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Tanaka KA, Henderson R, Thangaraju K, Morita Y, Mazzeffi MA, Strauss E, Katneni U, Buehler PW. In vitro effects of emicizumab on activated clotting time in blood samples from cardiac surgical patients. Haemophilia 2021; 28:183-190. [PMID: 34735039 DOI: 10.1111/hae.14452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heparin management in hemophilia A (HA) patients with a factor VIII (FVIII) inhibitor can be challenging due to severe activated clotting time (ACT) prolongations. It is important to better understand the impact of emicizumab, a FVIII mimetic on ACT, and tissue factor (TF)-based coagulation assays. METHODS Whole blood from 18 patients undergoing cardiopulmonary bypass (CPB) were mixed in vitro with pooled normal plasma, FVIII-deficient or FVIII-inhibitor plasma to affect functional FVIII levels. ACTs and heparin concentration by protamine titration were measured in whole blood mixture with/without emicizumab (50-100 μg/ml). Thrombin generation and plasmin generation were measured in the patient's plasma mixed with normal plasma or FVIII-inhibitor plasma to assess the impact of emicizumab under low TF activation. RESULTS FVIII inhibitors prolonged ACTs by 2.2-fold compared to those in normal plasma mixture at baseline. During CPB, ACTs in normal plasma mixture, and FVIII-deficient mixture were in 400s, but ACTs reached 900s in FVIII-inhibitor mixture. Emicizumab shortened ACTs by up to 100s in normal plasma mixture, and FVIII-deficient mixtures. ACTs remained over 600s in FVIII-inhibitor mixture, despite adding emicizumab at 100 μg/ml. Heparin concentration measured by TF-based protamine titration was unaffected. Emicizumab enhanced thrombin peak in the presence of FVIII inhibitors, whereas plasmin generation was mainly affected by thrombin generation, and systemic use of ɛ-aminocaproic acid. CONCLUSIONS FVIII inhibitors extensively prolong ACTs in heparinized whole blood, and clinical levels of emicizumab partially reverse ACT values. Protamine titration should be considered for optimal heparin monitoring in emicizumab-treated patients with FVIII inhibitors.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Reney Henderson
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kiruphagaran Thangaraju
- Departments of Pathology and Pediatrics, Center for Blood Oxygen Transport, University of Maryland, Baltimore, Maryland, USA
| | - Yoshihisa Morita
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Erik Strauss
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Upendra Katneni
- Departments of Pathology and Pediatrics, Center for Blood Oxygen Transport, University of Maryland, Baltimore, Maryland, USA
| | - Paul W Buehler
- Departments of Pathology and Pediatrics, Center for Blood Oxygen Transport, University of Maryland, Baltimore, Maryland, USA
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Lin PS, Yao YT. Perioperative Management of Hemophilia A Patients Undergoing Cardiac Surgery: A Literature Review of Published Cases. J Cardiothorac Vasc Anesth 2020; 35:1341-1350. [PMID: 32723585 DOI: 10.1053/j.jvca.2020.06.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To investigate the perioperative management of patients with hemophilia A (HA) who undergo cardiac surgery. DESIGN Retrospective analysis of the published literature. SETTING University hospital. PARTICIPANTS HA patients undergoing cardiac surgery. INTERVENTIONS The PubMed, Embase, Web of Science Core Collection, CNKI, VIP, and WANFANG databases were searched with the terms "hemophilia A," "cardiac surgery," "cardiopulmonary bypass," "coronary artery bypass graft," "valve disease," and "congenital heart disease" to identify relevant articles. Data regarding patient characteristics, perioperative management protocols, and clinical outcomes were extracted and analyzed. MEASUREMENTS AND MAIN RESULTS Fifty articles, with 72 patients aging from 12 days to 80 years, were included. The analyzed population consisted of 36 (50%) mild HA, 10 (14%) moderate HA, and 25 (35%) severe HA patients. Factor VIII inhibitors were detected in 7 cases. Surgical procedures included 27 coronary artery bypass grafting procedures, 15 valve surgeries, 8 combined coronary artery bypass grafting with valve surgery procedures (1 with left ventricular assist device), 1 ventricular aneurysm resection with valve surgery, 11 corrections of congenital heart disease, 7 adult aortic surgeries, 3 heart transplantations, and 1 repair of heart injury. Factor VIII concentrates were used as a substitution therapy to ensure normalization of perioperative coagulation function. Although an uneventful clinical outcome was achieved in the majority of cases, 20% of patients developed complications with different severities. CONCLUSIONS Execution of a perioperative management strategy with a multidisciplinary approach, a thorough factor replacement protocol, and careful monitoring of factor levels facilitate an optimal outcome for HA patients undergoing cardiac surgery.
