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Frere C, Mazzeffi M, Maier CL, Helms J, Steiner ME, Sullenger BA, Tanaka KA, Connors JM, Levy JH. Acquired von Willebrand syndrome during extracorporeal membrane oxygenation support: a comprehensive review of current evidence: communication from the ISTH SSC on perioperative and critical care thrombosis and hemostasis. J Thromb Haemost 2024; 22:2608-2628. [PMID: 38925492 DOI: 10.1016/j.jtha.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 06/11/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
During extracorporeal membrane oxygenation (ECMO) support, the high shear stress in the ECMO circuit results in increased proteolysis of von Willebrand factor (VWF), loss of VWF high-molecular-weight multimers, and impaired ability to bind to platelets and collagen. These structural changes in VWF are consistent with acquired von Willebrand syndrome (AVWS) type 2A and may contribute to the bleeding diathesis frequently observed in ECMO patients. We performed a systematic review of all clinical studies evaluating the prevalence and associated outcomes of AVWS in ECMO patients. Our findings suggest that almost all ECMO patients develop partial or complete loss of VWF high-molecular-weight multimers within a few hours of device implantation. The AVWS persists as long as the patient is supported by ECMO. Weaning from ECMO rapidly and completely resolves the AVWS. Nevertheless, few studies have reported bleeding outcomes in ECMO patients with AVWS, and the extent to which AVWS contributes to the bleeding diathesis during ECMO support cannot be determined by current evidence. Data supporting the use of VWF concentrates to prevent bleeding complications in ECMO patients remain limited.
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Affiliation(s)
- Corinne Frere
- Department of Hematology, Sorbonne Université, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Julie Helms
- Department of Medical Intensive Care, Strasbourg University (UNISTRA), Strasbourg University Hospital, Strasbourg, France; INSERM (French National Institute of Health and Medical Research), UMR (Unité mixte de recherche) 1260, Regenerative Nanomedicine (RNM), Strasbourg, France
| | - Marie E Steiner
- Department of Pediatrics, Divisions of Hematology/Oncology and Critical Care, University of Minnesota, Minneapolis, Minnesota, USA
| | - Bruce A Sullenger
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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Pascreau T, Gougeon M, Fessler J, Zia Chahabi S, Le Guen M, Vasse M. Interest in the new thromboelastometry device, Clot Pro®, for predicting thrombocytopenia and hypofibrinogenemia during lung transplantation. Thromb Res 2024; 233:203-211. [PMID: 38128338 DOI: 10.1016/j.thromres.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/30/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Lung transplantation is associated with high proportion of transfusion. Monitoring of coagulopathy using viscoelastic tests could aid in the perioperative management of bleeding. The aim of the study was to assess the predictive cut-off values for thrombocytopenia and hypofibrinogenemia using the new thromboelastography analyzer, ClotPro. METHODS We retrospectively enrolled 65 patients who underwent lung transplantation and were sampled for both viscoelastic assays and conventional coagulation assays simultaneously during the procedure. We characterized the correlation between the EX-test (extrinsic pathway) and platelet count as well as between the FIB-test (extrinsic pathway after platelet inhibition) and fibrinogen concentration. Then, we used ROC curve analysis to determine the optimal EX-test and FIB-test values for predicting thrombocytopenia and hypofibrinogenemia. RESULTS All the amplitude values of the EX-test (A5, A10, A20, MCF) showed correlation with platelets count (Spearman's rank correlation coefficient ranging from 0.75 to 0.77, all p < 0.0001). We also observed a strong correlation between the amplitude values of the FIB-test (A5, A10, A20 and MCF) and the fibrinogen concentration (Spearman's rank correlation coefficient ranging from 0.68 to 0.71, all p < 0.0001). The AUCs of the EX-test values for thrombocytopenia <100 G/L and <80 G/L ranged from 0.80 to 0.93. Similarly, the AUCs of the FIB-test values for hypofibrinogenemia <1.5 g/L and <2 g/L ranged from 0.74 to 0.83. These results indicate that only the five-minute parameter of thromboelastometry is sufficient for detecting thrombocytopenia and hypofibrinogenemia in patients undergoing lung transplantation. The proposed cut off values for the EX-test to predict thrombocytopenia <80 G/L showed high sensitivity (>86 %), high specificity (>89 %) and high negative predictive value (>95 %). FIB-test cut off values predictive of fibrinogen below 1.5 g/L showed sensitivity (>78 %), specificity (>55 %) and negative predictive value (>88 %). CONCLUSIONS Our study provided preliminary results that are useful for developing a ClotPro-based algorithm to guide transfusion in lung transplantation. Future interventional studies will be necessary to validate these cut-off values of ClotPro for guiding transfusion.
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Affiliation(s)
- Tiffany Pascreau
- Department of clinical biology, Foch hospital, Suresnes, France; Université Paris-Saclay, INSERM, Hémostase inflammation thrombose HITH U1176, Le Kremlin-Bicêtre, France.
