-2141.1995.tb05229.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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13
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Ceriana P, Maurelli M, Locatelli A, Bianchi T, Chiaudani G, Domenegati E, Pagnin A. Pseudomyxoma of the right atrium in a patient with heparin-associated thrombocytopenia and antiphospholipid antibodies. J Cardiothorac Vasc Anesth 1995; 9:308-11. [PMID: 7545451 DOI: 10.1016/s1053-0770(05)80327-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- P Ceriana
- Department of Anesthesia and Intensive Care 1, IRCCS Policlinico San Matteo, Pavia, Italy
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14
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Dietrich W, Barankay A, Hähnel C, Richter JA. High-dose aprotinin in cardiac surgery: three years' experience in 1,784 patients. J Cardiothorac Vasc Anesth 1992; 6:324-7. [PMID: 1377036 DOI: 10.1016/1053-0770(92)90150-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The effect of the proteinase-inhibitor aprotinin on blood loss and homologous blood requirement in cardiac surgery was investigated. In a prospective study, 902 adult patients were treated with high-dose aprotinin (total greater than 5 x 10(6) kallikrein inactivator units [KIU]; group A), while 882 patients without aprotinin administration served as the controls (group C). Both groups were operated on between January 1987 and October 1989, and included patients with primary coronary artery bypass grafting (n = 525 group C, n = 560 group A), valve replacement (n = 292 group C, n = 264 group A), or combined procedures (n = 65 group C, n = 78 group A), as well as cardiac reoperations (n = 91 group C, n = 110 group A). The average blood loss 36 hours postoperatively in the aprotinin group was 679 +/- 419 mL, compared with 1,038 +/- 671 mL in the control group (P less than 0.05). Total homologous blood requirement was also significantly less in group A (942 +/- 1,630 mL) compared with group C (1,999 +/- 2,283 mL) (P less than 0.05), a reduction of 53%. Serum creatinine concentrations did not show intergroup differences on the first postoperative day (group A, 1.2 +/- 0.7; group C, 1.3 +/- 0.5 mg/dL) or on discharge from the intensive care unit (ICU). Thus, impairment of renal function as a consequence of aprotinin treatment was not observed. Three patients developed signs of mild circulatory depression after injection of aprotinin, which responded promptly to vasopressor therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- W Dietrich
- Institute for Anesthesiology, Department of Cardiovascular Surgery, Munich, Germany
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15
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16
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Harder MP, Eijsman L, Roozendaal KJ, van Oeveren W, Wildevuur CR. Aprotinin reduces intraoperative and postoperative blood loss in membrane oxygenator cardiopulmonary bypass. Ann Thorac Surg 1991; 51:936-41. [PMID: 1710098 DOI: 10.1016/0003-4975(91)91009-k] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
To determine whether aprotinin can provide a significant improvement of hemostasis in cardiopulmonary bypass using a membrane oxygenator, we tested this drug in a prospective, randomized, double-blind, placebo-controlled clinical trial. The subjects were 80 male patients undergoing cardiopulmonary bypass for coronary artery bypass grafting. Forty patients received aprotinin and 40 patients served as placebo controls. Aprotinin (4 x 10(6) KIU) was given as a continuous infusion, starting before operation and continuing until after cardiopulmonary bypass; additionally, 2 x 10(6) KIU aprotinin was added to the pump prime. Intraoperative and postoperative bleeding, respectively two thirds and one third of the total perioperative blood loss, were both significantly reduced in the aprotinin-treated group (p less than 0.01). The total average perioperative blood loss, corrected to a hemoglobin concentration of 7 mmol/L, was 550 mL in the aprotinin-treated patients versus 900 mL in the control patients. This reduction in blood loss, furthermore, significantly decreased the amount of postoperative blood transfusions (p less than 0.05) and increased the percentage of patients who did not receive postoperative donor blood from 42% to 68%. Aprotinin increased the activated clotting time significantly during cardiopulmonary bypass, which led to a reduction in heparin usage. The improved hemostasis during operation, despite the prolonged activated clotting time, might even abolish the need for heparin conversion with protamine at the end of cardiopulmonary bypass, thus allowing retransfusion through cardiotomy suction to be continued, which saves the blood that is currently lost with vacuum suction.