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Affiliation(s)
- Pei-Shuang Lin
- Department of Anesthesiology, Fujian Medical University Affiliated First Quanzhou Hospital, Fujian, China
| | - Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
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Mingot-Castellano ME, Álvarez-Román MT, López-Fernández MF, Altisent-Roca C, Canaro-Hirnyk MI, Jiménez-Yuste V, Cid-Haro AR, Pérez-Garrido R, Sedano-Balbas C. Spanish consensus guidelines on prophylaxis with bypassing agents for surgery in patients with haemophilia and inhibitors. Eur J Haematol 2016; 96:461-74. [DOI: 10.1111/ejh.12730] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2015] [Indexed: 01/18/2023]
Affiliation(s)
| | | | | | | | | | | | - Ana Rosa Cid-Haro
- Thrombosis and Haemostasis Unit; Hospital Universitario La Fe; Valencia Spain
| | | | - Carmen Sedano-Balbas
- Haematology Department; Hospital Universitario Marqués de Valdecilla; Cantabria Spain
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Abstract
With advances in care, increasing numbers of people with hemophilia (PWH) achieve near-normal life expectancies and present with typical age-related cardiovascular conditions. Evidence-based guidelines for medical or surgical management of cardiovascular conditions in individuals with hemophilia are limited. Published recommendations exist for the management of some common cardiovascular conditions (eg, ischemic heart disease, atrial fibrillation), but identifying optimal strategies for anticoagulant or antithrombotic therapy constitutes the primary challenge of managing nonoperative cardiovascular disease (CVD) in PWH. In general, as long as factor concentrates or other hemostatic therapies maintain adequate hemostasis, the recommended medical and surgical management of CVD in PWH parallels that in individuals without hemophilia. The presence of factor inhibitors complicates hemophilia management. Published outcomes of CVD treatment in PWH are similar to those in the general population. Specific knowledge about factor replacement, factor inhibitors, and disease-specific treatment distinguishes the cardiovascular care of PWH from similar care of individuals without this rare bleeding disorder. Furthermore, a multidisciplinary approach incorporating a hematologist with an onsite coagulation laboratory, ideally associated with a hemophilia treatment center, is integral to the management of CVD in PWH.
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Barbara DW, McKenzie KM, Parikh SA, Ashrani AA, Pruthi RK, Burkhart HM, Suri RM, Mauermann WJ. Successful Perioperative Management of Severe Bleeding From Undiagnosed Acquired Factor VIII Inhibitors. J Cardiothorac Vasc Anesth 2014; 29:731-4. [PMID: 24462516 DOI: 10.1053/j.jvca.2013.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Indexed: 11/11/2022]
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Quader M, Rusina Z, Lewis NP, Martin L, Katlaps G. Left Ventricular Assist Device and Heart Transplantation in Hemophilia A Patient. Ann Thorac Surg 2013; 96:2245-7. [DOI: 10.1016/j.athoracsur.2013.04.095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/22/2013] [Accepted: 04/02/2013] [Indexed: 11/27/2022]
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Damodar S, Bhat P, Kumar P, Tr R, Gupta R. Successful aortic valve replacement surgery in a patient with severe haemophilia a with low titre inhibitor. Indian J Hematol Blood Transfus 2013; 30:64-6. [PMID: 25332538 DOI: 10.1007/s12288-013-0249-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 03/13/2013] [Indexed: 11/28/2022] Open
Abstract
In spite of the modern day innovations, managing severe Haemophilia patients with inhibitors continues to be a challenge. The management of patients with severe haemophilia with inhibitors who are undergoing major surgeries like open heart surgery is technically demanding, fraught with peri-operative complications and needs a multidisciplinary approach. We describe a young man with severe haemophilia with low titre inhibitors who underwent a successful open heart surgery and aortic valve replacement, supported only with bolus doses of Factor VIII and tranexamic acid without any complications.
