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Li T, Bo F, Meng X, Wang D, Ma J, Dai Z. The effect of perioperative antithrombin supplementation on blood conservation and postoperative complications after cardiopulmonary bypass surgery: A systematic review, meta-analysis and trial sequential analysis. Heliyon 2023; 9:e22266. [PMID: 38053853 PMCID: PMC10694320 DOI: 10.1016/j.heliyon.2023.e22266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
Study objective Antithrombin (AT) activity is reduced during cardiopulmonary bypass (CPB) surgery. Guidelines has demonstrated that perioperative AT supplementation contributed to blood conservation and prevent perioperative thrombotic complications and target organ injury owing to its role in reducing thrombin generation. But these recommends is lack of support of meta-analysis in the guidelines. This meta-analysis aims to include all the relevant randomized controlled trails (RCT) on patients who experienced cardiac surgeries with CPB and investigate the effect of perioperative AT on blood conservation and complications after cardiac surgery. Methods Standard published RCTs were searched from bibliographic databases to identify all evidence reporting perioperative AT supplementation for patients undergoing cardiovascular surgeries. The primary outcome was postoperative blood loss, the secondary outcomes were blood component transfusion (red blood cell (RBC), fresh frozen plasma (FFP), platelet and autologous blood), postoperative morbidity and in hospital mortality. The relative risk (RR) for dichotomous outcomes and the standardized mean difference (SMD) for continuous outcomes were estimated using a random-effects model. Trial sequential analysis (TSA) was performed using TSA software 0.9.5.10. Results 13 RCTs with 996 participants undergoing different cardiovascular surgeries were included. Meta-analysis showed AT did not decrease postoperative blood loss (SMD -0.01, 95%CI -0.2 to 0.19). Subgroup analysis showed the effect of AT on postoperative blood loss was not associated with age, RCT type, surgery type, injection time of AT and AT deficiency. TSA further suggested that no additional studies were required for the stable result. Perioperative AT also did not reduce RBC ((SMD 0.10, 95%CI -0.66 to 0.85), (RR 0.99, 95%CI 0.83 to 1.19)), FFP ((SMD 0.11, 95%CI -0.19 to 0.41), (RR 1.30, 95%CI 0.90 to 1.87)), platelet (RR 1.10, 95%CI 0.83 to 1.46) and autologous blood (SMD 0.46, 95%CI -0.12 to 1.8504) transfusions. Perioperative AT significantly increased in hospital mortality (RR 2.53, 95%CI 1.02 to 6.28) and acute kidney injury (AKI) (RR 3.72, 95%CI 1.73 to 8.04) incidence. There was no significant difference in postoperative reexploration, thromboembolism, ECMO/IABP support, and stroke incidence between AT and non-AT group. Conclusions With the improvement of AT level and heparin sensitivity, perioperative AT has no significant effect on blood conservation. And it is noteworthy that the treatment increased in hospital mortality and the incidence of AKI after cardiac surgery.
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Affiliation(s)
- Tao Li
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - FengShan Bo
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - XiangRui Meng
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - Di Wang
- Department of Internal Medicine, Yantai Haigang Hospital, Yantai, 264000, Shandong, China
| | - Jiahai Ma
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - Zhao Dai
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
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Fang ZA, Bruzdoski K, Kostousov V, Hui SKR, Vener D, Gottlieb E, Teruya J. Low antithrombin levels in neonates and infants undergoing congenital heart surgery result in more red blood cell and plasma transfusion on cardiopulmonary bypass. Transfusion 2020; 60:2841-2848. [PMID: 32939767 DOI: 10.1111/trf.16082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/05/2020] [Accepted: 08/09/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neonates have lower levels of antithrombin (AT) due to immature liver synthetic function. AT deficiency may lead to inadequate anticoagulation with heparin during cardiac surgery resulting in consumption of coagulation factors and increased blood transfusion. The goal of this study is to examine the effect of AT level on the transfusion requirements of neonates and infants undergoing open heart surgery. STUDY DESIGN AND METHODS This is a prospective, observational study at a tertiary pediatric referral center. Neonates and infants up to 6 months of age undergoing congenital heart surgery with cardiopulmonary bypass (CPB) were enrolled. Demographic, intraoperative, transfusion, and complications data were collected. Preoperative AT level was measured after induction of anesthesia. Prior to separation from CPB, a second blood sample was drawn and AT, thrombin antithrombin complex (TAT), D-dimer, and anti-Xa levels were measured. Linear and logistic regression were performed for data analysis. RESULTS Preoperative low AT level was significantly associated with increased transfusion of red blood cells (RBCs) and fresh frozen plasma (FFP) during CPB, but not after separation from CPB. The incidence of thrombosis and re-operation were not associated with preoperative AT levels. There was no association between TAT, D-dimer, and anti-Xa levels at the end of CPB and preoperative AT levels. CONCLUSION Low preoperative AT level is associated with increased transfusion of RBC and FFP on CPB in neonates and infants undergoing congenital heart surgery. Low preoperative AT level did not result in coagulation activation after CPB and after surgery.
