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Wang L, Hao F, Tian S, Dong H, Nie J, Ma G. Targeting polysaccharides such as chitosan, cellulose, alginate and starch for designing hemostatic dressings. Carbohydr Polym 2022; 291:119574. [DOI: 10.1016/j.carbpol.2022.119574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 12/21/2022]
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2
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Wang JK, Li Y, Zhao XL, Liu YB, Tan J, Xing YY, Adi D, Wang YT, Fu ZY, Ma YT, Liu SM, Liu Y, Wang Y, Shi XJ, Lu XY, Song BL, Luo J. Ablation of Plasma Prekallikrein Decreases LDL Cholesterol by Stabilizing LDL Receptor and Protects against Atherosclerosis. Circulation 2022; 145:675-687. [PMID: 35189703 DOI: 10.1161/circulationaha.121.056491] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: High blood cholesterol accelerates the progression of atherosclerosis that is an asymptomatic process lasting for decades. Rupture of atherosclerotic plaques induces thrombosis that results in myocardial infarction or stroke. Lowering cholesterol levels is beneficial for preventing atherosclerotic cardiovascular disease (ASCVD). Methods: Low-density lipoprotein (LDL) receptor (LDLR) was used as the bait to identify its binding proteins in the plasma, and the coagulation factor prekallikrein (PK, encoded by the KLKB1 gene) was revealed. The correlation between serum PK protein content and lipid levels in young Chinese Han was then analyzed. To investigate the effects of PK ablation on LDLR and lipid levels in vivo, we genetically deleted Klkb1 in hamsters and heterozygous Ldlr knockout mice, as well as knocked Klkb1 down using adeno-associated virus-mediated shRNA in rats. The additive effect of PK and PCSK9 inhibition was evaluated as well. We also applied the anti-PK neutralizing antibody that blocked PK and LDLR interaction to mice. Mice lacking both PK and Apolipoprotein e (Klkb1-/-Apoe-/-) were generated to assess the role of PK in atherosclerosis. Results: PK directly bound LDLR and induced its lysosomal degradation. The serum PK concentrations positively correlated with LDL cholesterol levels in 198 young Chinese Han adults. Genetic depletion of Klkb1 increased hepatic LDLR and decreased circulating cholesterol in multiple rodent models. Inhibition of PCSK9 with Evolocumab further decreased plasma LDL cholesterol levels in Klkb1-deficient hamsters. The anti-PK neutralizing antibody could similarly lower plasma lipids through upregulating hepatic LDLR. Ablation of Klkb1 slowed down the progression of atherosclerosis in mice on Apoe-deficient background. Conclusions: PK regulates circulating cholesterol levels through binding to LDLR and inducing its lysosomal degradation. Ablation of PK stabilizes LDLR, decreases LDL cholesterol and prevents atherosclerotic plaque development. This study suggests that PK is a promising therapeutic target to treat ASCVD.
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Affiliation(s)
- Jin-Kai Wang
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
| | - Yang Li
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiao-Lu Zhao
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
| | - Yuan-Bin Liu
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
| | - Jing Tan
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
| | - Yu-Ying Xing
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
| | - Dilare Adi
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yong-Tao Wang
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Zhen-Yan Fu
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yi-Tong Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Song-Mei Liu
- Department of Clinical Laboratory, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yong Liu
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
| | - Yan Wang
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
| | - Xiong-Jie Shi
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
| | - Xiao-Yi Lu
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
| | - Bao-Liang Song
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
| | - Jie Luo
- The Institute for Advanced Studies, Hubei Key Laboratory of Cell Homeostasis, College of Life Sciences, TaiKang Center for Life and Medical Sciences, TaiKang Medical School, Wuhan University, Wuhan, China
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Terent’eva VA, Sveshnikova AN, Panteleev MA. Biophysical mechanisms of contact activation of blood-plasma clotting. Biophysics (Nagoya-shi) 2017. [DOI: 10.1134/s0006350917050232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Lopez M, Feng C, Vasilyeva O, Eaton MP. Supplemental Antithrombin Is Effective in Achieving Adequate Anticoagulation in Infants and Children With an Inadequate Response to Heparin. J Cardiothorac Vasc Anesth 2017; 31:896-900. [DOI: 10.1053/j.jvca.2016.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Indexed: 01/19/2023]
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Grima C. The effects of intermittent prebypass heparin dosing in patients undergoing coronary artery bypass grafting. Perfusion 2016; 18:283-9. [PMID: 14604244 DOI: 10.1191/0267659103pf668oa] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this study, 10 patients (Group B) were given three consecutive prebypass doses of heparin (100 IU/kg) with a 4 min interval prior to cardiopulmonary bypass (CPB) institution. They were compared with 10 patients (Group A) receiving the standard single prebypass heparin dose (300 IU/kg). The haemostatic response and anticoagulant monitoring during the perioperative period were investigated by point-of-care and several coagulation tests. Results of both groups were also correlated to blood loss. Three patients in Group B required additional heparin during bypass as compared with six patients in Group A. This suggests that intermittent prebypass heparin dosing is more effective in maintaining adequate levels of anticoagulation during CPB. Group B had a lower mean decrease in factor VIII (13.9% versus 43.2%), fibrinogen (38.5% versus 46.6%), antithrombin III (34.7% versus 40.1%) and platelet count (23.2% versus 28.9%) during bypass while only one unit of red cell concentrate was required postoperatively as compared with four units in Group A. In one patient, high fibrinolytic assays were associated with a haemorrhagic pericardial effusion occurring beyond 24 hours postsurgery.
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Affiliation(s)
- Carmel Grima
- Haematology Section, Department of Pathology, St. Luke's Hospital, G'Mangia, Malta.