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Affiliation(s)
- Sharat Damodar
- Department of Haematology, Narayana Hrudayalaya, No. 258/A, Bomasandra Industrial Area, Anekal Taluq, Bangalore, 560099 Karnataka India
| | - Prashantha Bhat
- Department of Haematology, Narayana Hrudayalaya, No. 258/A, Bomasandra Industrial Area, Anekal Taluq, Bangalore, 560099 Karnataka India
| | - Praveen Kumar
- Department of Cardiac Surgery, Narayana Hrudayalaya, Bangalore, 560099 Karnataka India
| | - Rajesh Tr
- Department of Cardiac Surgery, Narayana Hrudayalaya, Bangalore, 560099 Karnataka India
| | - Ratan Gupta
- Intensive Care Unit, Narayana Hrudayalaya, Bangalore, 560099 Karnataka India
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Kulkarni R. Comprehensive care of the patient with haemophilia and inhibitors undergoing surgery: practical aspects. Haemophilia 2012; 19:2-10. [PMID: 22925397 DOI: 10.1111/j.1365-2516.2012.02922.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2012] [Indexed: 11/30/2022]
Abstract
Congenital haemophilia is a rare and complex condition for which dedicated specialized and comprehensive care has produced measurable improvements in clinical outcomes and advances in patient management. Among these advances is the ability to safely perform surgery in patients with inhibitor antibodies to factors VIII and IX, in whom all but the most necessary of surgeries were once avoided due to the risk for uncontrollable bleeding due to ineffectiveness of replacement therapy. Nevertheless, surgery continues to pose a major challenge in this relatively rare group of patients because of significantly higher costs than in patients without inhibitors, as well as a high risk for bleeding and other complications. Because of the concentration of expertise and experience, it is recommended that any surgery in patients with haemophilia and inhibitors be planned in conjunction with a haemophilia treatment centre (HTC) and performed in a hospital that incorporates a HTC. Coordinated, standard pre-, intra- and postoperative assessments and planning are intended to optimize surgical outcome and utilization of resources, including costly factor concentrates and other haemostatic agents, while minimizing the risk for bleeding and other adverse consequences both during and after surgery. This article will review the special considerations for patients with inhibitors as they prepare for and move through surgery and recovery, with an emphasis on the roles and responsibilities of individual members of the multidisciplinary team in facilitating this process.
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Affiliation(s)
- R Kulkarni
- Division of Pediatric and Adolescent Hematology/Oncology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI 48824, USA.
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Ventricular assist device as a bridge to transplant, and extracorporeal membrane oxygenation for primary graft failure in a child with hemophilia A. Pediatr Crit Care Med 2011; 12:e432-5. [PMID: 21926657 DOI: 10.1097/pcc.0b013e31822f1b63] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To report the management of hemophilia in a patient with dilated cardiomyopathy during application of the Berlin-Heart biventricular assist. DESIGN Case report. INTERVENTIONS AND RESULTS The Berlin-Heart biventricular assist was successfully used as a bridge to heart transplantation (178 days) in a child with hemophilia A; post-transplant extracorporeal membrane oxygenation was implanted until the patient recovered from primary graft failure. Anticoagulant therapy varied as a function of patient status: 1) postoperative bleeding was treated by partial replacement of deficient factors (VII and VIII) and hemoderivatives in order to maintain factor VIII at 50% of normal levels; 2) once the bleeding had stopped, the effect of the hemophilia itself maintained the degree of anticoagulation required by the ventricular assist device; and 3) transplant surgery was followed by complete replacement of factor VIII and intravenous heparinization (a simple way of preventing clot formation in the device and to ensure proper scarring of surgical wounds). CONCLUSIONS Selection of anticoagulant therapy as a function of patient status in terms of bleeding and surgical-wound scarring progress is vital for the proper functioning of support techniques (Berlin-Heart biventricular assist and extracorporeal membrane oxygenation) in hemophiliac patients. Collagen dressings placed on surgical wounds achieved good functional and aesthetic results, as well as mechanically isolating the scars from the exterior.