| | - Marine Gougeon
- Department of clinical biology, Foch hospital, Suresnes, France
| | - Julien Fessler
- Department of Anesthesiology and Pain Medicine, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | | | - Morgan Le Guen
- Department of Anesthesiology and Pain Medicine, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Marc Vasse
- Department of clinical biology, Foch hospital, Suresnes, France; Université Paris-Saclay, INSERM, Hémostase inflammation thrombose HITH U1176, Le Kremlin-Bicêtre, France
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Czerwińska-Jelonkiewicz K, Sanetra K, Buszman PP, Gryszko L, Wood A, Crescenzi O, Milewski K, Buszman PE. Hemostatic disorders in patients with infective endocarditis undergoing urgent surgical valve replacement - Rethinking current beliefs. Int J Cardiol 2023; 388:131112. [PMID: 37343789 DOI: 10.1016/j.ijcard.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/19/2023] [Accepted: 06/02/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Although infective endocarditis (IE) represents a unique model of thrombo-inflammatory disease, the most frequent early complications of surgical valve replacement (SVR) in IE population are coagulopathy and bleeding. The hemostatic capacity and procedure-related coagulation disorders of IE patients undergoing SVR are unknown. The aims of this study were to test periprocedural hemostasis in IE patients undergoing urgent SVR, and to assess the association between disorders of hemostasis and early bleeding as well as with thromboembolic events. METHODS A prospective, two-center, hypothesis generating, observational study was performed between Dec 2017 and Jan 2020. Periprocedural hemostasis of IE patients was assessed using Total Thrombus-formation Analysis System (T-TAS Plus) within 24 h before and 72 h post SVR. RESULTS Overall, 25 patients with active IE undergoing urgent SVR were tested. Hemostatic capacity of IE patients was significantly impaired pre-SVR as well as post-SVR compared to normal values, in most aspects of T-TAS assays under high and low shear forces, including prolonged activation of coagulation (T10), final clot formation (OT) and clot strength (AUC30). Post-SVR T-TAS results were significantly associated with early bleeding and with red blood cell, platelet, and fresh frozen plasma administration. No association with thrombo-embolic events was found. CONCLUSIONS Patients with active IE undergoing urgent SVR have significantly reduced hemostatic capacity before and after SVR. Hemostatic insufficiency post-SVR is related to bleeding and blood products transfusion. T-TAS may be helpful in assessment of periprocedural hemostasis in patients with IE undergoing SVR.
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Affiliation(s)
- Katarzyna Czerwińska-Jelonkiewicz
- Division of Cardiology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; Adults Intensive Care Unit, Royal Brompton and Harefiled Hospitals, NHS Foundation Trust, London, United Kingdom.
| | - Krzysztof Sanetra
- Division of Cardiology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; Department of Cardiac Surgery, American Heart of Poland Inc., Bielsko-Biała, Poland
| | - Piotr P Buszman
- Division of Cardiology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; Center for Cardiovascular Research and Development, American Heart of Poland Inc., Poland
| | - Leszek Gryszko
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Alice Wood
- Cardiology Department, Glenfield Hospital, Leicester, United Kingdom
| | - Oliviero Crescenzi
- Department of Anaesthesia and Critical Care, Royal Brompton and Harefiled Hospitals, NHS Foundation Trust, London, United Kingdom
| | - Krzysztof Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland Inc., Poland
| | - Paweł E Buszman
- Medical University of Silesia, Epidemiology Department, Katowice, Poland
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Keneally RJ, Gonzalez-Almada A, Wargowsky R, Fernandez X, Kochar O, Cresswell G, Sarani B, Tanaka K, Mazzeffi MA. In Vitro Analysis of Platelet Adhesion, Aggregation, and Surface GP1bα Expression in Stored Refrigerated Whole Blood: A Pilot Study. Anesth Analg 2023; 136:920-926. [PMID: 37058728 DOI: 10.1213/ane.0000000000006277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
BACKGROUND Warm, fresh whole blood (WB) has been used by the US military to treat casualties in Iraq and Afghanistan. Based on data in that setting, cold-stored WB has been used to treat hemorrhagic shock and severe bleeding in civilian trauma patients in the United States. In an exploratory study, we performed serial measurements of WB's composition and platelet function during cold storage. Our hypothesis was that in vitro platelet adhesion and aggregation would decrease over time. METHODS WB samples were analyzed on storage days 5, 12, and 19. Hemoglobin, platelet count, blood gas parameters (pH, Po2, Pco2, and Spo2), and lactate were measured at each timepoint. Platelet adhesion and aggregation under high shear were assessed with a platelet function analyzer. Platelet aggregation under low shear was assessed using a lumi-aggregometer. Platelet activation was assessed by measuring dense granule release in response to high-dose thrombin. Platelet GP1bα levels were measured with flow cytometry, as a surrogate for adhesive capacity. Results at the 3 study timepoints were compared using repeat measures analysis of variance and post hoc Tukey tests. RESULTS Measurable platelet count decreased from a mean of (163 + 53) × 109 platelets per liter at timepoint 1 to (107 + 32) × 109 at timepoint 3 (P = .02). Mean closure time on the platelet function analyzer (PFA)-100 adenosine diphosphate (ADP)/collagen test increased from 208.7 + 91.5 seconds at timepoint 1 to 390.0 + 148.3 at timepoint 3 (P = .04). Mean peak granule release in response to thrombin decreased significantly from 0.7 + 0.3 nmol at timepoint 1 to 0.4 + 0.3 at timepoint 3 (P = .05). Mean GP1bα surface expression decreased from 232,552.8 + 32,887.0 relative fluorescence units at timepoint 1 to 95,133.3 + 20,759.2 at timepoint 3 (P < .001). CONCLUSIONS Our study demonstrated significant decreases in measurable platelet count, platelet adhesion, and aggregation under high shear, platelet activation, and surface GP1bα expression between cold-storage days 5 and 19. Further studies are needed to understand the significance of our findings and to what degree in vivo platelet function recovers after WB transfusion.