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Szymusiak M, Donovan AJ, Smith SA, Ransom R, Shen H, Kalkowski J, Morrissey JH, Liu Y. Colloidal Confinement of Polyphosphate on Gold Nanoparticles Robustly Activates the Contact Pathway of Blood Coagulation. Bioconjug Chem 2015; 27:102-9. [DOI: 10.1021/acs.bioconjchem.5b00524] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Stephanie A. Smith
- Department
of Biochemistry, University of Illinois at Urbana−Champaign, Urbana, Illinois 61801, United States
| | | | | | | | - James H. Morrissey
- Department
of Biochemistry, University of Illinois at Urbana−Champaign, Urbana, Illinois 61801, United States
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Discriminatory power of the intraoperative cell salvage use in the prediction of platelet and plasma transfusion in patients undergoing cardiac surgery. Transfus Apher Sci 2015; 53:208-12. [DOI: 10.1016/j.transci.2015.03.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 11/20/2022]
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8
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Enzymes produced by autoactivation of blood factor XII in buffer. Biomaterials 2015; 37:1-12. [DOI: 10.1016/j.biomaterials.2014.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 09/15/2014] [Indexed: 10/24/2022]
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Bønding Andreasen J, Hvas AM, Ravn HB. Marked changes in platelet count and function following pediatric congenital heart surgery. Paediatr Anaesth 2014; 24:386-92. [PMID: 24471808 DOI: 10.1111/pan.12347] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Reduced hemostatic capacity is common following congenital heart surgery using cardiopulmonary bypass (CPB). The etiology is multifactorial with dilutional coagulopathy, as well as platelet adhesion and activation in the CPB circuit and oxygenator. The purpose of the present study was to evaluate platelet count and function in children following CPB. METHODS In a prospective, observational study comprising 40 children, platelet count and function (Multiplate Analyzer(®)) were measured before surgery, immediately after bypass, and on the first postoperative day. Furthermore, conventional coagulation analysis and thromboelastometry (ROTEM(®)) were carried out. RESULTS A significant decrease in platelet count was observed immediately after coming of bypass (P < 0.001) and persisted to the first postoperative day (P = 0.002). Platelet function was reduced immediately after bypass after induction with ADP (P < 0.001) or TRAP (P = 0.03). The duration of CPB correlated significantly with the decrease in platelet count (r = -0.62, P = 0.0001) and reduction in platelet function (r = -0.42-0.63; P < 0.01). Moderate to deep hypothermia during CPB was associated with a decreased platelet function (P = 0.01-0.12), whereas cyanosis or previous heart surgery caused no further changes in platelet function following CPB. CONCLUSION Both platelet count and platelet function were significantly reduced after CPB in children undertaken correctional heart surgery. Duration of CPB and hypothermia was associated with significant changes in platelet function.
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Affiliation(s)
- Jo Bønding Andreasen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
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Li Y, Liao X, Liu P, Shang X, Ma G, Chen H, Fan J. Surface group mediates the adsorption of in situ generated thrombin and its interaction with anti-thrombin in the protein corona of SBA-15. RSC Adv 2014. [DOI: 10.1039/c4ra02106a] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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11
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Chow BA, Donahue SW, Vaughan MR, McConkey B, Vijayan MM. Serum immune-related proteins are differentially expressed during hibernation in the American black bear. PLoS One 2013; 8:e66119. [PMID: 23825529 PMCID: PMC3692520 DOI: 10.1371/journal.pone.0066119] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 05/01/2013] [Indexed: 11/23/2022] Open
Abstract
Hibernation is an adaptation to conserve energy in the face of extreme environmental conditions and low food availability that has risen in several animal phyla. This phenomenon is characterized by reduced metabolic rate (∼25% of the active basal metabolic rate in hibernating bears) and energy demand, while other physiological adjustments are far from clear. The profiling of the serum proteome of the American black bear (Ursus americanus) may reveal specific proteins that are differentially modulated by hibernation, and provide insight into the remarkable physiological adaptations that characterize ursid hibernation. In this study, we used differential gel electrophoresis (DIGE) analysis, liquid chromatography coupled to tandem mass spectrometry, and subsequent MASCOT analysis of the mass spectra to identify candidate proteins that are differentially expressed during hibernation in captive black bears. Seventy serum proteins were identified as changing by ±1.5 fold or more, out of which 34 proteins increased expression during hibernation. The majority of identified proteins are involved in immune system processes. These included α2-macroglobulin, complement components C1s and C4, immunoglobulin μ and J chains, clusterin, haptoglobin, C4b binding protein, kininogen 1, α2-HS-glycoprotein, and apoplipoproteins A-I and A-IV. Differential expression of a subset of these proteins identified by proteomic analysis was also confirmed by immunodetection. We propose that the observed serum protein changes contribute to the maintenance of the hibernation phenotype and health, including increased capacities for bone maintenance and wound healing during hibernation in bears.
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Affiliation(s)
- Brian A. Chow
- Department of Biology, University of Waterloo, Waterloo, Ontario, Canada
| | - Seth W. Donahue
- Department of Mechanical Engineering, Colorado State University, Fort Collins, Colorado, United States of America
| | - Michael R. Vaughan
- Department of Fish and Wildlife Conservation, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, United States of America
| | - Brendan McConkey
- Department of Biology, University of Waterloo, Waterloo, Ontario, Canada
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Abstract
BACKGROUND Successful management of bleeding disorders after congenital heart surgery requires detection of specific coagulation disturbances. Whole-blood rotation thromboelastometry (RoTEM®) provides continuous qualitative haemostatic profiles, and the technique has shown promising results in adult cardiac surgery. SETTING To compare the performance of RoTEM® with that of conventional coagulation tests in children, we conducted a descriptive study in children undergoing congenital cardiac surgery. For that purpose, 60 children were enrolled and had blood samples taken before, immediately after, and 1 day after surgery. Conventional coagulation tests included: activated partial thromboplastin time, prothrombin time, fibrinogen, fibrin D-dimer, thrombin clotting time, factor XIII, and platelet count. RESULTS Post-surgical haemostatic impairment was present to some degree in all children, as seen by pronounced changes in activated partial thromboplastin time, prothrombin time, thrombin clotting time, and platelet count, as well as RoTEM® analysis. RoTEM® showed marked changes in clotting time - prolonged by 7-18% - clot formation time - prolonged by 46-71% - maximum clot firmness - reduced by 10-19%, and maximum velocity - reduced by 29-39%. Comparison of the two techniques showed that conventional coagulation tests and RoTEM® performed equally well with regard to negative predictive values for excessive post-operative drain production - more than 20 millilitres per kilogram per 24 hours after surgery - with an area under the curve of approximately 0.65. CONCLUSION RoTEM® can detect haemostatic impairments in children undergoing cardiac surgery and the method should be considered as a supplement in the perioperative care of the children where targeted transfusion therapy is necessary to avoid volume overload.
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Makar M, Taylor J, Zhao M, Farrohi A, Trimming M, D’Attellis N. Perioperative Coagulopathy, Bleeding, and Hemostasis During Cardiac Surgery. ACTA ACUST UNITED AC 2010. [DOI: 10.1177/1944451609357759] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac surgery patients use 10%-25% of the blood products transfused annually in the United States. The transfusion of red blood cells or blood products has been the subject of intense scrutiny over the past 10 years. Bleeding after cardiac surgery can be surgical or nonsurgical and lead to hemodynamic compromise and surgical reexploration. Because hemorrhage and blood product transfusions are associated with multiple negative outcomes, including increased mortality, it is prudent to understand the mechanisms responsible for nonsurgical bleeding. This review focuses on the physiology of the normal coagulation and fibrinolysis, risk factors associated with patients presenting for cardiac surgery, impairments of normal hemostasis associated with cardiac surgery and cardiopulmonary bypass (CPB), and potential interventions to reduce perioperative blood loss and blood transfusion.