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VALENTINO LA, COOPER DL, GOLDSTEIN B. Surgical Experience with rFVIIa (NovoSeven) in congenital haemophilia A and B patients with inhibitors to factors VIII or IX. Haemophilia 2011; 17:579-89. [DOI: 10.1111/j.1365-2516.2010.02460.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Successful cryoablation of atrioventricular nodal reentrant tachycardia in a child with hemophilia A. J Pediatr Hematol Oncol 2010; 32:404-6. [PMID: 20505535 DOI: 10.1097/mph.0b013e3181e0040d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report the hematologic and invasive electrophysiologic management of a 12-year-old boy with mild hemophilia A (factor VIII deficiency) and atrioventricular nodal reentrant tachycardia. Thoughtful preparation with detailed input from the patient's comprehensive hemophilia center combined with vigilant pericatheterization hematologic management allowed for safe and successful cryoablation of this arrhythmia. Strategies for the management of patients with bleeding disorders who require invasive cardiac catheterization or surgery are reviewed.
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Defining the role of recombinant activated factor VII in pediatric cardiac surgery: where should we go from here? Pediatr Crit Care Med 2009; 10:572-82. [PMID: 19451849 DOI: 10.1097/pcc.0b013e3181a642d5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Postoperative hemorrhage is a recognized complication of pediatric cardiac surgery. Both the immature coagulation system and increased susceptibility to hemodilution increase the likelihood of pediatric patients developing coagulopathy when compared with adult counterparts. Treatment options remain limited. Recombinant factor VII (rFVIIa) is a hemostatic agent increasingly used to reduce hemorrhage in other surgical settings, the role of which is unclear in this population. This article systematically reviews the published literature on the use of rFVIIa in pediatric cardiac surgery. DATA SOURCES AND STUDY SELECTION A systematic literature search identified reports of rFVIIa administration in pediatric patients undergoing cardiac surgery. Where possible, individual patient-specific data were extracted and pooled statistical analysis was performed. DATA EXTRACTION AND SYNTHESIS Twenty-nine articles reporting on the administration of rFVIIa to 169 patients were identified. rFVIIa has been administered to patients with predefined congenital abnormalities of hemostasis to arrest hemorrhage refractory to other interventions and prophylactically in the hope of reducing blood loss. Treatment regimens vary widely, in terms of both first and cumulative dose. Data on chest tube blood loss and two markers of coagulation were pooled and analyzed, and significant improvements were demonstrated. Mortality was 4.4% for the entire cohort but 20% of patients on extracorporeal membrane oxygenation suffered significant thromboembolic complications. CONCLUSIONS rFVIIa has an increasingly accepted role in the management of patients with congenital coagulopathies undergoing major surgery. However, randomized trials are required to define the role of rFVIIa as an adjunct to control major hemorrhage in the pediatric cardiac surgical population. Any future work must focus not only on benefits but also on patient safety, particularly, risk of morbid thromboembolic complication.
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TEITEL JM, CARCAO M, LILLICRAP D, MULDER K, RIVARD GE, ST-LOUIS J, SMITH F, WALKER I, ZOURIKIAN N. Orthopaedic surgery in haemophilia patients with inhibitors: a practical guide to haemostatic, surgical and rehabilitative care. Haemophilia 2009; 15:227-39. [DOI: 10.1111/j.1365-2516.2008.01840.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Gandhi MJ, Pierce RA, Zhang L, Moon MR, Despotis GJ, Moazami N. Use of activated recombinant factor VII for severe coagulopathy post ventricular assist device or orthotopic heart transplant. J Cardiothorac Surg 2007; 2:32. [PMID: 17617902 PMCID: PMC1939840 DOI: 10.1186/1749-8090-2-32] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Accepted: 07/06/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ventricular assist devices(VAD) implantation/removal is a complex surgical procedure with perioperative bleeding complications occurring in nearly half of the cases. Recombinant activated factor VII (rFVIIa) has been used off-label to control severe hemorrhage in surgery and trauma. We report here our experience with rFVIIa as a rescue therapy to achieve hemostasis in patients undergoing orthotopic heart transplant (OHT) and/or VAD implantation. METHODS A retrospective review was conducted from Jan 03 to Aug 05 for patients who received rFVIIa for the management of intractable bleeding unresponsive to standard hemostatic blood component therapy. Blood loss and the quantity of blood products, prior to, and for at least 12 hours after, administration of rFVIIa were recorded. RESULTS Mean patient age was 53, (38-64 yrs), mean dose of rFVIIa administered was 78.3 microg/kg (24-189 microg/kg) in 1-3 doses. All patients received the drug either intraoperatively or within 6 hours of arrival in ICU. Mean transfusion requirements and blood loss were significantly reduced after rFVIIa administration (PRBC's; 16.9 +/- 13.3 to 7.1 +/- 6.9 units, FFP; 13.1 +/- 8.2 to 4.1 +/- 4.9 units, platelets; 4.0 +/- 2.8 to 2.1 +/- 2.2 units, p < 0.04 for all). 5 patients expired including 3 with thromboembolic cause. One patient developed a lower extremity arterial thrombus, and another deep vein thrombosis. CONCLUSION In this review, there was a significant decrease in transfusion requirement and blood loss after rFVIIa administration. Although, 5/17 developed thromboembolic complications, these patients may have been at higher risk based on the multiple modality therapy used to manage intractable bleeding. Nevertheless, the exact role of rFVIIa with respect to development of thromboembolic complications cannot be clearly determined. Further investigation is needed to determine rFVIIa's safety and its effectiveness in improving postoperative morbidity and mortality.