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Affiliation(s)
- Ryan J Keneally
- From the Department of Anesthesiology, The George Washington University, Washington, District of Columbia
| | - Alberto Gonzalez-Almada
- From the Department of Anesthesiology, The George Washington University, Washington, District of Columbia
| | - Richard Wargowsky
- From the Department of Anesthesiology, The George Washington University, Washington, District of Columbia
| | - Xiomara Fernandez
- Department of Pathology, The George Washington University, Washington, District of Columbia
| | - Olga Kochar
- Laboratory and Transfusion Services, George Washington University, Washington, District of Columbia
| | - Gregory Cresswell
- The George Washington University, School of Medicine and Health Sciences, Washington, District of Columbia
| | - Babak Sarani
- Department of Surgery, The George Washington University, Washington, District of Columbia
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma, Norman, Oklahoma
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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Mazzeffi M, Gonzalez-Almada A, Wargowsky R, Ting L, Moskowitz K, Hockstein M, Davison D, Levy JH, Tanaka KA. In Vitro Treatment of Extracorporeal Membrane Oxygenation Coagulopathy with Recombinant von Willebrand Factor or Lyophilized Platelets. J Cardiothorac Vasc Anesth 2023; 37:522-527. [PMID: 36690556 DOI: 10.1053/j.jvca.2022.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/23/2022] [Accepted: 12/25/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The objective was to compare primary hemostasis between adult ECMO patients and cardiac surgical patients before heparinization and cardiopulmonary bypass. Furthermore, the authors explored whether in vitro treatment of ECMO patient blood samples with recombinant von Willebrand Factor (vWF) or lyophilized platelets improved primary hemostasis in vitro. DESIGN Prospective cohort study. SETTING Single academic medical center. PARTICIPANTS Ten cardiac surgical patients and 8 adult ECMO patients. INTERVENTIONS Cardiac surgical patients and ECMO patients had blood samples collected, and in vitro platelet thrombus formation was assessed using the ATLAS PST device. The ECMO patients had platelet thrombus formation evaluated at baseline and after in vitro treatment with recombinant vWF or lyophilized platelets, whereas cardiac surgical patients had a single blood sample obtained before heparinization and cardiopulmonary bypass run. MEASUREMENTS AND MAIN RESULTS Median maximum force (39.7 v 260.2 nN) and thrombus area (0.05 v 0.11) at 5 minutes were lower in untreated ECMO patient samples compared with cardiac surgical patients (p = 0.008 and p < 0.001, respectively). The ECMO patient samples treated with recombinant vWF demonstrated an increase in both platelet maximum force (median value of 222.1 v 39.7 nN) (p = 0.01) and platelet thrombus area (median value of 0.16 v 0.05; p = 0.001). The ECMO patient samples treated with lyophilized platelets demonstrated no increase in platelet maximum force (median value of 193.3 v 39.7 nN; p = 0.18); however, there was a significant increase in platelet thrombus area (median value of 0.13 v 0.05; p = 0.04). CONCLUSIONS Recombinant vWF and lyophilized platelets may help to restore primary hemostasis in ECMO patients. Future studies should further evaluate the safety and efficacy of these potential therapeutics in ECMO patients.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA.
| | - Alberto Gonzalez-Almada
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Richard Wargowsky
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | | | - Max Hockstein
- Department of Critical Care Medicine, Medstar Washington Hospital Center, Washington, DC
| | - Danielle Davison
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma, Oklahoma City, OK
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Raasveld SJ, Volleman C, Combes A, Broman LM, Taccone FS, Peters E, Ten Berg S, van den Brom CE, Thiele H, Lorusso R, Henriques JPS, Vlaar APJ. Knowledge gaps and research priorities in adult veno-arterial extracorporeal membrane oxygenation: a scoping review. Intensive Care Med Exp 2022; 10:50. [PMID: 36424482 PMCID: PMC9691798 DOI: 10.1186/s40635-022-00478-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE This scoping review aims to identify and describe knowledge gaps and research priorities in veno-arterial extracorporeal membrane oxygenation (VA-ECMO). METHODS An expert panel was recruited consisting of eight international experts from different backgrounds. First, a list of priority topics was made. Second, the panel developed structured questions using population, intervention, comparison and outcomes (PICO) format. All PICOs were scored and prioritized. For every selected PICO, a structured literature search was performed. RESULTS After an initial list of 49 topics, eight were scored as high-priority. For most of these selected topics, current literature is limited to observational studies, mainly consisting of retrospective cohorts. Only for ECPR and anticoagulation, randomized controlled trials (RCTs) have been performed or are ongoing. Per topic, a summary of the literature is stated including recommendations for further research. CONCLUSIONS This scoping review identifies and presents an overview of knowledge gaps and research priorities in VA-ECMO. Current literature is mostly limited to observational studies, although with increasing attention for this patient population, more RCTs are finishing or ongoing. Translational research, from preclinical trials to high-quality or randomized controlled trials, is important to improve the standard practices in this critically ill patient population. Take-home message This scoping review identifies and presents an overview of research gaps and priorities in VA-ECMO. Translational research, from preclinical trials to high-quality or randomized controlled trials, is important to improve the standard practices in this critically ill patient population.
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Affiliation(s)
- Senta Jorinde Raasveld
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
| | - Carolien Volleman
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS1166-ICAN, Paris, France
- Service de Médicine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Hospital Pitié-Salpêtrière, Paris, France
| | - Lars Mikael Broman
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Elma Peters
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne Ten Berg
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charissa E van den Brom
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Anesthesiology, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science GmbH, Leipzig, Germany
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - José P S Henriques
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Critical Care, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, The Netherlands.
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Sun W, Han D, Awad MA, Leibowitz JL, Griffith BP, Wu ZJ. Role of thrombin to non-physiological shear stress induced platelet activation and function alternation. Thromb Res 2022; 219:141-149. [PMID: 36179652 DOI: 10.1016/j.thromres.2022.09.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/08/2022] [Accepted: 09/20/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Non-physiological shear stress (NPSS) and thrombin have two distinct mechanisms for activating platelets. NPSS in mechanically assisted circulation (MAC) devices can cause platelet dysfunction, e.g., by shedding its key receptors. In addition, patients with heart failure have increased levels of thrombin generation, which may further affect the NPSS-induced platelet dysfunction, resulting in device-associated complications. This study aimed to assess the combined effect of NPSS and thrombin in platelet activation, expression of adhesion receptors on the platelet surface, and alterations of platelet aggregation. METHODS Fresh human blood from healthy donors was divided into two groups; one group was treated by adding 0.01 U/mL thrombin, and another group not treated with thrombin served as a control comparison. They were then pumped through a novel blood shearing device which produces similar shear stress conditions to those in the MAC devices. Three levels of NPSS (i.e., 75, 125, and 175 Pa) with a 1.0 s exposure time were selected for the shearing conditions. Expression of platelet activation markers (PAC-1, activated GPIIb/IIIa and CD62P, platelet surface P-selectin) were investigated along with the shedding of platelet receptors (GPIb, GPIIb/IIIa, and GPVI), generation of platelet microparticles, and Phosphatidylserine (PS)-positive platelets detected by flow cytometry. Platelet aggregation (induced by collagen/ristocetin) was measured by Lumi-aggregometry. RESULTS Platelet receptors were shed after exposure to NPSS showing a positive correlation with the level of shear stress. The generation of platelet microparticles and PS-positive platelets also increased with greater NPSS. Elevated NPSS decreased the platelet aggregation capacity. Platelet activation level increased with greater NPSS. Being treated by thrombin can further exacerbate these characteristics under same level of NPSS, except that platelet activation level drastically dropped after the exposure to 175 Pa NPSS in the thrombin-treated blood. CONCLUSION After being treated by thrombin, platelets became more susceptible to NPSS, resulting in more receptor shedding, platelet microparticles, and PS-positive platelets, thus limiting platelet aggregation capacity after exposure to NPSS. Platelet activation, in terms of PAC-1 and P-selectin, is an interim status competing between the expression and shedding of these makers/receptors. When platelets have reached a saturation level of activation, exposure to excessive NPSS can potentially impair activation.