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Affiliation(s)
- Moody Makar
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jamie Taylor
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Maxnu Zhao
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ali Farrohi
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Trimming
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicola D’Attellis
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
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Despotis G, Eby C, Lublin DM. A review of transfusion risks and optimal management of perioperative bleeding with cardiac surgery. Transfusion 2008; 48:2S-30S. [PMID: 18302579 DOI: 10.1111/j.1537-2995.2007.01573.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- George Despotis
- Departments of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri 63110, USA.
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15
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Plasma kallikrein is activated on dermatan sulfate and cleaves factor H. Biochem Biophys Res Commun 2008; 370:646-50. [DOI: 10.1016/j.bbrc.2008.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Accepted: 04/07/2008] [Indexed: 11/21/2022]
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Abstract
Hemostasis and fibrinolysis, the biological processes that maintain proper blood flow, are the consequence of a complex series of cascading enzymatic reactions. Serine proteases involved in these processes are regulated by feedback loops, local cofactor molecules, and serine protease inhibitors (serpins). The delicate balance between proteolytic and inhibitory reactions in hemostasis and fibrinolysis, described by the coagulation, protein C and fibrinolytic pathways, can be disrupted, resulting in the pathological conditions of thrombosis or abnormal bleeding. Medicine capitalizes on the importance of serpins, using therapeutics to manipulate the serpin-protease reactions for the treatment and prevention of thrombosis and hemorrhage. Therefore, investigation of serpins, their cofactors, and their structure-function relationships is imperative for the development of state-of-the-art pharmaceuticals for the selective fine-tuning of hemostasis and fibrinolysis. This review describes key serpins important in the regulation of these pathways: antithrombin, heparin cofactor II, protein Z-dependent protease inhibitor, alpha(1)-protease inhibitor, protein C inhibitor, alpha(2)-antiplasmin and plasminogen activator inhibitor-1. We focus on the biological function, the important structural elements, their known non-hemostatic roles, the pathologies related to deficiencies or dysfunction, and the therapeutic roles of specific serpins.
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Affiliation(s)
- J C Rau
- Department of Pathology and Laboratory Medicine, Carolina Cardiovascular Biology Center, School of Medicine, University of North Carolina, Chapel Hill, NC 27599-7035, USA.
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Schinzel H, Berghoff K, Beuermann I, Sauer O, von Mach MA, Weilemann LS. Anticoagulation with low-molecular-weight heparin (dalteparin) in plasmapheresis therapy: initial experience. Transfusion 2006; 46:624-9. [PMID: 16584439 DOI: 10.1111/j.1537-2995.2006.00755.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND In contrast to other extracorporeal treatments no established regime exists for anticoagulation with low-molecular-weight heparin (LMWH) in plasmapheresis therapy. A study was conducted to investigate whether LMWH (dalteparin-Na) is suitable as an effective anticoagulant in plasmapheresis therapy. STUDY DESIGN AND METHODS Eleven patients with autoimmune neurological diseases and the necessity for a plasmapheresis therapy were enrolled. A capillary membrane filter was used. A total of 2000 mL of human plasma was isovolumetrically exchanged per plasmapheresis cycle. The anticoagulation was accomplished with a single bolus of LMWH (dalteparin) of 80 to 90 IU per kg of body weight. The system was visually monitored. Anti-factor (F)Xa activity, thrombin-antithrombin III complex (TAT), and prothrombin fragment 1+2 (F 1+2) were determined at regular intervals. Samples were taken from the collected plasma pool to determine the loss of LMWH during the plasmapheresis procedure. RESULTS All plasmapheresis cycles with LMWH were successful without complications. Approximately 40 percent of the initially administered LMWH bolus was lost by the large porous filter during the plasmapheresis. The anti-FXa values were determined to be 0.5 IU per mL during the entire plasmapheresis. TAT values were elevated (TAT median, 14.3 microg/L). F 1+2 values measured before the filter cartridge remained within the normal range for the entire plasmapheresis cycle (<1.2 nmol/L) and were increasingly elevated after the filter. CONCLUSION Our initial experiences with LMWH for anticoagulation in plasmapheresis indicate that a body weight adjusted dose of LMWH (dalteparin) is suitable for anticoagulation in plasmapheresis therapy. No complications were observed. The data are encouraging. Further investigations will show if and how the present anticoagulation regime could be further optimized.
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Affiliation(s)
- Helmut Schinzel
- Medical Clinic and Policlinic II, Johannes Gutenberg University of Mainz, Germany.
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Pallister I, Empson K. The effects of surgical fracture fixation on the systemic inflammatory response to major trauma. J Am Acad Orthop Surg 2005; 13:93-100. [PMID: 15850366 DOI: 10.5435/00124635-200503000-00002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure, both of which are caused by activation of the systemic inflammatory response. This activation results in tissue recruitment of and injury by circulating polymorphonuclear leukocytes. The reasons for clinical benefits of early fracture stabilization in major trauma are unknown. Published studies indicate that fracture surgery increases the posttraumatic inflammatory response. Major surgery to stabilize fractures carries a higher complication rate when performed on patients whose hypovolemic shock is not fully corrected. Thus, fracture care should be tailored to the patient, not dictated by the injured bone. Understanding the impact of fracture surgery on the systemic inflammatory response to major trauma is necessary to refine treatment and to apply it optimally to all patients.
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Affiliation(s)
- Ian Pallister
- Department of Trauma & Orthopaedics, Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, United Kingdom
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Green JA, Spiess BD. Current status of antifibrinolytics in cardiopulmonary bypass and elective deep hypothermic circulatory arrest. ACTA ACUST UNITED AC 2003; 21:527-51. viii. [PMID: 14562564 DOI: 10.1016/s0889-8537(03)00042-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Cardiopulmonary bypass (CPB) results in many physiologic derangements, including activation of the hemostatic and fibrinolytic pathways. Deep hypothermic circulatory arrest (DHCA) adds a further insult to the coagulation systems because it involves more extreme hypothermia and organ ischemia related to blood stasis. The abnormalities induced by CPB disrupt the checks and balances in the hemostatic and fibrinolytic systems, resulting in a pathologic state that leads to excessive bleeding and other perioperative complications. Prophylactic antifibrinolytic therapy can attenuate the response to this insult by restoring the delicate balance within these systems, potentially reducing the complication rate and improving patient outcomes.
