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Lwin TN, Mudannayake R, MacDonald S, Arrowsmith JE, Burt C, Besser M, Falter F. Assessing the impact of different heparin dosing regimens for cardiopulmonary bypass on anticoagulation: the HepDOSE pilot study. Can J Anaesth 2024; 71:234-243. [PMID: 37985627 DOI: 10.1007/s12630-023-02645-6] [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: 02/02/2023] [Revised: 07/11/2023] [Accepted: 07/23/2023] [Indexed: 11/22/2023] Open
Abstract
PURPOSE It has been suggested that a larger heparin dose during cardiopulmonary bypass (CPB) is associated with reduced perioperative coagulopathy and thromboembolic complications. We investigated the effect of different heparin doses during routine elective cardiac surgery. Our primary outcomes include blood loss and transfusion and secondary outcomes investigate the effects on coagulation biomarkers. METHODS In this prospective pilot trial, we allocated 60 patients undergoing cardiac surgery on CPB in a single tertiary cardiac centre into three groups to receive an initial dose of 300, 400, or 500 units (U) per kilogram of intravenous heparin prior to the commencement of CPB. Blood was sampled after induction of anesthesia, at 30 and 60 min of CPB, and three minutes after heparin reversal with protamine. Samples were analyzed for fibrinopeptide A (FPA), fibrinopeptide B (FPB), D-dimer, and thrombin-antithrombin (TAT) complexes. Postoperative blood loss and transfusion was measured for the first 24-hr period after surgery. RESULTS The total mean (95% CI) administered heparin dose in the 300 U·kg-1, 400 U·kg-1, and 500 U·kg-1 groups were 39,975 (36,528 to 43,421) U, 43,195 (36,940 to 49,449) U and 47,900 (44,807 to 50,992) U, respectively. There were no statistically significant differences in FPA, FPB or D-dimer levels at the measured time intervals. There was a trend towards lower TAT levels while on CPB with greater heparin dosing, which was statistically significant after the administration of protamine. The clinical significance appears to be negligible, as there is no difference in overall blood loss and amount of packed red blood cell transfusion or other blood product transfusion. CONCLUSION This pilot study indicates that, while larger heparin dosing for routine cardiac surgery results in subtle biochemical changes in coagulation, there is no demonstrable benefit in postoperative blood loss or transfusion requirements.
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Affiliation(s)
- Thar Nyan Lwin
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Rahul Mudannayake
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Stephen MacDonald
- Division of Clinical Haematology and Blood Transfusion, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joseph E Arrowsmith
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Christiana Burt
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Martin Besser
- Division of Clinical Haematology and Blood Transfusion, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Florian Falter
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
- Department of Anaesthetics and Critical Care, The Royal Papworth Hospital NHS Foundation Trust, Papworth Road, Cambridge Biomedical Campus, Cambridge, CB2 0AY, UK.
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Assessing Plasmin Generation in Health and Disease. Int J Mol Sci 2021; 22:ijms22052758. [PMID: 33803235 PMCID: PMC7963172 DOI: 10.3390/ijms22052758] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/20/2021] [Accepted: 03/05/2021] [Indexed: 12/13/2022] Open
Abstract
Fibrinolysis is an important process in hemostasis responsible for dissolving the clot during wound healing. Plasmin is a central enzyme in this process via its capacity to cleave fibrin. The kinetics of plasmin generation (PG) and inhibition during fibrinolysis have been poorly understood until the recent development of assays to quantify these metrics. The assessment of plasmin kinetics allows for the identification of fibrinolytic dysfunction and better understanding of the relationships between abnormal fibrin dissolution and disease pathogenesis. Additionally, direct measurement of the inhibition of PG by antifibrinolytic medications, such as tranexamic acid, can be a useful tool to assess the risks and effectiveness of antifibrinolytic therapy in hemorrhagic diseases. This review provides an overview of available PG assays to directly measure the kinetics of plasmin formation and inhibition in human and mouse plasmas and focuses on their applications in defining the role of plasmin in diseases, including angioedema, hemophilia, rare bleeding disorders, COVID-19, or diet-induced obesity. Moreover, this review introduces the PG assay as a promising clinical and research method to monitor antifibrinolytic medications and screen for genetic or acquired fibrinolytic disorders.