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Affiliation(s)
- Wenji Sun
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dong Han
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Morcos A Awad
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joshua L Leibowitz
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zhongjun J Wu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Fischell Department of Bioengineering, A. James Clark School of Engineering, University of Maryland, College Park, MD, USA.
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Mazzeffi M, Henderson R, Krause E, Rabin J, Madathil R, Chow J, Grazioli A, Meyer M, Wu Z, Tanaka K. In Vitro Comparison of Recombinant and Plasma-Derived von Willebrand Factor Concentrate for Treatment of Acquired von Willebrand Syndrome in Adult Extracorporeal Membrane Oxygenation Patients. Anesth Analg 2021; 134:312-321. [PMID: 34903705 DOI: 10.1213/ane.0000000000005831] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Coagulopathic bleeding is common during adult extracorporeal membrane oxygenation (ECMO), and acquired von Willebrand syndrome is a contributing factor. We compared ECMO patient blood samples that were treated in vitro with recombinant von Willebrand Factor concentrate and plasma-derived von Willebrand Factor concentrate. Our hypothesis was that recombinant von Willebrand Factor (vWF) would have greater efficacy in increasing vWF function. Secondarily, we hypothesized that recombinant vWF would have less impact on thrombin generation. METHODS Thirty ECMO patients and 10 cardiac surgical controls were enrolled in the study. ECMO patient blood samples were treated in vitro with low- and high-dose recombinant vWFs and low- and high-dose plasma-derived vWFs. Whole blood ristocetin-induced platelet aggregation (RIPA), plasma ristocetin cofactor activity (RCo), and thrombin generation were compared between ECMO patient blood samples and control blood samples and between vWF-treated ECMO patient blood samples and nontreated samples. RESULTS ECMO patient blood samples had severely reduced median RIPA compared to control samples 2 ohms (1-12 [25th-75th percentile]) vs 20 ohms (11-42) (P < .001). Treatment of ECMO patient blood samples with high-dose recombinant vWF significantly increased median RIPA to 10 ohms (2-15) (P < .001), while low-dose recombinant vWF and low- and high-dose plasma-derived vWFs did not significantly increase RIPA; 6 ohms (3-14), 4 ohms (1-13), and 6 ohms (2-10), respectively (P = .25, >.99, and >.99). Treatment with high-dose recombinant vWF and low- and high-dose plasma-derived vWFs significantly increased median plasma RCo to 4.7 international units (IU)/mL (3.7-5.9), 3.3 IU/mL (2.7-4.8), and 3.9 IU/mL (3.4-5.3), respectively, compared to controls 1.8 IU/mL (1.5-2.3) (all P < .001). Treatment with low- and high-dose plasma-derived vWFs significantly increased mean endogenous thrombin potential (6270.2 ± 2038.7 and 6313.1 ± 1913.3) compared to nontreated samples (5856.7 ± 1924.6) (P = .04 and .006), whereas treatment with low- and high-dose recombinant vWFs had no significant effect on mean endogenous thrombin potential (5776.1 ± 2087.3 and 5856.2 ± 1946.4) (P > .99 for both comparisons). CONCLUSIONS In vitro treatment of ECMO patient blood samples with high-dose recombinant vWF was superior to low-dose recombinant vWF and plasma-derived vWF in terms of improving RIPA. In addition, recombinant vWF treatment did not increase endogenous thrombin potential, which may reduce overall thrombotic risk if it used to treat acquired von Willebrand syndrome in ECMO patients.
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Affiliation(s)
- Michael Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Reney Henderson
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Eric Krause
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Joseph Rabin
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ronson Madathil
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan Chow
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Alison Grazioli
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Meyer
- Vitalant Coagulation Laboratory, Pittsburgh, Pennsylvania
| | - Zhongjun Wu
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting. Anesth Analg 2021; 133:1478-1493. [PMID: 34559091 DOI: 10.1213/ane.0000000000005733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the second part of the Society of Cardiovascular Anesthesiologists Extracorporeal Membrane Oxygenation (ECMO) working group expert consensus statement, venoarterial (VA) and venovenous (VV) ECMO management and troubleshooting in the operating room are discussed. Expert consensus statements are provided about intraoperative monitoring, anesthetic drug dosing, and management of intraoperative problems in VA and VV ECMO patients.