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Affiliation(s)
- Jeffrey A Green
- Department of Anesthesiology, Virginia Commonwealth University, Medical College of Virginia Campus, 1200 East Broad Street, PO Box 980695, Richmond, VA 23209, USA.
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Casati V, Sandrelli L, Speziali G, Calori G, Grasso MA, Spagnolo S. Hemostatic effects of tranexamic acid in elective thoracic aortic surgery: a prospective, randomized, double-blind, placebo-controlled study. J Thorac Cardiovasc Surg 2002; 123:1084-91. [PMID: 12063454 DOI: 10.1067/mtc.2002.120717] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We studied the hemostatic effects of tranexamic acid in patients undergoing elective surgery involving the thoracic aorta. METHODS In a double-blind, randomized fashion, 60 consecutive patients were assigned to two treatment groups: 30 patients (placebo group) received infusion of saline solution, and 30 (treatment group) received tranexamic acid (1 g before skin incision, an infusion of 400 mg/h during the operation, and 500 mg in the pump priming). Perioperative bleeding was considered as a primary outcome. Perioperative allogeneic transfusions, major thrombotic complications (myocardial infarction, pulmonary embolism, renal insufficiency), and surgical outcomes were also considered. RESULTS Patients treated with tranexamic acid showed significant reductions in postoperative bleeding, both in terms of the amount collected during the first 4 postoperative hours (median 307 mL, interquartile range 253-361 mL in the placebo group vs median 211 mL, interquartile range 108-252 mL in the treatment group, P =.002) and in terms of total bleeding (median 722 mL, interquartile range 574-952 mL in the placebo group vs median 411 mL, interquartile range 313-804 mL in the treatment group, P =.04). Consequently, the number of patients transfused differed significantly between groups (21 patients [72.4%] in the placebo group vs 13 [44.8%] in the treatment group, P =.033). Patients in the treatment group showed significant reductions in the total amount for the entire group of packed red cells transfused (13,500 mL in the treatment group vs 28,000 mL in the placebo group, P =.012) and in the total amount of allogeneic transfusions (23,400 mL in the treatment group vs 53,000 mL in the placebo group, P =.024). No differences in perioperative thrombotic complications were found. CONCLUSIONS In this initial series of patients undergoing thoracic aortic surgery, tranexamic acid appeared effective in reducing perioperative bleeding, with a significant reduction in the need for allogeneic transfusions and without any increased risk of thrombotic complications.
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Affiliation(s)
- Valter Casati
- Division of Cardiac Anesthesia and Intensive Care, Policlinico di Monza, Monza, Italy.
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Despotis GJ, Avidan MS, Hogue CW. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001; 72:S1821-31. [PMID: 11722116 DOI: 10.1016/s0003-4975(01)03211-8] [Citation(s) in RCA: 200] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients undergoing cardiac surgery with cardiopulmonary bypass are at risk for excessive microvascular bleeding, which often leads to transfusion of allogeneic blood and blood components as well as reexploration in a smaller subset of patients. Excessive bleeding after cardiac surgery is generally related to a combination of several alterations in the hemostatic system pertaining to hemodilution, excessive activation of the hemostatic system, and potentially the use of newer, longer-acting antiplatelet or antithrombotic agents. Although several nonpharmacologic strategies have been proposed, this review summarizes the role of pharmacologic interventions as means to attenuate the alterations in the hemostatic system during CPB in an attempt to reduce excessive bleeding, transfusion, and reexploration. Specifically, agents that inhibit platelets, fibrinolysis, factor Xa and thrombin, as well as broad-spectrum agents, have been investigated with respect to their role in reducing consumption of clotting factors and better preservation of platelet function. Prophylactic administration of agents with antifibrinolytic, anticoagulant, and possibly antiinflammatory properties can decrease blood loss and transfusion. Although aprotinin seems to be the most effective blood conservation agent (which is most likely related to its broad-spectrum nature), agents with isolated antifibrinolytic properties may be as effective in low-risk patients. The ability to reduce blood product transfusions and to decrease operative times and reexploration rates favorably affects patient outcomes, availability of blood products, and overall health care costs.
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Affiliation(s)
- G J Despotis
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Despotis GJ, Goodnough LT. Management approaches to platelet-related microvascular bleeding in cardiothoracic surgery. Ann Thorac Surg 2000; 70:S20-32. [PMID: 10966007 DOI: 10.1016/s0003-4975(00)01604-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Patients undergoing cardiac surgery with cardiopulmonary bypass are at increased risk for microvascular bleeding that requires perioperative transfusion of blood components. Platelet-related defects have been shown to be the most important hemostatic abnormality in this setting. The exact association between preoperative use of potent platelet inhibitors and either bleeding or transfusion in patients undergoing cardiac surgical procedures is currently being defined. Laboratory evaluation of platelets and coagulation factors can facilitate the optimal administration of pharmacologic and transfusion-based therapy. However, their turnaround time makes laboratory-based methods impractical for concurrent management of surgical patients, which has led many investigators to study the role of point-of-care coagulation tests in this setting. Use of point-of-care tests of hemostatic function can optimize the management of excessive bleeding and reduce transfusion. Accordingly, point-of-care tests that assess platelet function may also identify patients at risk for acquired, platelet-related bleeding. The ability to reduce the unnecessary use of blood products and to decrease operative time or reexploration rates has important consequences for blood inventory, blood costs, and overall health care costs.
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Affiliation(s)
- G J Despotis
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Anticoagulation and Anticoagulation Reversal With Cardiac Surgery Involving Cardiopulmonary Bypass: An Update. J Cardiothorac Vasc Anesth 1999. [DOI: 10.1016/s1053-0770(21)00594-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
BACKGROUND Bleeding is an important cause of morbidity in thoracic aortic surgery. METHODS We reviewed the mechanisms for fibrinolysis in aortic surgery and the propensity for intervention. Several studies have addressed the safety and efficacy of aprotinin. RESULTS The endothelium regulates the balance between thrombosis and fibrinolysis. During hypothermic circulatory arrest, thrombin generation stimulates protein C production and tissue plasminogen activator release to promote fibrinolysis. Hypothermia also adversely affects platelet function and coagulation. Controversy exists regarding the effectiveness and dangers of antifibrinolytic agents after circulatory arrest. CONCLUSIONS Fibrinolysis remains problematic during thoracic aortic aneurysm surgery. Heparin management is complicated by aprotinin and insufficient heparin may result in thrombotic events. Aprotinin is safe during rewarming or postoperatively.
