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Jia B, Ding C, Deng J, Qi W, Yao Y. The association between heparin sensitivity index and postoperative blood loss in Chinese patients undergoing elective off-pump coronary artery bypass grafting: a single center retrospective study. J Cardiothorac Surg 2024; 19:426. [PMID: 38978097 PMCID: PMC11229182 DOI: 10.1186/s13019-024-02966-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 06/30/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND The heparin sensitivity index (HSI) is closely associated with perioperative ischemic events and increased blood loss in cardiac surgery. Previous studies have produced conflicting results. Therefore, this study aimed to investigate the relationship between HSI and postoperative blood loss specifically in Chinese patients undergoing elective off-pump coronary artery bypass grafting (OPCAB). METHODS Patients underwent OPCAB between March 2021 and July 2022 were retrospectively included. Enrolled patients were classified into Low-HSI (HSILOW; HSI < 1.3) and Normal-HSI (HSINORM; HSI ≥ 1.3) groups. HSI = [(activated clotting time (ACT) after heparin) - (baseline ACT)] / [loading dose of heparin (IU/kg)]. Primary outcome included postoperative blood loss at 24 h. Secondary outcomes were total postoperative blood loss, transfusion requirement of red blood cell (RBC), fresh frozen plasma (FFP), platelet concentrates (PC), and other complications. RESULTS We retrospectively analyzed 303 Chinese OPCAB patients. HSILOW group had higher preoperative platelet (PLT) count (221 × 109/L vs. 202 × 109/L; P = 0.041) and platelet crit (PCT) value (0.23% vs. 0.22%; P = 0.040) compared to HSINORM group. Two groups showed no significant differences in postoperative blood loss at 24 h (460 mL vs. 470 mL; P = 0.252), total blood loss (920 mL vs. 980 mL; P = 0.063), RBC transfusion requirement (3.4% vs. 3.1%; P = 1.000), FFP transfusion requirement (3.4% vs. 6.2%; P = 0.380), and other complications. Preoperative high PLT count was associated with low intraoperative HSI value (odds ratio: 1.006; 95% confidence interval: 1.002, 1.011; P = 0.008). CONCLUSIONS Intraoperative HSI value was not associated with postoperative blood loss in Chinese patients undergoing OPCAB. Preoperative high PLT count was an independent predictor of low intraoperative HSI value.
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Affiliation(s)
- Bin Jia
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510006, China
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Chenying Ding
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
- Department of Anesthesiology, The First Hospital of Hohhot, Hohhot, 010020, China
| | - Jinhe Deng
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510006, China
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Wenhui Qi
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
- Department of Anesthesiology, Harrison International Peace Hospital, Hengshui, 053000, China
| | - Yuntai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China.
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Khalil MA, Kaddoura R, Omar AS, Abohamar AD, Izham M. Optimum heparin dose in off-pump coronary artery bypass grafting: A systematic review and meta-analysis. Perfusion 2024; 39:675-683. [PMID: 36858479 DOI: 10.1177/02676591231159506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
INTRODUCTION Off-pump coronary artery bypass grafting (OPCABG) was introduced many years ago aiming to reduce the known complications of conventional on-pump coronary surgeries. Heparin is required during the procedures, but the available protocols have diverse dosage regimens. The primary objective of this systematic review is to examine the effect of different heparin doses on the outcomes of OPCABG. EVIDENCE ACQUISITION MEDLINE and EMBASE were searched. Four reviewers identified eligible clinical trials. Two reviewers extracted data and independently assessed the risk of bias using Cochrane tool. The primary outcome was the activated clotting time (ACT) at three minutes. The secondary outcomes were proportion of patients requiring blood products and the length of hospital stay. An aggregate data approach was used. EVIDENCE SYNTHESIS Three single-center randomized studies recruiting 256 patients were included. The studies compared low-dose (1.5-2 mg/kg) and high-dose (3 mg/kg) heparin boluses. The overall mean difference for ACT after three minutes between low- and high-dose heparin is - 126.16 (95% CI: - 142.19, - 110.14). The proportion of patients requiring blood products after surgery [odd ratio 1.27 (95% CI: 0.69, 2.32)] or the overall length of stay [mean difference -0.15 (95% CI: -0.84, 0.53)] did not differ between the heparin doses. CONCLUSIONS In OPCABG, high-dose compared with low-dose heparin did not affect the utilization of more blood products or increased the overall length of stay. Unsurprisingly, ACT values were higher in the high-dose heparin group. Larger and adequately powered randomized clinical trials are indicated to resolve the uncertainty.