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Affiliation(s)
- Michael A Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alton, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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10
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Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists- Part II, Intraoperative Management and Troubleshooting. J Cardiothorac Vasc Anesth 2021; 35:3513-3527. [PMID: 34774253 DOI: 10.1053/j.jvca.2021.07.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alton, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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11
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Sikora J, Karczmarska-Wódzka A, Bugieda J, Sobczak P. The Use of Total Thrombus Formation Analysis System as a Tool to Assess Platelet Function in Bleeding and Thrombosis Risk-A Systematic Review. Int J Mol Sci 2021; 22:8605. [PMID: 34445311 PMCID: PMC8395324 DOI: 10.3390/ijms22168605] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Today there are many devices that can be used to study blood clotting disorders by identifying abnormalities in blood platelets. The Total Thrombus Formation Analysis System is an automated microchip flow chamber system that is used for the quantitative analysis of clot formation under blood flow conditions. For several years, researchers have been using a tool to analyse various clinical situations of patients to identify the properties and biochemical processes occurring within platelets and their microenvironment. METHODS An investigation of recent published literature was conducted based on PRISMA. This review includes 52 science papers directly related to the use of the Total Clot Formation Analysis System in relation to bleeding, surgery, platelet function assessment, anticoagulation monitoring, von Willebrand factor and others. CONCLUSION Most available studies indicate that The Total Thrombus Formation Analysis System may be useful in diagnostic issues, with devices used to monitor therapy or as a significant tool for predicting bleeding events. However, T-TAS not that has the potential for diagnostic indications, but allows the direct observation of the flow and the interactions between blood cells, including the intensity and dynamics of clot formation. The device is expected to be of significant value for basic research to observe the interactions and changes within platelets and their microenvironment.
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Affiliation(s)
- Joanna Sikora
- Research and Education Unit for Experimental Biotechnology, Department of Transplantology and General Surgery, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (A.K.-W.); (J.B.)
| | - Aleksandra Karczmarska-Wódzka
- Research and Education Unit for Experimental Biotechnology, Department of Transplantology and General Surgery, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (A.K.-W.); (J.B.)
| | - Joanna Bugieda
- Research and Education Unit for Experimental Biotechnology, Department of Transplantology and General Surgery, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (A.K.-W.); (J.B.)
| | - Przemysław Sobczak
- Department of Hematology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland;
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12
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Hensley NB, Mazzeffi MA. Pro-Con Debate: Fibrinogen Concentrate or Cryoprecipitate for Treatment of Acquired Hypofibrinogenemia in Cardiac Surgical Patients. Anesth Analg 2021; 133:19-28. [PMID: 34127586 DOI: 10.1213/ane.0000000000005513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cryoprecipitate has been the gold standard for treating acquired hypofibrinogenemia in cardiac surgery for nearly 50 years. More recently, fibrinogen concentrate has been used off-label in the United States and is the standard in European countries and Canada to treat the acquired hypofibrinogenemia during cardiac surgery. Fibrinogen concentrate has multiple potential advantages including rapid reconstitution, greater dose predictability, viral inactivation during processing, and reduced transfusion-related adverse events. However, because fibrinogen concentrate lacks the other components contained in the cryoprecipitate, it may not be the "ideal" product for replacing fibrinogen in all cardiac surgical patients, particularly those with longer cardiopulmonary bypass duration. In this Pro-Con commentary article, we discuss the advantages and disadvantages of using fibrinogen concentrate and cryoprecipitate to treat acquired hypofibrinogenemia in cardiac surgical patients.
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Affiliation(s)
- Nadia B Hensley
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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13
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Moussa MD, Soquet J, Lamer A, Labreuche J, Gantois G, Dupont A, Abou-Arab O, Rousse N, Liu V, Brandt C, Foulon V, Leroy G, Schurtz G, Jeanpierre E, Duhamel A, Susen S, Vincentelli A, Robin E. Evaluation of Anti-Activated Factor X Activity and Activated Partial Thromboplastin Time Relations and Their Association with Bleeding and Thrombosis during Veno-Arterial ECMO Support: A Retrospective Study. J Clin Med 2021; 10:jcm10102158. [PMID: 34067573 PMCID: PMC8156165 DOI: 10.3390/jcm10102158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We aimed to investigate the relationship between anti-activated Factor X (anti-FXa) and activated Partial Thromboplastin Time (aPTT), and its modulation by other haemostasis co-variables during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. We further investigated their association with serious bleeding and thrombotic complications. METHODS This retrospective single-center study included 265 adults supported by VA-ECMO for refractory cardiogenic shock from January 2015 to June 2019. The concordance of anti-FXa and aPTT and their correlations were assessed in 1699 paired samples. Their independent associations with serious bleeding or thrombotic complications were also analysed in multivariate analysis. RESULTS The concordance rate of aPTT with anti-FXa values was 50.7%, with 39.3% subtherapeutic aPTT values. However, anti-FXa and aPTT remained associated (β = 0.43 (95% CI 0.4-0.45) 10-2 IU/mL, p < 0.001), with a significant modulation by several biological co-variables. There was no association between anti-FXa nor aPTT values with serious bleeding or with thrombotic complications. CONCLUSION During VA-ECMO, although anti-FXa and aPTT were significantly associated, their values were highly discordant with marked sub-therapeutic aPTT values. These results should favour the use of anti-FXa. The effect of biological co-variables and the failure of anti-FXa and aPTT to predict bleeding and thrombotic complications underline the complexity of VA-ECMO-related coagulopathy.