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Affiliation(s)
- S Westaby
- Oxford Heart Centre, John Radcliffe Hospital, Headington, England
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Despotis GJ, Skubas NJ, Goodnough LT. Optimal management of bleeding and transfusion in patients undergoing cardiac surgery. Semin Thorac Cardiovasc Surg 1999; 11:84-104. [PMID: 10378853 DOI: 10.1016/s1043-0679(99)70002-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are at increased risk for excessive perioperative blood loss requiring transfusion of blood products. Point-of-care evaluation of platelets, coagulation factors, and fibrinogen can enable physicians to rapidly assess bleeding abnormalities, facilitate the optimal administration of pharmacological and transfusion-based therapy, and also identify patients with surgical bleeding. The ability to reduce the unnecessary use of blood products in this setting has important implications for emerging issues in blood inventory and blood costs. The ability to decrease surgical time, along with exploration rates, has important consequences for health care costs in an increasingly managed health care environment.
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Affiliation(s)
- G J Despotis
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO 63110, USA
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Despotis GJ, Hogue CW. Pathophysiology, prevention, and treatment of bleeding after cardiac surgery: a primer for cardiologists and an update for the cardiothoracic team. Am J Cardiol 1999. [DOI: 10.1016/s0002-9149(98)00944-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Trusolino L, Pugliese L, Comoglio PM. Interactions between scatter factors and their receptors: hints for therapeutic applications. FASEB J 1998; 12:1267-80. [PMID: 9761771 DOI: 10.1096/fasebj.12.13.1267] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The scatter factors, which include hepatocyte growth factor and macrophage stimulating protein, stand out from other cytokines because of their uncommon biological properties. In addition to promoting cell growth and protection from apoptosis, they are involved in the control of cell dissociation, migration into extracellular matrices, and a unique process of differentiation called 'branching morphogenesis'. Through the concerted regulation of these complex phenomena, scatter factors promote development, regeneration, and reconstruction of normal organ architecture. In transformed epithelia, scatter factors can mediate tumor invasive growth, a harmful feature of neoplastic progression in which cancer cells invade surrounding tissues, penetrate across the vascular walls, and eventually disseminate throughout the body, giving rise to systemic metastases. A much-debated issue in basic biology, which has strong implications for experimental medicine, is how to dissociate the favorable effects of growth factors from their adverse ones. Accordingly, to find agonists or antagonists with potential therapeutic applications is a crucial undertaking for current research. Domain-mapping analyses of growth factor molecules can help to isolate specific structural requirements for the induction of selective biological effects. Based on the observation that certain growth factors must undergo posttranslational modifications to exert a full response, it is possible to interfere with their activation mechanisms to modulate their functions. Finally, the identification of cell type-specific coreceptors able to potentiate their activity allows drawing of a functional body map, where some organs or tissues may be more responsive than others to growth factors. This review is focused on how, and to what extent, scatter factors can behave 'well' or 'badly' according to their molecular structure, the way they are activated, and the way they interact with cell surface receptors and coreceptors.
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Affiliation(s)
- L Trusolino
- Division of Molecular Oncology, IRCC, Institute for Cancer Research, University of Torino School of Medicine, 10060 Candiolo, Torino,
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Cohen G, Ivanov J, Weisel RD, Rao V, Mohabeer MK, Mickle DA. Aprotinin and dipyridamole for the safe reduction of postoperative blood loss. Ann Thorac Surg 1998; 65:674-83. [PMID: 9527194 DOI: 10.1016/s0003-4975(97)01428-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Aprotinin (APR) reduces postoperative blood loss but may induce thrombosis. Dipyridamole (DIP) limits platelet aggregation and may reduce the thrombotic complications associated with APR. METHODS To evaluate the safety and effectiveness of combined APR and DIP, we undertook a prospective randomized trial in patients undergoing cardiac operations. Patients were stratified according to risk for bleeding (low or high), and received either DIP with placebo (DIP group; n = 59) or DIP with APR (DIP + APR group; n = 56). Blood samples were obtained for the measurement of hematologic and biochemical parameters. Blood loss and transfusion requirements were documented postoperatively. RESULTS Postoperative blood loss and transfusion requirements were significantly lower in the DIP + APR group at 6, 12, and 24 hours after bypass (p < 0.01). No significant differences were found between groups in the incidence of perioperative mortality (DIP, 0%; DIP + APR, 3%), myocardial infarction (DIP, 0%; DIP + APR, 3%), stroke (DIP, 1%; DIP + APR, 1%), or potential thrombotic events (death, myocardial infarction, and stroke: DIP, 2%; DIP + APR, 5%). In addition, these rates did not differ from those of nonparticipating matched control patients. CONCLUSIONS Administration of both drugs simultaneously was more effective than DIP alone in reducing postoperative blood loss. A platelet inhibitor may be required to reduce the thrombotic complications associated with APR. Further studies evaluating graft patency and perioperative ischemia are necessary to confirm the potential benefits of the combination of a platelet inhibitor and APR.
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Affiliation(s)
- G Cohen
- Division of Cardiovascular Surgery and the Centre for Cardiovascular Research, The Toronto Hospital and the University of Toronto, Ontario, Canada
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31
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Westaby S. Aprotinin Fifteen Years Later. Semin Cardiothorac Vasc Anesth 1997. [DOI: 10.1177/108925329700100409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aprotinin, the broad-based bovine serine protease inhibitor, was first used as an antidote against the harmful proteases released through complement-induced neutrophil activation in the early 1980s. Since then, the safety and efficacy of aprotinin have been debated. Even now, fifteen years later, aprotinin's precise mechanism of action and clear indications for use have not been defined. This article discusses what aprotinin is, its role in the contact system of blood, how it improves hemostasis, the effect of temperature on it, its use in clinical practice, and which patients should receive it. The article concludes that aprotinin's hemostatic effects are useful in patients who are at increased risk from bleeding, but that it should not be considered a substitute for surgical skill. Early claims of absolute safety were premature. Risks between high- and low-dose regimens vary significantly, and more study is required. Alternatives to aprotinin such as the less expensive antifibrinolytic agent tranexamic acid are now available, but they also require additional study.
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Affiliation(s)
- Stephen Westaby
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, England
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32
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Despotis GJ, Levine V, Joist JH, Joiner-Maier D, Spitznagel E. Antithrombin III During Cardiac Surgery. Anesth Analg 1997. [DOI: 10.1213/00000539-199709000-00005] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Despotis GJ, Joist JH, Goodnough LT. Monitoring of hemostasis in cardiac surgical patients: impact of point-of-care testing on blood loss and transfusion outcomes. Clin Chem 1997. [DOI: 10.1093/clinchem/43.9.1684] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are at increased risk for excessive perioperative blood loss requiring transfusion of blood products. Strategies to optimize administration of heparin and protamine and the assessment of their effects on coagulation are evolving in cardiac surgical patients. Two recent evaluations have focused on the use of multiple point-of-care (POC) coagulation assays for patient-specific adjustment of heparin and protamine dosage. These studies indicate that blood loss and transfusion requirements in cardiac surgical patients may be reduced with more accurate control of heparin anticoagulation and its reversal. Blood component administration in patients with excessive post-CPB bleeding is generally empiric in part, related to turnaround times of laboratory-based tests. Methods are now available for rapid, POC assessment of coagulation to allow appropriate, targeted therapy for acquired hemostatic abnormalities. Recent studies indicate that a rapid evaluation of thrombocytopenia and coagulation factor deficiencies with POC tests can facilitate the optimal administration of pharmacologic and transfusion-based therapy in patients who exhibit excessive bleeding after CPB. POC tests that assess platelet function have been developed, and their use may facilitate identification of which patients at risk for excessive blood loss may respond to pharmacologic interventions such as desmopressin acetate or antifibrinolytic agents.