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Affiliation(s)
- Zhe Amy Fang
- Department of Anesthesiology and Pain Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karen Bruzdoski
- Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| | - Vadim Kostousov
- Department of Pathology, Texas Children's Hospital, Houston, Texas, USA.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - Shiu-Ki Rocky Hui
- Department of Pathology, Texas Children's Hospital, Houston, Texas, USA.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - David Vener
- Department of Anesthesiology and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Erin Gottlieb
- Texas Center for Pediatric and Congenital Heart Disease, The University of Texas Dell Medical School/Dell Children's Medical Center, Austin, Texas, USA
| | - Jun Teruya
- Department of Pathology, Texas Children's Hospital, Houston, Texas, USA.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.,Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Jooste EH, Scholl R, Wu YH, Jaquiss RDB, Lodge AJ, Ames WA, Homi HM, Machovec KA, Greene NH, Donahue BS, Shah N, Benkwitz C. Double-Blind, Randomized, Placebo-Controlled Trial Comparing the Effects of Antithrombin Versus Placebo on the Coagulation System in Infants with Low Antithrombin Undergoing Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 33:396-402. [PMID: 30072263 DOI: 10.1053/j.jvca.2018.05.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine whether precardiopulmonary bypass (CPB) normalization of antithrombin levels in infants to 100% improves heparin sensitivity and anticoagulation during CPB and has beneficial effects into the postoperative period. DESIGN Randomized, double-blinded, placebo-controlled prospective study. SETTING Multicenter study performed in 2 academic hospitals. PARTICIPANTS The study comprised 40 infants younger than 7 months with preoperative antithrombin levels <70% undergoing CPB surgery. INTERVENTIONS Antithrombin levels were increased with exogenous antithrombin to 100% functional level intraoperatively before surgical incision. MEASUREMENTS AND MAIN RESULTS Demographics, clinical variables, and blood samples were collected up to postoperative day 4. Higher first post-heparin activated clotting times (sec) were observed in the antithrombin group despite similar initial heparin dosing. There was an increase in heparin sensitivity in the antithrombin group. There was significantly lower 24-hour chest tube output (mL/kg) in the antithrombin group and lower overall blood product unit exposures in the antithrombin group as a whole. Functional antithrombin levels (%) were significantly higher in the treatment group versus placebo group until postoperative day 2. D-dimer was significantly lower in the antithrombin group than in the placebo group on postoperative day 4. CONCLUSION Supplementation of antithrombin in infants with low antithrombin levels improves heparin sensitivity and anticoagulation during CPB without increased rates of bleeding or adverse events. Beneficial effects may be seen into the postoperative period, reflected by significantly less postoperative bleeding and exposure to blood products and reduced generation of D-dimers.