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Affiliation(s)
- Manish J Gandhi
- Department of Pathology and Immunology, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
- Mayo Clinic, Division of Transfusion Medicine, 200 First St SW, Rochester, MN 55901
| | - Richard A Pierce
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Lini Zhang
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Marc R Moon
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - George J Despotis
- Department of Pathology and Immunology, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
- Department of Anesthesiology, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Nader Moazami
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
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STEINER MARIEE, KEY NIGELS. Use of recombinant activated factor VII in the management of medical and surgical bleeding: a critical review. ACTA ACUST UNITED AC 2006. [DOI: 10.1111/j.1778-428x.2006.00033.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Yilmaz BT, Alioglu B, Ozyurek E, Akay HT, Mercan S, Ozbek N. Successful use of recombinant factor VIIa (NovoSeven) during cardiac surgery in a pediatric patient with Glanzmann thrombasthenia. Pediatr Cardiol 2005; 26:843-5. [PMID: 15690232 DOI: 10.1007/s00246-004-0919-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Glanzmann thrombasthenia is a rare, hereditary, congenital disorder of platelet function characterized by inappropriate bleeding that is difficult to control. Recombinant activated factor VII (rFVIIa) is a new treatment that is used to stop bleeding and provide surgical support for these patients. This report describes the use of rFVIIa to prevent serious bleeding during and after open-heart surgery in a child with Glanzmann thrombasthenia.
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Affiliation(s)
- B T Yilmaz
- Department of Pediatrics, Pediatric Hematology Unit, Baskent University Faculty of Medicine, 6.cad No:72/3 06490, Bahcelievler, Ankara, Turkey
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Khakhar AK, Chan NG, Allan DS, Chakrabarti S, McAlister VC. Catastrophic microangiopathy induced by high-titre factor VIII inhibitors after liver transplantation for haemophilia A with cirrhosis. Haemophilia 2005; 11:623-8. [PMID: 16236113 DOI: 10.1111/j.1365-2516.2005.01145.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Liver transplantation may induce immune tolerance to factor VIII inhibitors but de novo development of inhibitors after transplantation may cause intractable haemorrhage. We report a patient with mild haemophilia A and high-titre FVIII inhibitors who received an orthotopic liver transplantation for complications of hepatitis C virus cirrhosis. Recombinant activated FVII was used in addition to routine haemostatic agents. Conventional immunosuppression was supplemented with antithymocyte globulin and cyclophosphamide. FVIII inhibitors disappeared from the circulation with liver transplantation but they were found to have bound to the graft endothelium, which became activated and induced catastrophic microangiopathy. A subsequent anamnestic response resulted in FVIII inhibitor titres of 1000 Bethesda Units. Uncontrollable haemorrhage persisted until the recipient's death. In patients with high-titre FVIII inhibitors resilient desensitization is required before liver transplantation.
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Affiliation(s)
- A K Khakhar
- Department of Surgery, University of Western Ontario, ON, Canada
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20
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Abstract
The widespread application of antithrombotic agents carries significant potential for inducing excessive peri-operative hemorrhage during cardiac surgery. Specific surgical and medical strategies can be employed to attenuate this bleeding. These antithrombotic agents and anti-hemorrhagic measures will be reviewed in depth.