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Affiliation(s)
| | - J Heinrich Joist
- Departments of Pathology and Internal Medicine, St. Louis University School of Medicine, St. Louis, MO 63110
| | - Lawrence T Goodnough
- Departments of Anesthesiology, Internal Medicine, and Pathology, Washington University School of Medicine, St. Louis, MO 63110
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Despotis GJ, Levine V, Joist JH, Joiner-Maier D, Spitznagel E. Antithrombin III during cardiac surgery: effect on response of activated clotting time to heparin and relationship to markers of hemostatic activation. Anesth Analg 1997; 85:498-506. [PMID: 9296400 DOI: 10.1097/00000539-199709000-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED This study was designed to determine if, and to what extent, antithrombin III (AT) levels affect the response of the activated clotting time (ACT) to heparin in concentrations used during cardiac surgery, and to characterize the relationship between AT levels and markers of activation of coagulation during cardiopulmonary bypass (CPB). After informed consent, blood specimens obtained from eight normal volunteers (Phase I) were used to measure the response of the kaolin and celite ACT to heparin after in vitro addition of AT (200 U/dL) and after dilution with AT-deficient plasma to yield AT concentrations of 20, 40, 60, 80, and 100 U/dL. In Phase II, blood specimens collected before the administration of heparin and prior to discontinuation of CPB, were used to measure the response of the kaolin ACT to heparin (preheparin only), AT concentration, and a battery of coagulation assays in 31 patients undergoing repeat or combined cardiac surgical procedures. In Phase I, strong linear relationships were observed between kaolin (slope = 1.04 AT - 2, r2 = 0.78) and celite (slope = 1.36 AT + 6, r2 = 0.77) ACT slopes and AT concentrations below 100 U/dL. In the pre-CPB period of Phase II, only factors V (partial r = -0.49) and VIII (partial r = -0.63) were independently associated with heparin-derived slope using multivariate analysis; an inverse relationship was observed between AT and fibrinopeptide A levels (r = -0.41) at the end of CPB. Our findings indicate that the responsiveness of whole blood (ACT) to heparin at the high concentrations used with CPB is progressively reduced when the AT concentration decreases below 80 U/dL. Because AT is variably, and sometimes extensively, reduced in many patients before and during CPB, AT supplementation in these patients might be useful in reducing excessive thrombin-mediated consumption of labile hemostatic blood components, excessive microvascular bleeding, and transfusion of blood products. IMPLICATIONS Heparin, a drug with anticoagulant properties, is routinely given to patients undergoing cardiac surgery to prevent clot formation within the cardiopulmonary bypass circuit. However, when levels are reduced, heparin is not as effective. Findings within this study indicate that administration of antithrombin III may help to preserve the hemostatic system during cardiopulmonary bypass.
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Affiliation(s)
- G J Despotis
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Abstract
BACKGROUND Surgical bleeding with possible associated coagulopathies is a major source of morbidity and mortality. More than 27% of patients receive unnecessary blood or blood-product transfusions during cardiac operations. Analysis of the cost-benefit of pharmacologic hemostasis can be accomplished by relating all the components of cost, which include both direct and indirect costs to both direct and indirect benefits to the patient. METHODS A significant reduction in transfusion requirements can be achieved by the systematic application of a clinical algorithm. An alternative is to use drugs that enhance hemostasis. Four such drugs commonly used are desmopressin acetate, tranexamic acid, epsilon-aminocaproic acid, and aprotinin. All these agents have been shown to successfully reduce bleeding and the need for transfusion. It appears that the order of efficacy (greatest to least) is aprotinin, tranexamic acid, epsilon-aminocaproic acid, and desmopressin acetate. RESULTS Cost/benefit analysis associated with the use of these agents is complex. The direct costs of these drug treatments can be balanced against the costs related to blood and blood-product administration. Using epsilon-aminocaproic acid, blood used is valued at $30, whereas the drug treatment cost is less than $2. Aprotinin use results in costs of more than $500, with the drug costing $900. CONCLUSIONS Improved hemostasis should also result in indirect cost savings from reduced operating room time, reduced intensive care unit and hospital stay, and the avoidance of reoperation for bleeding.
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Affiliation(s)
- D E Harmon
- Department of Cardiovascular and Transplant Anesthesia, Alton Ochsner Clinic, New Orleans, Louisiana 70121, USA
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Kojima S, Shiba M, Kuramochi M, Yamamoto A. Effect of nafamostat mesilate on bradykinin generation and hemodynamics during LDL apheresis. Artif Organs 1995; 19:135-9. [PMID: 7763192 DOI: 10.1111/j.1525-1594.1995.tb02302.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Dextran-sulfate (DS) cellulose used for low-density lipoprotein (LDL) apheresis seems to be a weak activator of the contact phase of the intrinsic coagulation pathway because the surface of this substance has negative charges. Heparin, a commonly used anticoagulant, has no effect on this process whereas the process is inhibited by a newly developed anticoagulant, nafamostat mesilate (NM). The effects on bradykinin generation were compared between heparin and NM. Five patients with severe hypercholesterolemia were treated with LDL apheresis using either heparin or NM on a different day. During apheresis with heparin, factor XII, high molecular weight kininogen, and prekallikrein were markedly decreased by passing through the DS column. A distinct generation of bradykinin was observed by passing plasma through the DS column, and this led to the rise of bradykinin levels from 12 +/- 5 (mean +/- SE) to 72 +/- 14 pg/ml after treatment of 1,000 ml of plasma. NM suppressed almost completely the rise of bradykinin levels. Although blood pressure was apt to decrease during apheresis with heparin, there was no significant difference in blood pressure between heparin and NM. Since an angiotensin-converting enzyme inhibitor may lead to a marked rise in blood levels of bradykinin by suppressing its degradation, the use of NM is recommended for apheresis in patients taking this drug.