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Affiliation(s)
- Mohamed A Khalil
- Anesthesia Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Rasha Kaddoura
- Department of Clinical pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Amr S Omar
- Department of Cardiothoracic Surgery/Cardiac Anesthesia & ICU, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
- Department of Critical Care Medicine, Beni-Suef University, Beni Suef, Egypt
- Weill Cornell Medical College, Ar-Rayyan, Qatar
| | - Ahmed D Abohamar
- Anesthesia Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Zhao J, Zhao F, Yuan J, Liu H, Wang Y. Gut microbiota metabolites, redox status, and the related regulatory effects of probiotics. Heliyon 2023; 9:e21431. [PMID: 38027795 PMCID: PMC10643359 DOI: 10.1016/j.heliyon.2023.e21431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/29/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Oxidative stress is a state of imbalance between oxidation and antioxidation. It is caused by excess levels of free radicals and leads to the damage of DNA, proteins, and lipids. The crucial role of gut microbiota in regulating oxidative stress has been widely demonstrated. Studies have suggested that the redox regulatory effects of gut microbiota are related to gut microbiota metabolites, including fatty acids, lipopolysaccharides, tryptophan metabolites, trimethylamine-N-oxide and polyphenolic metabolites. In recent years, the potential benefits of probiotics have been gaining increasing scientific interest owing to their ability to modulate gut microbiota and oxidative stress. In this review, we summarise the adverse health effects of oxidative stress and discuss the role of the gut microbiota and its metabolites in redox regulation. Based on the influence of gut microbiota metabolites, the roles of probiotics in preventing oxidative stress are highlighted.
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Affiliation(s)
| | | | - Junmeng Yuan
- College of Animal Science and Technology, Qingdao Agricultural University, 266109, Qingdao, China
| | - Huawei Liu
- College of Animal Science and Technology, Qingdao Agricultural University, 266109, Qingdao, China
| | - Yang Wang
- College of Animal Science and Technology, Qingdao Agricultural University, 266109, Qingdao, China
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Kimura Y, Okahara S, Abo K, Koyama Y, Kuriyama M, Ono K, Hidaka H. Infective Endocarditis Is a Risk Factor for Heparin Resistance in Adult Cardiovascular Surgical Procedures: A Retrospective Study. J Cardiothorac Vasc Anesth 2021; 35:3568-3573. [PMID: 34144872 DOI: 10.1053/j.jvca.2021.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Heparin resistance (HR), defined as a decrease in heparin responsiveness, can result in adverse events with prolonged duration of surgery. Although some clinical risk factors have been suggested, the relationship with the surgical diagnosis is unclear. The aim of present study was to elucidate the clinical predictors of HR including the surgical diagnosis. DESIGN This retrospective cohort study determined the incidence of HR (defined as activated clotting time [ACT] <400 seconds after 250-350 IU/kg of heparin administration) and heparin sensitivity index (HSI) was calculated from the rate of change in ACT per heparin dose. Preoperative demographic data, medication history, and laboratory data also were analyzed. SETTING Single institution, tertiary care hospital. PARTICIPANTS Adult patients who underwent cardiovascular surgery with cardiopulmonary bypass between January 2012 and September 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 287 patients, 88 (30.7%) were classified as HR. In univariate analysis, infective endocarditis (IE), platelet count, and serum fibrinogen and albumin levels were associated with HR. After adjustment for baseline ACT and initial heparin dose, IE (odds ratio 4.57, [95% CI: 1.10-19.1]; p = 0.037) and albumin ≤3.5 g/dL (3.17, [1.46-6.93]; p = 0.004) were associated independently with HR. Patients with IE had significantly lower HSI than those with other diseases. All HR patients were treated with additional heparin, and 17 of them received human antithrombin-III concentrate. CONCLUSIONS Infective endocarditis and preoperative hypoalbuminemia were associated independently with HR. The optimal anticoagulation strategy for patients with these risk factors requires further investigations based on the authors' findings.