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Zhou ZF, Zhai W, Yu LN, Sun K, Sun LH, Xing XF, Yan M. Comparison of the in-vivo effect of two tranexamic acid doses on fibrinolysis parameters in adults undergoing valvular cardiac surgery with cardiopulmonary bypass - a pilot investigation. BMC Anesthesiol 2021; 21:33. [PMID: 33530942 PMCID: PMC7852217 DOI: 10.1186/s12871-021-01234-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background The blood saving efficacy of TXA in cardiac surgery has been proved in several studies, but TXA dosing regimens were varied in those studies. Therefore, we performed this study to investigate if there is a dose dependent in-vivo effect of TXA on fibrinolysis parameters by measurement of fibrinolysis markers in adults undergoing cardiac surgery with CPB. Methods A double-blind, randomized, controlled prospective trial was conducted from February 11, 2017 to May 05, 2017. Thirty patients undergoing cardiac valve surgery were identified and randomly divided into a placebo group, low-dose group and high-dose group by 1: 1: 1. Fibrinolysis parameters were measured by plasma levels of D-Dimers, plasminogen activator inhibitor-1 (PAI-1), thrombin activatable fibrinolysis inhibitor (TAFI), plasmin-antiplasmin complex (PAP), tissue plasminogen activator (tPA) and thrombomodulin (TM). Those proteins were measured at five different sample times: preoperatively before the TXA injection (T1), 5 min after the TXA bolus (T2), 5 min after the initiation of CPB (T3), 5 min before the end of CPB (T4) and 5 min after the protamine administration (T5). A Thrombelastography (TEG) and standard coagulation test were also performed. Results Compared with the control group, the level of the D-Dimers decreased in the low-dose and high-dose groups when the patients arrived at the ICU and on the first postoperative morning. Over time, the concentrations of PAI-1, TAFI, and TM, but not PAP and tPA, showed significant differences between the three groups (P < 0.05). Compared with the placebo group, the plasma concentrations of PAI-1 and TAFI decreased significantly at the T3 and T4 (P < 0.05); TAFI concentrations also decreased at the T5 in low-dose group (P < 0.05). Compared with the low-dose group, the concentration of TM increased significantly at the T4 in high-dose group. Conclusions The in-vivo effect of low dose TXA is equivalent to high dose TXA on fibrinolysis parameters in adults with a low bleeding risk undergoing valvular cardiac surgery with cardiopulmonary bypass, and a low dose TXA regimen might be equivalent to high dose TXA for those patients. Trial registration ChiCTR-IPR-17010303, Principal investigator: Zhen-feng ZHOU, Date of registration: January 1, 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01234-8.
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Affiliation(s)
- Zhen-Feng Zhou
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine Zhejiang University, Hangzhou, China.,Department of Anesthesiology, Hangzhou Women's Hospital (The Affiliated Women's Hospital of Hangzhou Normal University), Hangzhou, China
| | - Wen Zhai
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine Zhejiang University, Hangzhou, China.,Department of Anesthesiology, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medicine College), Hangzhou, China
| | - Li-Na Yu
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine Zhejiang University, Hangzhou, China
| | - Kai Sun
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine Zhejiang University, Hangzhou, China
| | - Li-Hong Sun
- Department of Anesthesiology, Women's Hospital, School of Medicine Zhejiang University, Hangzhou, China
| | - Xiu-Fang Xing
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine Zhejiang University, Hangzhou, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine Zhejiang University, Hangzhou, China.