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Affiliation(s)
- Edmund H Jooste
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Rebecca Scholl
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Yi-Hung Wu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Robert D B Jaquiss
- Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center and Children's Medical Center, Dallas, TX
| | - Andrew J Lodge
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Duke University Medical Center, Durham
| | - Warwick A Ames
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - H Mayumi Homi
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Kelly A Machovec
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Nathaniel H Greene
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Brian S Donahue
- Division of Pediatric Cardiac Anesthesiology, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Nirmish Shah
- Division of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, NC
| | - Claudia Benkwitz
- Department of Anesthesia and Perioperative Care, UCSF Benioff Children's Hospital, San Francisco, CA
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Current and future trends in coagulation management for congenital heart surgery. J Thorac Cardiovasc Surg 2017; 153:1511-1515. [DOI: 10.1016/j.jtcvs.2016.11.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/09/2016] [Accepted: 11/15/2016] [Indexed: 01/04/2023]
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Stansfield BK, Wise L, Ham PB, Patel P, Parman M, Jin C, Mathur S, Harshfield G, Bhatia J. Outcomes following routine antithrombin III replacement during neonatal extracorporeal membrane oxygenation. J Pediatr Surg 2017; 52:609-613. [PMID: 27847121 DOI: 10.1016/j.jpedsurg.2016.10.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/05/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND We sought to examine the effect of routine antithrombin III (AT3) infusion on hemorrhagic and thrombotic complications, blood product utilization, and circuit lifespan in neonatal extracorporeal membrane oxygenation (ECMO). METHODS We performed a retrospective cohort study of 162 infants placed on ECMO for hypoxic respiratory failure. Infants requiring ECMO for primary cardiac support were excluded. Demographic data, time on ECMO, blood product usage, coagulation profile, and complications were compared between 90 control patients and 72 patients treated with AT3. RESULTS Infants receiving AT3 during ECMO had less thrombotic and similar bleeding complications as compared to infants receiving standard anticoagulation therapy. Total blood product infusion during ECMO was decreased (54.7±20.1 vs. 67.4±34.9mL/kg per day, p=0.001) in infants receiving AT3 during ECMO. Tighter control of activated clotting time and higher serum heparin anti-Xa levels were observed in the AT3 cohort during the first days of ECMO support. 1st ECMO circuit lifespan did not differ between groups. CONCLUSIONS Routine administration of AT3 in neonates receiving ECMO therapy was associated with tighter control of anticoagulation and a reduction in thrombotic events without increasing unwanted bleeding. However, circuit lifespan was unaffected. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Brian K Stansfield
- Department of Pediatrics, Augusta University, Augusta, GA, USA; Vascular Biology Center, Augusta University, Augusta, GA, USA.
| | - Linda Wise
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - P Benson Ham
- Department of Surgery, Augusta University, Augusta, GA, USA
| | - Pinkal Patel
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Malinda Parman
- Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Chan Jin
- Department of Biostatistics and Epidemiology, Augusta University, Augusta, GA
| | - Sunil Mathur
- Department of Biostatistics and Epidemiology, Augusta University, Augusta, GA
| | - Gregory Harshfield
- Department of Pediatrics, Augusta University, Augusta, GA, USA; Georgia Prevention Institute, Augusta University, Augusta, GA, USA
| | - Jatinder Bhatia
- Department of Pediatrics, Augusta University, Augusta, GA, USA
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Abstract
In this Editor's Review, articles published in 2016 are organized by category and briefly summarized. We aim to provide a brief reflection of the currently available worldwide knowledge that is intended to advance and better human life while providing insight for continued application of technologies and methods of organ Replacement, Recovery, and Regeneration. As the official journal of The International Federation for Artificial Organs, The International Faculty for Artificial Organs, the International Society for Mechanical Circulatory Support, the International Society for Pediatric Mechanical Cardiopulmonary Support, and the Vienna International Workshop on Functional Electrical Stimulation, Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level." Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. We were pleased to publish our second Virtual Issue in April 2016 on "Tissue Engineering in Bone" by Professor Tsuyoshi Takato. Our first was published in 2011 titled "Intra-Aortic Balloon Pumping" by Dr. Ashraf Khir. Other peer-reviewed Special Issues this year included contributions from the 11th International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion edited by Dr. Akif Ündar and selections from the 23rd Congress of the International Society for Rotary Blood Pumps edited by Dr. Bojan Biocina. We take this time also to express our gratitude to our authors for offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide meaningful suggestions to the author's work whether eventually accepted or rejected. Without these excellent and dedicated reviewers the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, John Wiley & Sons for their expert attention and support in the production and marketing of Artificial Organs. We look forward to reporting further advances in the coming years.
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Punzalan RC, Gottschall JL. Use and Future Investigations of Recombinant and Plasma-Derived Coagulation and Anticoagulant Products in the Neonate. Transfus Med Rev 2016; 30:189-96. [PMID: 27576087 DOI: 10.1016/j.tmrv.2016.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/18/2016] [Indexed: 12/27/2022]
Abstract
Although congenital bleeding disorders can manifest in the newborn period, the most common causes of bleeding and thrombosis in neonates are acquired conditions. Factor concentrates are used for specific diagnoses (hemophilia with inhibitors, specific factor deficiency, von Willebrand disease) and approved indications, and increasingly for off-label indications (bleeding in surgery cardiopulmonary bypass, extracorporeal membrane oxygenation). We will review the approved indications for factor products in the neonate and discuss the evidence and rationale for off-label use of factor products in management of bleeding and thrombosis in the neonate.
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Affiliation(s)
- Rowena C Punzalan
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
| | - Jerome L Gottschall
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
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