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Affiliation(s)
- S Kojima
- Department of Clinical Research, Tohsei National Hospital, Shizuoka, Japan
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Huyzen RJ, Harder MP, Huet RC, Boonstra PW, Brenken U, van Oeveren W. Alternative perioperative anticoagulation monitoring during cardiopulmonary bypass in aprotinin-treated patients. J Cardiothorac Vasc Anesth 1994; 8:153-6. [PMID: 7515704 DOI: 10.1016/1053-0770(94)90054-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Monitoring of anticoagulation during cardiopulmonary bypass by means of the activated coagulation time (ACT) has become questionable due to the prolongation in the clotting time of patients receiving aprotinin. Because the celite-based ACT only indicates intrinsic coagulation, and sufficient anticoagulation is needed to also prevent extrinsic coagulation, the ACT may not be reliable. Three different clotting times, the celite-based ACT, the kaolin-based activated coagulation time (AKT) and the high-dose thrombin time (HITT), were compared in a prospective, double-blind, placebo-controlled study of 20 patients who were to undergo cardiopulmonary bypass. As expected, neither the kaolin-based assay nor the high-dose thrombin time was influenced by aprotinin, whereas the celite-based ACT was significantly prolonged in aprotinin-treated patients as compared to control patients (P < 0.05). This study confirms that both kaolin-based and thrombin-based tests provide a reliable means of determining the degree of heparinization in the presence of aprotinin during cardiopulmonary bypass.
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Affiliation(s)
- R J Huyzen
- Division of Cardiothoracic Anaesthesia, University Hospital Groningen, The Netherlands
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Tabuchi N, Haan JD, Boonstra PW, Oeveren WV. Activation of fibrinolysis in the pericardial cavity during cardiopulmonary bypass. J Thorac Cardiovasc Surg 1993. [DOI: 10.1016/s0022-5223(19)34036-x] [Citation(s) in RCA: 128] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Aprotinin is a nonspecific serine protease inhibitor extracted from bovine lung. It was first used during cardiopulmonary bypass to inhibit plasmin-induced complement activation. By chance significant reductions of blood loss and blood requirements were noted in treated patients. Subsequent investigation showed improved hemostasis to result from protection of platelet adhesive receptors (Gp Ib) at the onset of cardiopulmonary bypass. Without aprotinin the contact system of plasma is massively activated on first passage through the cardiopulmonary bypass circuit. Activation of the intrinsic coagulation pathway causes thrombin formation, which impairs platelet adhesive function. Aprotinin blocks contact activation of the kallikrein system during cardiopulmonary bypass and in synergy with heparin prevents thrombin formation through inhibition of the intrinsic clotting cascade. It is likely that neither thrombin nor platelets become involved in the blood-foreign surface contact activation process in aprotinin-treated patients. The fact that the hemostatic process is affected from the very beginning of cardiopulmonary bypass is substantiated by the fact that low-dose aprotinin therapy (2 x 10(6) KIU aprotinin added to the pump prime) leads to the same preservative effect on Gp Ib receptors and blood loss as continuous high-dose infusion (6 x 10(6) KIU) throughout the whole surgical procedure. In the presence of heparin aprotinin prolongs the activated clotting time and the in vitro activated partial thromboplastin time. This has important implications for heparin dosage. An inhibitory effect on the endothelial cell anticoagulant function may also have consequences during hypothermic low flow and circulatory arrest states.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S Westaby
- Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, England
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Kunapuli S, DeLa Cadena R, Colman R. Deletion mutagenesis of high molecular weight kininogen light chain. Identification of two anionic surface binding subdomains. J Biol Chem 1993. [DOI: 10.1016/s0021-9258(18)53802-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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41
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Katcher HL, Samuel M, Villanueva GB. A simple and rapid method to study the association of the contact proteins of blood coagulation. Thromb Res 1992; 68:443-50. [PMID: 1341054 DOI: 10.1016/0049-3848(92)90056-g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Native and reduced SDS polyacrylamide gel electrophoresis on the automated PhastSystem (Pharmacia) were used to demonstrate protein-protein binding interactions and structural changes during proteolytic activations of the proteins involved in contact activation. The "mobility shift" assay in native gels has been used to visualize the kinetics of activation of factor XII by dextran sulfate as well as the formation of kallikrein-cleaved high molecular weight kininogen. It shows the formation of prekallikrein-high molecular weight kininogen complexes and factor XII-dextran sulfate complex for the first time in gels. The use of automation makes this procedure fast and reproducible using nanogram amounts of protein in relatively short time.
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Affiliation(s)
- H L Katcher
- Department of Biochemistry and Molecular Biology, New York Medical College, Valhalla 10595
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42
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Wang JS, Lin CY, Hung WT, Thisted RA, Karp RB. In vitro effects of aprotinin on activated clotting time measured with different activators. J Thorac Cardiovasc Surg 1992. [DOI: 10.1016/s0022-5223(19)34702-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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43
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Samuel M, Pixley R, Villanueva M, Colman R, Villanueva G. Human factor XII (Hageman factor) autoactivation by dextran sulfate. Circular dichroism, fluorescence, and ultraviolet difference spectroscopic studies. J Biol Chem 1992. [DOI: 10.1016/s0021-9258(18)41830-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Hafner G, Swars H, Ehrenthal W, Schinzel H, Weilemann LS, Prellwitz W. The control of anti-coagulation in acute dialyses with sensitive laboratory parameters. Scand J Clin Lab Invest 1992; 52:289-96. [PMID: 1332180 DOI: 10.1080/00365519209088361] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
In seven patients who had to be dialysed between four and 13 times due to acute renal failure, low molecular weight heparin (LMWH) Fragmin was used for anticoagulation. According to dose-finding studies, 80-90 U kg-1 body weight of LMWH as a single bolus were administered initially, producing dose-related levels of 0.3-1.5 anti-factor Xa U ml-1 in plasma. Apart from the anti-Xa activity in the plasma, the thrombin anti-thrombin III complex (TAT complex) and a fibrin degradation product (D-dimer) were measured as parameters of a coagulation activation. A sufficient anti-coagulation during dialysis was supposed to exist at a normal range (5.0 micrograms l-1 or below) of TAT complex. Pathological TAT concentrations at the end of dialysis indicated the requirement of an increased dose for the next dialysis. These concentrations reflected a need for more heparin if, for example, inflammation, indicated by increasing C-reactive protein levels (CRP), occurred. The increase of TAT complex and D-dimer during dialysis showed a good agreement (p less than 0.001). Due to a single bolus application before dialysis, one measurement of TAT at the end of the dialysis was sufficient. The determination of the TAT complex concentration enabled a heparinization better adapted to the clinical situation of intensive-care patients undergoing acute dialyses, so that the coagulation system was not additionally activated by the extracorporeal circulation.