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Affiliation(s)
- Mouhamed Djahoum Moussa
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
- Correspondence: ; Tel.: +33-320-445-962
| | - Jérôme Soquet
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Antoine Lamer
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
- Univ. Lille, INSERM, CHU Lille, CIC-IT 1403, 59000 Lille, France
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
| | - Julien Labreuche
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
- CHU Lille, Department of Biostatistics, 59000 Lille, France
| | - Guillaume Gantois
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Annabelle Dupont
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 80054 Amiens, France;
- MP3CV, EA7517, CURS, Jules Verne University of Picardie, 80054 Amiens, France
| | - Natacha Rousse
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Vincent Liu
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Caroline Brandt
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Valentin Foulon
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Guillaume Leroy
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | | | - Emmanuel Jeanpierre
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - Alain Duhamel
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
- CHU Lille, Department of Biostatistics, 59000 Lille, France
| | - Sophie Susen
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - André Vincentelli
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Emmanuel Robin
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
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14
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Shah A, Dave S, Galvagno S, George K, Menne AR, Haase DJ, McCormick B, Rector R, Dahi S, Madathil RJ, Deatrick KB, Ghoreishi M, Gammie JS, Kaczorowski DJ, Scalea TM, Menaker J, Herr D, Tabatabai A, Krause E. A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part II: Clinical Management. MEMBRANES 2021; 11:306. [PMID: 33919390 PMCID: PMC8143287 DOI: 10.3390/membranes11050306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/15/2021] [Accepted: 04/17/2021] [Indexed: 01/14/2023]
Abstract
(1) Background: COVID-19 acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS); however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on VV-ECMO and alterations to traditional management strategies. (2) Methods: We conducted a retrospective review of our institutional strategies for managing patients with COVID-19 who required VV-ECMO in a dedicated airlock biocontainment unit (BCU), from March to June 2020. The data collected included the time course of admission, VV-ECMO run, ventilator length, hospital length of stay, and major events related to bleeding, such as pneumothorax and tracheostomy. The dispensation of sedation agents and trial therapies were obtained from institutional pharmacy tracking. A descriptive statistical analysis was performed. (3) Results: Forty COVID-19 patients on VV-ECMO were managed in the BCU during this period, from which 21 survived to discharge and 19 died. The criteria for ECMO initiation was altered for age, body mass index, and neurologic status/cardiac arrest. All cannulations were performed with a bedside ultrasound-guided percutaneous technique. Ventilator and ECMO management were routed in an ultra-lung protective approach, though varied based on clinical setting and provider experience. There was a high incidence of pneumothorax (n = 19). Thirty patients had bedside percutaneous tracheostomy, with more procedural-related bleeding complications than expected. A higher use of sedation was noted. The timing of decannulation was also altered, given the system constraints. A variety of trial therapies were utilized, and their effectiveness is yet to be determined. (4) Conclusions: Even in a high-volume ECMO center, there are challenges in caring for an expanded capacity of patients during a viral respiratory pandemic. Though institutional resources and expertise may vary, it is paramount to proceed with insightful planning, the recognition of challenges, and the dynamic application of lessons learned when facing a surge of critically ill patients.
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Affiliation(s)
- Aakash Shah
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - Sagar Dave
- Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (K.G.); (T.M.S.); (D.H.)
| | - Samuel Galvagno
- Program in Trauma, Department of Anesthesiology, School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
| | - Kristen George
- Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (K.G.); (T.M.S.); (D.H.)
| | - Ashley R. Menne
- Program in Trauma, Department of Emergency Medicine, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (A.R.M.); (D.J.H.)
| | - Daniel J. Haase
- Program in Trauma, Department of Emergency Medicine, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (A.R.M.); (D.J.H.)
| | - Brian McCormick
- Perfusion Services, University of Maryland Medical Center, Baltimore, MD 21201, USA; (B.M.); (R.R.)
| | - Raymond Rector
- Perfusion Services, University of Maryland Medical Center, Baltimore, MD 21201, USA; (B.M.); (R.R.)
| | - Siamak Dahi
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - Ronson J. Madathil
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - Kristopher B. Deatrick
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - Mehrdad Ghoreishi
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - James S. Gammie
- Department of Surgery, Division of Cardiac Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (R.J.M.); (K.B.D.); (M.G.); (J.S.G.)
| | - David J. Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Thomas M. Scalea
- Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (K.G.); (T.M.S.); (D.H.)
| | - Jay Menaker
- Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA 94143, USA;
| | - Daniel Herr
- Program in Trauma, Department of Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA; (S.D.); (K.G.); (T.M.S.); (D.H.)
| | - Ali Tabatabai
- Program in Trauma, Department of Medicine, Division of Pulmonary and Critical Care, School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
| | - Eric Krause
- Department of Surgery, Division of Thoracic Surgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA;
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15
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Mazzeffi MA, Chow JH, Tanaka K. COVID-19 Associated Hypercoagulability: Manifestations, Mechanisms, and Management. Shock 2021; 55:465-471. [PMID: 32890309 PMCID: PMC7959868 DOI: 10.1097/shk.0000000000001660] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/17/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022]
Abstract
ABSTRACT Patients with severe coronavirus disease-2019 (COVID-19) frequently have hypercoagulability caused by the immune response to the severe acute respiratory syndrome coronavirus-2 infection. The pathophysiology of COVID-19 associated hypercoagulability is not fully understood, but characteristic changes include: increased fibrinogen concentration, increased Factor VIII activity, increased circulating von Willebrand factor, and exhausted fibrinolysis. Anticoagulant therapy improves outcomes in mechanically ventilated patients with COVID-19 and viscoelastic coagulation testing offers an opportunity to tailor anticoagulant therapy based on an individual patient's coagulation status. In this narrative review, we summarize clinical manifestations of COVID-19, mechanisms, monitoring considerations, and anticoagulant therapy. We also review unique considerations for COVID-19 patients who are on extracorporeal membrane oxygenation.
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Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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16
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Patel PA, Henderson RA, Bolliger D, Erdoes G, Mazzeffi MA. The Year in Coagulation: Selected Highlights from 2020. J Cardiothorac Vasc Anesth 2021; 35:2260-2272. [PMID: 33781668 DOI: 10.1053/j.jvca.2021.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/28/2023]
Abstract
This is the second annual review in the Journal of Cardiothoracic and Vascular Anesthesia to cover highlights in coagulation for cardiac surgery. The goal of this article is to provide readers with a focused summary from the literature of the prior year's most important coagulation topics. In 2020, this included a discussion covering allogeneic transfusion, antiplatelet and anticoagulant therapy, factor concentrates, coagulation testing, mechanical circulatory support, and the effects of coronavirus disease 2019.