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Affiliation(s)
- Y Joseph Woo
- Minimally Invasive and Robotic Cardiac Surgery Program, Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania, Silverstein 6, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Szabo T, Ali S, Camporesi EM. Intraoperative Recombinant Activated Factor VII for Emergent Epidural Hematoma Evacuation. Anesth Analg 2004; 99:595-7, table of contents. [PMID: 15271747 DOI: 10.1213/01.ane.0000130394.85483.c7] [Citation(s) in RCA: 7] [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
We report a case of a chronically anticoagulated 59-yr-old woman who underwent an L4 to L5 epidural block to relieve her low back pain and subsequently developed a T7 to L5 epidural hematoma with cauda equina and conus compression. Fresh frozen plasma and vitamin K were given before surgery, whereas recombinant activated factor VII was administered during surgery to reverse the coagulopathy and to enable the emergent laminectomy and hematoma evacuation. Recombinant activated factor VII administration proved to be a useful adjunct in the emergent surgical management of a thoracolumbar epidural hematoma.
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Affiliation(s)
- Tamas Szabo
- Department of Anesthesiology, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.
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Stratmann G, deSilva AM, Tseng EE, Hambleton J, Balea M, Romo AJ, Mann MJ, Achorn NL, Moskalik WF, Hoopes CW. Reversal of Direct Thrombin Inhibition After Cardiopulmonary Bypass in a Patient with Heparin-Induced Thrombocytopenia. Anesth Analg 2004; 98:1635-1639. [PMID: 15155316 DOI: 10.1213/01.ane.0000114072.71353.d5] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED We treated persistent hemorrhage after cardiopulmonary bypass in a heart transplant recipient who had received anticoagulation with the direct thrombin inhibitor bivalirudin by a combination therapy aimed at reducing the plasma concentration of the thrombin antagonist (hemodialysis and modified ultrafiltration), increasing the concentration of thrombin at bleeding sites (recombinant factor VIIa), and increasing the plasma concentration of other coagulation factors (fresh frozen plasma and cryoprecipitate). The bleeding was controlled, and there was no thrombotic complication. IMPLICATIONS A combination of modified ultrafiltration, hemodialysis, and the administration of recombinant factor VIIa, fresh frozen plasma, and cryoprecipitate may reverse the anticoagulant effect of bivalirudin.
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Affiliation(s)
- Greg Stratmann
- Departments of *Anesthesia and Perioperative Care, †Surgery, and ‡Medicine, University of California at San Francisco; and §Golden Gate Perfusion, Inc., San Francisco, California
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Abstract
Congenital vascular lesions are classed as hemangiomas, vascular malformations, or vascular tumors according to their histology and etiology. The majority of hemangiomas are benign and often involute before the child reaches the age of 12. Severe hemangiomas and vascular malformations were historically viewed as effectively inoperable due to the high risk of potentially catastrophic bleeding during surgery. An effective system of classification and increasing range of therapeutic options have improved the prognosis for many patients, but surgical resection of these lesions remains a serious undertaking. Topical hemostatic agents are widely used and effective in many cases for the control of intraoperative bleeding. The main limitations of these agents are their variability and lack of efficacy in severe bleeding, or in coagulopathic or anticoagulant-treated patients. This paper reviews recent developments in this field, including the possible placental origin of hemangiomas, and discusses current approaches to hemostasis during reconstructive surgery. We also discuss the recent introduction of recombinant activated factor VII (rFVIIa) as a systemic hemostatic agent, including our own experience using this treatment.
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Affiliation(s)
- Milton Waner
- Department of Otolaryngology, University of Arkansas for Meedical Sciences, Little Rock, AR, USA
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24
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Stratmann G, Russell IA, Merrick SH. Use of recombinant factor VIIa as a rescue treatment for intractable bleeding following repeat aortic arch repair. Ann Thorac Surg 2003; 76:2094-7. [PMID: 14667657 DOI: 10.1016/s0003-4975(03)01052-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Hemorrhage, refractory to aggressive conventional therapy, at a rate of 16 L/hr following separation from cardiopulmonary bypass for aortic arch repair, was controlled with a dose of 90 microg/kg of recombinant factor VIIa, repeated once after 2 hours.
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Affiliation(s)
- Greg Stratmann
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, California 94143, USA.