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Affiliation(s)
- M P Harder
- Department of Cardiopulmonary Surgery, University Hospital, Groningen, The Netherlands
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18
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Dieck JA, Rizo-Patron C, Unisa A, Mathur V, Massumi GA. A new manifestation and treatment alternative for heparin-induced thrombosis. Chest 1990; 98:1524-6. [PMID: 2123154 DOI: 10.1378/chest.98.6.1524] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
We treated a coronary artery bypass patient whose postoperative course was complicated by heparin-induced thrombocytopenia and resultant pulmonary artery and saphenous vein graft thromboses. The pulmonary thromboemboli were found first, and pulmonary blood flow was restored with intravenously administered tissue plasminogen activator (tPA). A short time later, the vein grafts were found to be occluded, and we subsequently performed multivessel percutaneous transluminal coronary angioplasty (PTCA) using tPA as an adjuvant to oral warfarin sodium therapy with excellent results. We conclude that heparin-induced thromboses in the pulmonary arteries are amenable to thrombolytic therapy, including tPA, whereas this regimen appears to have little effect on saphenous vein grafts. We also found that a combination of warfarin and thrombolytic therapy is an alternative regimen for heparin-intolerant patients who require PTCA.
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Affiliation(s)
- J A Dieck
- Division of Adult Cardiology, Texas Heart Institute, Houston
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de Smet AA, Njoek Joen MC, Oeveren WV, Roozendaal KJ, Harder MP, Eijsman L, Wildevuur CR. Increased anticoagulation during cardiopulmonary bypass by aprotinin. J Thorac Cardiovasc Surg 1990. [DOI: 10.1016/s0022-5223(19)35496-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kappa JR, Fisher CA, Todd B, Stenach N, Bell P, Campbell F, Ellison N, Addonizio VP. Intraoperative management of patients with heparin-induced thrombocytopenia. Ann Thorac Surg 1990; 49:714-22; discussion 723. [PMID: 1692679 DOI: 10.1016/0003-4975(90)90008-t] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
For 11 patients with confirmed heparin-induced thrombocytopenia, we used reversible platelet inhibition with iloprost, a stable prostacyclin analogue, to permit safe heparin administration for cardiac (n = 9) or vascular (n = 2) operations. In vitro, iloprost (0.01 mumol/L) prevented both heparin-induced platelet aggregation and 14C-serotonin release in all patients. Therefore, intraoperatively, a continuous infusion of iloprost was started before administration of heparin and was continued until 15 minutes after administration of protamine. For cardiac patients, after heparin administration, the whole blood platelet count did not change (171,000 +/- 29,000/microL versus 174,000 +/- 29,000/microL, mean +/- standard error of the mean); no spontaneous platelet aggregation was observed, and plasma levels of the alpha-granule constituents platelet factor 4 and beta-thromboglobulin increased from 38 +/- 14 and 140 +/- 18 ng/mL to 591 +/- 135 and 235 +/- 48 ng/mL, respectively. Fibrinopeptide A levels actually decreased from 287 +/- 150 to 27 +/- 6 ng/mL. Furthermore, adenosine diphosphate-induced platelet activation was preserved, postoperative bleeding times were unchanged, and no heparin-related deaths occurred. Similar results were obtained in both vascular patients. We conclude that temporary platelet inhibition with iloprost now permits safe heparin administration in all patients with heparin-induced thrombocytopenia who require a cardiac or vascular operation.
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Affiliation(s)
- J R Kappa
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
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21
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Moberg PQ, Geary VM, Sheikh FM. Heparin-induced thrombocytopenia: a possible complication of heparin-coated pulmonary artery catheters. JOURNAL OF CARDIOTHORACIC ANESTHESIA 1990; 4:226-8. [PMID: 2131870 DOI: 10.1016/0888-6296(90)90242-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- P Q Moberg
- Department of Anesthesiology, Albany Medical Center, NY
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van Oeveren W, Wildevuur CR, Kazatchkine MD. Biocompatibility of extracorporeal circuits in heart surgery. TRANSFUSION SCIENCE 1989; 11:5-33. [PMID: 10171165 DOI: 10.1016/0955-3886(90)90004-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- W van Oeveren
- Department of Cardiopulmonary Surgery, University Hospital Groningen, The Netherlands
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23
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Cottrell ED, Kappa JR, Stenach N, Fisher CA, Tuszynski GP, Switalska HI, Addonizio VP. Temporary inhibition of platelet function with iloprost (ZK36374) preserves canine platelets during extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 1988. [DOI: 10.1016/s0022-5223(19)35205-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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