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Affiliation(s)
- Yoshikazu Kimura
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan.
| | - Shuji Okahara
- Department of Intensive Care Medicine, Okayama University Hospital, Okayama, Japan
| | - Kanae Abo
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
| | - Yusuke Koyama
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
| | - Mitsuhito Kuriyama
- Department of Cardiovascular Surgery, Saiseikai Imabari Hospital, Ehime, Japan
| | - Kazumi Ono
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hidekuni Hidaka
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
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Chakravarthy M, Prabhakumar D, Thimmannagowda P, Krishnamoorthy J, George A, Jawali V. Comparison of two doses of heparin on outcome in off-pump coronary artery bypass surgery patients: A prospective randomized control study. Ann Card Anaesth 2017; 20:8-13. [PMID: 28074788 PMCID: PMC5290702 DOI: 10.4103/0971-9784.197818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: While off pump coronary artery bypass surgery is practiced with an intention to reduce the morbidity associated with cardiopulmonary bypass, the resultant ‘hypercoagulability’ needs to be addressed. Complications such as cavitary thrombus possibly due to the hyper coagulability after off pump coronary artery bypass surgery have been described. Many clinicians use higher doses of heparin - up to 5 mg/kg in order to thwart this fear. Overall, there appears to be no consensus on the dose of heparin in off pump coronary artery bypass surgeries. Aim of the Study: The aim of the study was understand the differences in outcome of such as transfusion requirement, myocardial ischemia, and morbidity when two different doses were used for systemic heparinization. Methods: Elective patients scheduled for off pump coronary artery bypass surgery were included. Ongoing anti platelet medication was not an exclusion criteria, however, anti platelet medications were ceased about a week prior to surgery when possible. Thoracic epidural anesthesia was administered as an adjunct in patients who qualified for it. By computer generated randomization chart, patients were chosen to receive either 2 or 3 mg/kg of intravenous unfractioned heparin to achieve systemic heparinization with activated clotting time targeted at >240 secs. Intraoperative blood loss, postoperative blood loss, myocardial ischemic episodes, requirement of intraaortic balloon counter pulsation and transfusion requirement were analyzed. Results: Sixty two patients participated in the study. There was one conversion to cardiopulmonary bypass. The groups had comparable ACT at baseline (138.8 vs. 146.64 seconds, P = 0.12); 3 mg/kg group had significantly higher values after heparin, as expected. But after reversal with protamine, ACT and need for additional protamine was similar among the groups. Intraoperative (685.56 ± 241.42 ml vs. 675.15 ± 251.86 ml, P = 0.82) and postoperative blood loss (1906.29 ± 611.87 ml vs 1793.65 ± 663.54 ml, p value 0.49) were similar among the groups [Table 4]. The incidence of ECG changes of ischemia, arrhythmias, conversion to CPB, or need for intra-aortic balloon counter pulsation were not different. Conclusions: Use of either 2 or 3 mg/kg heparin for systemic heparinization in patients undergoing OPCAB did not affect the outcome.
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Affiliation(s)
- Murali Chakravarthy
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
| | - Dattatreya Prabhakumar
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
| | - Patil Thimmannagowda
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
| | | | - Antony George
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
| | - Vivek Jawali
- Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India
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Rasoli S, Zeinah M, Athanasiou T, Kourliouros A. Optimal intraoperative anticoagulation strategy in patients undergoing off-pump coronary artery bypass. Interact Cardiovasc Thorac Surg 2012; 14:629-33. [PMID: 22307394 DOI: 10.1093/icvts/ivs003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was what the optimal intraoperative anticoagulation strategy should be in patients undergoing off-pump coronary artery bypass graft (CABG) surgery. A total of 157 papers were identified using the reported search, of which 8 were judged to represent the best evidence. The authors, journal, date, country of publication, study type, patient group studied, relevant outcomes and results were tabulated. The quality of clinical trials was assessed. Off-pump CABG is currently considered as a safe and effective alternative to CABG with the use of cardiopulmonary bypass, especially in the presence of off-pump expertise and certain pathologies. Although most technical steps in off-pump revascularization are standardized, it appears that there is inconsistency in intraoperative anticoagulation practice. Surveys conducted in the USA and Europe confirm the lack of uniform policy, with heparin dose ranging between 70 and 500 U/kg and from full-dose protamine to no reversal of anticoagulation. Although the quality of evidence is low, there is a trend for utilization of heparin at 150 U/kg, followed by half-dose protamine reversal, which appears to provide adequate anticoagulation for the safe conduct of anastomoses and thromboprophylaxis without significantly increasing the risk of postoperative bleeding. However, more research is necessary before firm recommendations can be made.
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Affiliation(s)
- Sonia Rasoli
- Division of Surgery, Imperial College, London, UK
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