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25
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Thiagarajan RR, Roth SJ, Margossian S, Mackie AS, Neufeld EJ, Laussen PC, Forbess JM, Blume ED. Extracorporeal membrane oxygenation as a bridge to cardiac transplantation in a patient with cardiomyopathy and hemophilia A. Intensive Care Med 2003; 29:985-988. [PMID: 12719805 DOI: 10.1007/s00134-003-1748-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2003] [Accepted: 03/13/2003] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To report the use of extracorporeal membrane oxygenation (ECMO) as a bridge to cardiac transplantation in a patient with hemophilia A and dilated cardiomyopathy. DESIGN Case report. INTERVENTIONS AND RESULTS During ECMO factor VIII concentrate was administered to maintain a factor VIII level close to 50% of normal control both to decrease the risk of bleeding and to allow standard anticoagulation with heparin. The patient developed an inhibitor to exogenous factor VIII during hospitalization, which was successfully managed with a high-dose continuous infusion of factor VIII during ECMO, the transplant operation, and the postoperative period. CONCLUSIONS We report the successful use of ECMO as a bridge to cardiac transplantation in a patient with hemophilia A and low-level factor VIII inhibitors.
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Affiliation(s)
- Ravi R Thiagarajan
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Departments of Pediatrics and Surgery, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA.
| | - Stephen J Roth
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA, 02115, USA
- Departments of Pediatrics and Surgery, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
| | - Steven Margossian
- Division of Hematology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA, 02115, USA
- Departments of Pediatrics and Surgery, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
| | - Andrew S Mackie
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA, 02115, USA
- Departments of Pediatrics and Surgery, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
| | - Ellis J Neufeld
- Division of Hematology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA, 02115, USA
- Departments of Pediatrics and Surgery, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
| | - Peter C Laussen
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA, 02115, USA
- Departments of Pediatrics and Surgery, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
| | - Joseph M Forbess
- Department of Cardiovascular Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA, 02115, USA
- Departments of Pediatrics and Surgery, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
| | - Elizabeth D Blume
- Department of Cardiology, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA, 02115, USA
- Departments of Pediatrics and Surgery, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, 02115, USA
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26
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Nonthasoot B, Nivatvongs S. Multiple doses of recombinant factor VIIa in orthotopic liver transplantation: a case report. Transplant Proc 2003; 35:427-8. [PMID: 12591472 DOI: 10.1016/s0041-1345(02)03884-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- B Nonthasoot
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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27
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Ghosh K, Jijina F, Shetty S, Madkaikar M, Mohanty D. First-time development of FVIII inhibitor in haemophilia patients during the postoperative period. Haemophilia 2002; 8:776-80. [PMID: 12410646 DOI: 10.1046/j.1365-2516.2002.00687.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Development of inhibitor to FVIII in haemophilia patients is well-known and is not uncommon. However, their development for the first time during the postoperative period has hardly been reported. In a developing country such as India, where resources are limited, development of such an eventuality may prove disastrous. However, as many of our patients are sparingly treated, therefore, even if they test negative for the inhibitor preoperatively, they may get the requisite FVIII antigenic stimulation during the preoperative and immediate postoperative period, leading to the development of inhibitors during this critical time of wound healing. We describe here six patients who developed such an inhibitor, from a group of 35 patients with haemophilia A who underwent various surgical procedures (19%). We stress that such an eventuality may not remain rare in developing countries as more patients of severe haemophilia undergo surgery and are therefore challenged for the first time in their life with large amounts of FVIII concentrate during their preoperative period.
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Affiliation(s)
- K Ghosh
- Institute of Immunohaematology (ICMR), KEM Hospital, Parel, Mumbai, India
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28
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Govindaswamy S, Chandler J, Latimer R, Vuylsteke A. Management of the patient with coagulation disorders. Curr Opin Anaesthesiol 2002; 15:19-25. [PMID: 17019180 DOI: 10.1097/00001503-200202000-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Understanding normal haemostasis and the pathophysiology of its disorders is essential for providing optimal care and ensuring judicious usage of blood products, as is keeping abreast of novel therapeutic modalities in a rapidly evolving field. The growing availability of synthetic coagulation factors has (at least in the western hemisphere) helped to reduce morbidity and therapeutic complications, while expanding the indications and usage of these agents. Promising advances in gene therapy may indeed introduce a sea change in the next decade or two.
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