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Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT.
| | - Reney A Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Bolliger
- Department of Anesthesiology, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Michael A Mazzeffi
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
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17
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Mazzeffi M, Judd M, Rabin J, Tabatabai A, Menaker J, Menne A, Chow J, Shah A, Henderson R, Herr D, Tanaka K. Tissue Factor Pathway Inhibitor Levels During Veno-Arterial Extracorporeal Membrane Oxygenation in Adults. ASAIO J 2021; 67:878-883. [PMID: 33606392 DOI: 10.1097/mat.0000000000001322] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Tissue factor pathway inhibitor (TFPI) has multiple anticoagulant properties. To our knowledge, no studies have measured TFPI levels in adult veno-arterial (VA) extracorporeal membrane oxygenation patients. We hypothesized that adult VA ECMO patients would have increased TFPI levels and slowed tissue factor triggered thrombin generation. Twenty VA ECMO patients had TFPI levels and thrombin generation lag time measured on ECMO day 1 or 2, day 3, and day 5. TFPI levels and thrombin generation lag time were compared against healthy control plasma samples. Mean TFPI levels were significantly higher in ECMO patients on ECMO day 1 or 2 = 81,877 ± 19,481 pg/mL, day 3 = 73,907 ± 26,690 pg/mL, and day 5 = 77,812 ± 23,484 pg/mL compared with control plasma = 38,958 ± 9,225 pg/mL (P < 0.001 for all comparisons). Median thrombin generation lag time was significantly longer in ECMO patients on ECMO day 1 or 2 = 10.0 minutes [7.5, 13.8], day 3 = 9.0 minutes [6.8, 12.1], and day 5 = 10.7 minutes [8.3, 15.2] compared with control plasma = 3.6 minutes [2.9, 4.2] (P < 0.001 for all comparisons). TFPI is increased in VA ECMO patients and tissue factor triggered thrombin generation is slowed. Increased TFPI levels could contribute to the multifactorial coagulopathy that occurs during ECMO.
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Affiliation(s)
| | | | - Joseph Rabin
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center
| | - Ali Tabatabai
- Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center
| | - Jay Menaker
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center
| | - Ashley Menne
- Department of Emergency Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center
| | | | - Aakash Shah
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - Daniel Herr
- Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center
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18
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Roka-Moiia Y, Miller-Gutierrez S, Palomares DE, Italiano JE, Sheriff J, Bluestein D, Slepian MJ. Platelet Dysfunction During Mechanical Circulatory Support: Elevated Shear Stress Promotes Downregulation of α IIbβ 3 and GPIb via Microparticle Shedding Decreasing Platelet Aggregability. Arterioscler Thromb Vasc Biol 2021; 41:1319-1336. [PMID: 33567867 DOI: 10.1161/atvbaha.120.315583] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Yana Roka-Moiia
- Department of Medicine (Y.R.-M., S.M.-G.), Sarver Heart Center, University of Arizona, Tucson
| | - Samuel Miller-Gutierrez
- Department of Medicine (Y.R.-M., S.M.-G.), Sarver Heart Center, University of Arizona, Tucson
| | - Daniel E Palomares
- Department of Biomedical Engineering (D.E.P., M.J.S.), Sarver Heart Center, University of Arizona, Tucson
| | - Joseph E Italiano
- Brigham and Woman's Hospital, Harvard Medical School, Boston, MA (J.E.I.)
| | - Jawaad Sheriff
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY (J.S., D.B., M.J.S.)
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY (J.S., D.B., M.J.S.)
| | - Marvin J Slepian
- Department of Biomedical Engineering (D.E.P., M.J.S.), Sarver Heart Center, University of Arizona, Tucson.,Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY (J.S., D.B., M.J.S.)
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Mazzeffi M, Tanaka K, Wu YF, Zhang A, Kareddy N, Tadjou Tito E, Rock P, Michelson AD, Frelinger AL. Platelet surface GPIbα, activated GPIIb-IIIa, and P-selectin levels in adult veno-arterial extracorporeal membrane oxygenation patients. Platelets 2020; 33:116-122. [DOI: 10.1080/09537104.2020.1856360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yi-Feng Wu
- Center for Platelet Research Studies, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
- Department of Hematology and Oncology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation & College of Medicine, Tzu-Chi University, Hualien, Taiwan
| | - Aijun Zhang
- Center for Platelet Research Studies, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Niharika Kareddy
- Center for Platelet Research Studies, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Emmanuel Tadjou Tito
- Department of Anesthesiology, Rutgers University School of Medicine, Newark, NJ, USA
| | - Peter Rock
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alan D. Michelson
- Center for Platelet Research Studies, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Andrew L. Frelinger
- Center for Platelet Research Studies, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
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Understanding Extracorporeal Membrane Oxygenation Induced Coagulopathy: Many Pieces to the Puzzle. Crit Care Med 2020; 48:e732-e733. [PMID: 32697517 DOI: 10.1097/ccm.0000000000004370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Mansour A, Roussel M, Gaussem P, Nédelec-Gac F, Pontis A, Flécher E, Bachelot-Loza C, Gouin-Thibault I. Platelet Functions During Extracorporeal Membrane Oxygenation. Platelet-Leukocyte Aggregates Analyzed by Flow Cytometry as a Promising Tool to Monitor Platelet Activation. J Clin Med 2020; 9:jcm9082361. [PMID: 32718096 PMCID: PMC7464627 DOI: 10.3390/jcm9082361] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is an extracorporeal circulation used to manage patients with severe circulatory or respiratory failure. It is associated with both high bleeding and thrombosis risks, mainly as a result of biomaterial/blood interface phenomena, high shear stress, and complex inflammatory response involving the activation of coagulation and complement systems, endothelial cells, leukocytes, and platelets. Besides their critical role in hemostasis, platelets are important players in inflammatory reactions, especially due to their ability to bind and activate leukocytes. Hence, we reviewed studies on platelet function of ECMO patients. Moreover, we addressed the issue of platelet–leukocyte aggregates (PLAs), which is a key step in both platelet and leukocyte activation, and deserves to be investigated in these patients. A reduced expression of GPIb and GPVI was found under ECMO therapy, due to the shedding processes. However, defective platelet aggregation is inconsistently reported and is still not clearly defined. Due to the high susceptibility of PLAs to pre-analytical conditions, defining and strictly adhering to a rigorous laboratory methodology is essential for reliable and reproducible results, especially in the setting of complex inflammatory situations like ECMO. We provide results on sample preparation and flow cytometric whole blood evaluation of circulating PLAs.