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Affiliation(s)
- G Hafner
- Institute of Clinical Chemistry, Johannes Gutenberg University, Mainz, Germany
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Asakura S, Hurley RW, Skorstengaard K, Ohkubo I, Mosher DF. Inhibition of cell adhesion by high molecular weight kininogen. J Cell Biol 1992; 116:465-76. [PMID: 1370494 PMCID: PMC2289283 DOI: 10.1083/jcb.116.2.465] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
An anti-cell adhesion globulin was purified from human plasma by heparin-affinity chromatography. The purified globulin inhibited spreading of osteosarcoma and melanoma cells on vitronectin, and of endothelial cells, platelets, and mononuclear blood cells on vitronectin or fibrinogen. It did not inhibit cell spreading on fibronectin. The protein had the strongest antiadhesive effect when preadsorbed onto the otherwise adhesive surfaces. Amino acid sequence analysis revealed that the globulin is cleaved (kinin-free) high molecular weight kininogen (HKa). Globulin fractions from normal plasma immunodepleted of high molecular weight kininogen (HK) or from an individual deficient of HK lacked adhesive activity. Uncleaved single- chain HK preadsorbed at neutral pH, HKa preadsorbed at pH greater than 8.0, and HKa degraded further to release its histidine-rich domain had little anti-adhesive activity. These results indicate that the cationic histidine-rich domain is critical for anti-adhesive activity and is somehow mobilized upon cleavage. Vitronectin was not displaced from the surface by HKa. Thus, cleavage of HK by kallikrein results in both release of bradykinin, a potent vasoactive and growth-promoting peptide, and formation of a potent anti-adhesive protein.
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Affiliation(s)
- S Asakura
- Departments of Medicine, University of Wisconsin, Madison 53706
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McMullen BA, Fujikawa K, Davie EW. Location of the disulfide bonds in human plasma prekallikrein: the presence of four novel apple domains in the amino-terminal portion of the molecule. Biochemistry 1991; 30:2050-6. [PMID: 1998666 DOI: 10.1021/bi00222a007] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The location of 16 of the 18 disulfide bonds in human plasma prekallikrein was determined by amino acid sequence analysis of cystinyl peptides produced by chemical and enzymatic digestions. A unique structure, named the apple domain, was established for each of the four tandem repeats in the amino-terminal portion of the molecule. The apple domains (90 or 91 amino acids) contain 3 highly conserved disulfide bonds linking the first and sixth, second and fifth, and third and fourth half-cystine residues present in each repeat. The fourth tandem repeat contains an extra disulfide bond that forms a second small loop within the apple domain. The carboxyl-terminal portion of plasma prekallikrein containing the catalytic region of the molecule was found to have disulfide bonds located in positions similar to those of other serine proteases.
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Affiliation(s)
- B A McMullen
- Department of Biochemistry, University of Washington, Seattle 98195
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Sato H, Kojima J, Nakajima A, Morita T, Noishiki Y, Gu ZW, Li FM, Feng XD. Study on antithrombogenicity of poly[beta-(acetylsalicylyloxy)ethyl methacrylate] relative to poly(hydroxyethyl methacrylate). JOURNAL OF BIOMATERIALS SCIENCE. POLYMER EDITION 1991; 2:1-13. [PMID: 1863573 DOI: 10.1163/156856291x00016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The antithrombogenicity of a polymer made of aspirin bound to hydroxyethyl methacrylate (HEMA), abbreviated as ASA-polymer, was compared with that of poly(hydroxyethyl methacrylate) (PHEMA). Platelet from platelet rich plasma (PRP) incubated with ASA-polymer surface exhibited noticeable decreases in adhesion and aggregation as compared to platelets incubated with PHEMA. Low molecular weight components other than aspirin, which may be released from ASA-polymer during the incubation with PRP, or contact with ASA-polymer causing denaturation of platelets without morphological changes could be responsible for the decrease of adhesion and aggregation. Both PRP and PPP exposed to ASA-polymer-coated surfaces exhibited a much smaller partial thromboplastin time (PTT) than if exposed to PHEMA-coated surfaces; the PTT of ASA-polymer was similar to that of glass exposed plasma. With respect to the in vivo antithrombogenicity, the ASA-polymer surface led to thrombus formation. This may be due to the partial hydrolysis of the acetyl groups resulting in the formation of a negatively charged surface which in turn accelerates the coagulation cascade despite its inhibitory effects on platelet adhesion and aggregation. On the other hand, neointima formed around a thrombus layer on PHEMA-coated sutures after 14 days.
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Affiliation(s)
- H Sato
- Research Center for Medical Polymers and Biomaterials, Kyoto University, Japan
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Swars H, Hafner G, Weilemann LS, Ehrenthal W, Schinzel H, Prellwitz W, Meyer J. Acute dialysis: PMN-elastase as a new parameter for controlling individual anticoagulation with low molecular weight heparin (Fragmin). Intensive Care Med 1991; 17:52-6. [PMID: 1645379 DOI: 10.1007/bf01708410] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Despite the improvements in the development of dialyzer membranes with greater hemocompatibility, an activation of the coagulation system occurs when blood comes into contact with exogenous surfaces. The large number of heparin dosage regimens demonstrated the difficulty to adapt general therapeutic guidelines. Low molecular weight heparin (Fragmin) was administered as a single bolus dose for anticoagulation during 58 acute dialyses. Anti-Xa-activity, the plasma levels of the lysosomal elastase of the polymorphonuclear granulocytes ("PMN-elastase") and of the thrombin-antithrombin III-complex (TAT) were measured at hourly intervals. Therapeutic anti-Xa-levels did not show evidence of sufficient inhibition of thrombin formation. The PMN-elastase increased by 180 ng/ml 3 h after administration of the bolus dose, with no further increase occurring (plateau phase). This was considered to reflect adequate anticoagulative activity. Where anticoagulation was inadequate, the elastase values rose consistently. After 2 h the increase of the PMN-elastase showed that--and to what extent--coagulation had been activated. The determination of PMN-elastase, using the IMAC-principle, is a method which can be performed quickly with any conventional autoanalyzer. It makes it possible to monitor adequate anticoagulation, but PMN-elastase results must be proven during routine use before recommendation as a routine test.
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Affiliation(s)
- H Swars
- II. Medizinische Klinik, Johannes Gutenberg-Universität Mainz, FRG
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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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Hock J, Vogel R, Linke RP, Müller-Esterl W. High molecular weight kininogen-binding site of prekallikrein probed by monoclonal antibodies. J Biol Chem 1990. [DOI: 10.1016/s0021-9258(19)38500-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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