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Ozolina A, Strike E, Nikitina-Zake L, Jaunalksne I, Krumina A, Lacis R, Bjertnaes LJ, Vanags I. Polymorphisms on PAI-1 and ACE genes in association with fibrinolytic bleeding after on-pump cardiac surgery. BMC Anesthesiol 2015; 15:122. [PMID: 26340801 PMCID: PMC4560913 DOI: 10.1186/s12871-015-0101-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 08/26/2015] [Indexed: 12/11/2022] Open
Abstract
Background Carriers of plasminogen activator inhibitor -1 (PAI-1) -675 genotype 5G/5G may be associated with lower preoperative PAI-1 plasma levels and higher blood loss after heart surgery using cardiopulmonary bypass (CPB). We speculate if polymorphisms of PAI-1 -844 A/G and angiotensin converting enzyme (ACE) intron 16 I/D also might promote fibrinolysis and increase postoperative bleeding. Methods We assessed PAI-1 -844 A/G, and ACE intron 16 I/D polymorphisms by polymerase chain reaction technique and direct sequencing of genomic DNA from 83 open heart surgery patients that we have presented earlier. As primary outcome, accumulated chest tube drainage (CTD) at 4 and 24 h were analyzed for association with genetic polymorphisms. As secondary outcome, differences in plasma levels of PAI-1, t-PA/PAI-1 complex and D-dimer were determined for each polymorphism. SPSS® was used for statistical evaluation. Results The lowest preoperative PAI-1 plasma levels were associated with PAI-1 -844 genotype G/G, and higher CTD, as compared with genotype A/A at 4 and 24 h after surgery. Correspondingly, 4 h after the surgery CTD was higher in carriers of ACE intron 16 genotype I/I, as compared with genotype D/D. PAI-1 plasma levels and t-PA/PAI-1 complex reached nadir in carriers of ACE intron 16 genotype I/I, in whom we also noticed the highest D-dimer levels immediately after surgery. Notably, carriers of PAI-1 -844 genotype G/G displayed higher D-dimer levels at 24 h after surgery as compared with those of genotype A/G. Conclusions Increased postoperative blood loss secondary to enhanced fibrinolysis was associated with carriers of PAI-1 -844 G/G and ACE Intron 16 I/I, suggesting that these genotypes might predict increased postoperative blood loss after cardiac surgery using CPB. Electronic supplementary material The online version of this article (doi:10.1186/s12871-015-0101-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Agnese Ozolina
- Department of Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia. .,Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Eva Strike
- Department of Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia. .,Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Liene Nikitina-Zake
- Latvian Biomedical Research and Study Center, Ratsupites Street 1, Riga, Latvia.
| | - Inta Jaunalksne
- Clinical Immunology Centre, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia.
| | - Angelika Krumina
- Department of Infectology and Dermatology, Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Romans Lacis
- Department of Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia. .,Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Lars J Bjertnaes
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037, Tromsø, Norway.
| | - Indulis Vanags
- Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
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Ahn KT, Yamanaka K, Iwakura A, Hirose K, Nakatsuka D, Kusuhara T, Ikarashi J. Usefulness of intraoperative continuous infusion of tranexamic acid during emergency surgery for type A acute aortic dissection. Ann Thorac Cardiovasc Surg 2014; 21:66-71. [PMID: 24583703 DOI: 10.5761/atcs.oa.13-00339] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE We investigated the influence of intraoperative continuous tranexamic acid (TA) infusion on the amount of blood transfusion required in emergency surgery for type A acute aortic dissection. METHODS The study was based on the data of 55 consecutive patients who underwent surgery for type A acute aortic dissection. The patients were divided into 2 groups for comparison: Group T, consisting of 26 patients who received intraoperative continuous infusion of TA, and Group N, consisting of 29 patients who did not receive TA infusion during the surgery. RESULTS The mean amounts of blood transfusion required during and after surgery were compared between the 2 groups: they were 10.5 ± 8.7 and 16.2 ± 10.0 units of mannitol-adenine-phosphate-added red cell concentrate, 9.3 ± 8.6 and 17.1 ± 10.0 units of fresh frozen plasma, and 20.4 ± 12.2 and 29.7 ± 14.9 units of platelet concentrate, respectively, in Groups T and N. Thus, the amount of each of these blood products required was significantly reduced in Group T. CONCLUSIONS During emergency surgery for type A acute aortic dissection, continuous infusion of TA resulted in a significant reduction in the amount of blood transfusion required.
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Affiliation(s)
- Kun Tae Ahn
- Department of Cardiovascular Surgery, Kameda Medical Center, Kamogawa, Chiba, Japan
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Yavari M, Becker RC. Coagulation and fibrinolytic protein kinetics in cardiopulmonary bypass. J Thromb Thrombolysis 2008; 27:95-104. [PMID: 18214639 DOI: 10.1007/s11239-007-0187-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 12/17/2007] [Indexed: 12/29/2022]
Abstract
The development of Cardiopulmonary Bypass (CPB) catopulted the field of cardiothoracic surgery into a new dimension--one that changed the lives of individuals with congenital and acquired heart disease worldwide. Despite its contributions, CPB has clear limitations and creates unique challenges for clinicians and patients alike, stemming from profound hemostatic pertubations and accompanying risk for bleeding and possibly thrombotic complications.
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Affiliation(s)
- Maryam Yavari
- Duke Cardiovascular Thrombosis Center, Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
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