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Affiliation(s)
- Alexandre Mansour
- Department of Anesthesiology Critical Care Medicine and Perioperative Medicine, Rennes University Hospital, F-35000 Rennes, France;
- Rennes University Hospital, INSERM-CIC 1414, F-35000 Rennes, France
- Innovative Therapies in Haemostasis, Paris University, INSERM U1140, F-75006 Paris, France; (P.G.); (C.B.-L.)
| | - Mikael Roussel
- Department of Biological Hematology, Rennes University Hospital, F-35000 Rennes, France; (M.R.); (F.N.-G.); (A.P.)
- Microenvironment, Cell Differentiation, Immunology and Cancer, Rennes University, INSERM U1236, F-35000 Rennes, France
- Cytometrie Hematologique Francophone Association (CytHem), F-75013 Paris, France
| | - Pascale Gaussem
- Innovative Therapies in Haemostasis, Paris University, INSERM U1140, F-75006 Paris, France; (P.G.); (C.B.-L.)
- Department of Biological Hematology, AH-HP, Georges Pompidou European University Hospital, F-75015 Paris, France
| | - Fabienne Nédelec-Gac
- Department of Biological Hematology, Rennes University Hospital, F-35000 Rennes, France; (M.R.); (F.N.-G.); (A.P.)
| | - Adeline Pontis
- Department of Biological Hematology, Rennes University Hospital, F-35000 Rennes, France; (M.R.); (F.N.-G.); (A.P.)
| | - Erwan Flécher
- Cardio-Thoracic Surgery, Rennes University Hospital, INSERM U1099, F-35000 Rennes, France;
| | - Christilla Bachelot-Loza
- Innovative Therapies in Haemostasis, Paris University, INSERM U1140, F-75006 Paris, France; (P.G.); (C.B.-L.)
| | - Isabelle Gouin-Thibault
- Rennes University Hospital, INSERM-CIC 1414, F-35000 Rennes, France
- Department of Biological Hematology, Rennes University Hospital, F-35000 Rennes, France; (M.R.); (F.N.-G.); (A.P.)
- Correspondence:
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The authors reply. Crit Care Med 2020; 48:e733. [PMID: 32697518 DOI: 10.1097/ccm.0000000000004420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mazzeffi M, Bathula A, Tabatabai A, Menaker J, Kaczorowski D, Madathil R, Galvagno S, Pasrija C, Rector R, Tanaka K, Herr D. Von Willebrand Factor Concentrate Administration for Acquired Von Willebrand Syndrome- Related Bleeding During Adult Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 35:882-887. [PMID: 32758410 DOI: 10.1053/j.jvca.2020.06.083] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/26/2020] [Accepted: 06/27/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To review the use of Von Willebrand Factor (VWF) concentrate for treatment of acquired Von Willebrand syndrome (VWS)-related bleeding in adult extracorporeal membrane oxygenation (ECMO) patients and determine if it was associated with improved VWF laboratory parameters. DESIGN Retrospective observational cohort study. SETTING Tertiary care academic medical center. PARTICIPANTS Adult ECMO patients who received VWF concentrate for treatment of acquired VWS- related bleeding. INTERVENTIONS None, observational study. MEASUREMENTS AND MAIN RESULTS Ten adult ECMO patients received VWF concentrate for treatment of bleeding with evidence of acquired VWS over a 15-month period. Six patients were on veno-arterial ECMO and 4 were on veno-venous ECMO. The most common site of bleeding was airway or tracheal bleeding. The mean dose of VWF concentrate was 41 IU/kg. Mean VWF antigen was 263 ± 93 IU/dL before treatment and 394 ± 54 after treatment. Mean ristocetin cofactor activity was 127 ± 47 IU/dL before treatment and 240 ± 33 after treatment. The mean VWF ristocetin cofactor activity antigen ratio increased from 0.52 ± 0.14 before treatment to 0.62 ± 0.04 after treatment. Four of 10 patients had complete resolution of their bleeding within 24 hours, and 6 of 10 had complete resolution of their bleeding within 2- to- 4 days. There were 3 patients who had thrombotic events potentially related to VWF concentrate administration. No patient had an arterial thrombosis, stroke, or myocardial infarction. CONCLUSIONS VWF concentrate administration increases VWF function in adult ECMO patients, but also may be associated with increased thrombotic risk. Larger studies are needed to determine VWF concentrate's safety, efficacy, and optimal dosing in adult ECMO patients.
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Affiliation(s)
- Michael Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD.
| | - Allison Bathula
- University of Maryland Medical Center, Department of Pharmacy, Baltimore, MD
| | - Ali Tabatabai
- University of Maryland School of Medicine, Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - Jay Menaker
- University of Maryland School of Medicine, Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
| | - David Kaczorowski
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Ronson Madathil
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Samuel Galvagno
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Chetan Pasrija
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Raymond Rector
- University of Maryland School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Baltimore, MD
| | - Kenichi Tanaka
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD
| | - Daniel Herr
- University of Maryland School of Medicine, Department of Medicine, Program in Trauma, R Adams Cowley Shock Trauma Center, Baltimore, MD
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Mazzeffi MA, Patel PA, Bolliger D, Erdoes G, Tanaka K. The Year in Coagulation: Selected Highlights From 2019. J Cardiothorac Vasc Anesth 2020; 34:1745-1754. [DOI: 10.1053/j.jvca.2020.01.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 01/27/2020] [Indexed: 12/26/2022]
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Mazzeffi M. Patient Blood Management in Adult Extracorporeal Membrane Oxygenation Patients. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00384-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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