1
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Staessens S, Moussa MD, Pierache A, Rauch A, Rousse N, Boulleaux E, Ung A, Desender L, Pradines B, Vincentelli A, Mercier O, Labreuche J, Duhamel A, Van Belle E, Vincent F, Dupont A, Vanhoorelbeke K, Corseaux D, De Meyer SF, Susen S. Thrombus formation during ECMO: Insights from a detailed histological analysis of thrombus composition. J Thromb Haemost 2022; 20:2058-2069. [PMID: 35703468 PMCID: PMC9349827 DOI: 10.1111/jth.15784] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/20/2022] [Accepted: 06/10/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVES Intra-device thrombosis remains one of the most common complications during extracorporeal membrane oxygenation (ECMO). Despite anticoagulation, approximately 35% of patients develop thrombi in the membrane oxygenator, pump heads, or tubing. The aim of this study was to describe the molecular and cellular features of ECMO thrombi and to study the main drivers of thrombus formation at different sites in the ECMO circuits. APPROACH AND RESULTS Thrombi (n = 85) were collected immediately after veno-arterial-(VA)-ECMO circuit removal from 25 patients: 23 thrombi from the pump, 25 from the oxygenator, and 37 from the tubing. Quantitative histological analysis was performed for the amount of red blood cells (RBCs), platelets, fibrin, von Willebrand factor (VWF), leukocytes, and citrullinated histone H3 (H3Cit). ECMO thrombi consist of a heterogenous composition with fibrin and VWF being the major thrombus components. A clustering analysis of the four major histological parameters identified two typical thrombus types: RBC-rich and RBC-poor/fibrin-rich thrombi with no significant differences in VWF and platelet content. Thrombus composition was not associated with the thrombus location, except for higher amounts of H3Cit that were found in pump and oxygenator thrombi compared to tubing samples. We observed higher blood leukocyte count and lactate dehydrogenase levels in patients with fibrin-rich thrombi. CONCLUSION We found that thrombus composition is heterogenous, independent of their location, consisting of two types: RBC-rich and a fibrin-rich types. We also found that NETs play a minor role. These findings are important to improve current anticoagulation strategies in ECMO.
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Affiliation(s)
- Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Mouhamed D Moussa
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Adeline Pierache
- ULR 2694-METRICS (Evaluation des technologies de santé et des pratiques médicales), University of Lille, Centre Hospitalier Universitaire Lille, Lille, France
| | - Antoine Rauch
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Natacha Rousse
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Eric Boulleaux
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Alexandre Ung
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Linda Desender
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Bénédicte Pradines
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - André Vincentelli
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Olaf Mercier
- Research and Innovation Laboratory, INSERM U999, Marie Lannelongue Hospital, Paris Sud Saclay University, Le Plessis Robinson, France
| | - Julien Labreuche
- ULR 2694-METRICS (Evaluation des technologies de santé et des pratiques médicales), University of Lille, Centre Hospitalier Universitaire Lille, Lille, France
| | - Alain Duhamel
- ULR 2694-METRICS (Evaluation des technologies de santé et des pratiques médicales), University of Lille, Centre Hospitalier Universitaire Lille, Lille, France
| | - Eric Van Belle
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Flavien Vincent
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Annabelle Dupont
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Delphine Corseaux
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Sophie Susen
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011- EGID, Lille, France
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Bote J, Corkrey HA, Koupenova M. Human Platelets and Influenza Virus: Internalization and Platelet Activation. Platelets 2022; 33:184-191. [PMID: 34369285 PMCID: PMC8821732 DOI: 10.1080/09537104.2021.1961710] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Influenza infection has long been associated with prothrombotic outcomes in patients and platelets are the blood component predominantly responsible for thrombosis. In this review, we outline what is known about influenza interaction with human platelets, virion internalization, and viral RNA sensing, and the consequent impact on platelet function. We further discuss activation of platelets by IgG-influenza complexes and touch upon mechanisms of environmental platelet activation that relate to prothrombotic outcomes in patients during infection.
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Affiliation(s)
- Josiah Bote
- University of Massachusetts Medical School, Department of Medicine, Division of Cardiovascular Medicine, Worcester, MA 01605, USA
| | - Heather A. Corkrey
- University of Massachusetts Medical School, Department of Medicine, Division of Cardiovascular Medicine, Worcester, MA 01605, USA
| | - Milka Koupenova
- University of Massachusetts Medical School, Department of Medicine, Division of Cardiovascular Medicine, Worcester, MA 01605, USA,Corresponding Author: Milka Koupenova, University of Massachusetts Medical School, Albert Sherman Center, 368 Plantation St, S7-1041, Worcester, MA 01605, Tel: (774) 455-6646,
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3
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Chandler WL. Coagulation activation during extracorporeal membrane oxygenation (ECMO). Thromb Res 2022; 211:154-160. [DOI: 10.1016/j.thromres.2022.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 12/16/2022]
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4
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COVID-19 and Extracorporeal Membrane Oxygenation. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1353:173-195. [DOI: 10.1007/978-3-030-85113-2_10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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5
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Gimenez BT, Cezarette GN, Bomfim ADS, Monteiro WM, Russo EMDS, Frantz FG, Sampaio SV, Sartim MA. Role of crotoxin in coagulation: novel insights into anticoagulant mechanisms and impairment of inflammation-induced coagulation. J Venom Anim Toxins Incl Trop Dis 2020; 26:e20200076. [PMID: 33293940 PMCID: PMC7702976 DOI: 10.1590/1678-9199-jvatitd-2020-0076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 11/04/2020] [Indexed: 12/24/2022] Open
Abstract
Background: Snake venom phospholipases A2 (svPLA2) are
biologically active toxins, capable of triggering and modulating a wide
range of biological functions. Among the svPLA2s, crotoxin (CTX)
has been in the spotlight of bioprospecting research due to its role in
modulating immune response and hemostasis. In the present study, novel
anticoagulant mechanisms of CTX, and the modulation of inflammation-induced
coagulation were investigated. Methods: CTX anticoagulant activity was evaluated using platelet poor plasma (PPP)
and whole blood (WB), and also using isolated coagulation factors and
complexes. The toxin modulation of procoagulant and pro-inflammatory effects
was evaluated using the expression of tissue factor (TF) and cytokines in
lipopolysaccharide (LPS)-treated peripheral blood mononuclear cells (PBMC)
and in WB. Results: The results showed that CTX impaired clot formation in both PPP and WB, and
was responsible for the inhibition of both intrinsic (TF/factor VIIa) and
extrinsic (factor IXa/factor VIIIa) tenase complexes, but not for factor Xa
and thrombin alone. In addition, the PLA2 mitigated the
prothrombinase complex by modulating the coagulation phospholipid role in
the complex. In regards to the inflammation-coagulation cross talk, the
toxin was capable of reducing the production of the pro-inflammatory
cytokines IL-1β, IL-6 and TNF-α, and was followed by decreased levels of TF
and procoagulant activity from LPS-treated PBMC either isolated or in
WB. Conclusion: The results obtained in the present study recognize the toxin as a novel
medicinal candidate to be applied in inflammatory diseases with coagulation
disorders.
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Affiliation(s)
- Bruna Terada Gimenez
- Department of Clinical Analysis, Toxicology and Food Science, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Gabriel Neves Cezarette
- Department of Clinical Analysis, Toxicology and Food Science, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Aline de Sousa Bomfim
- Center for Cell-Based Therapy and Regional Blood Center of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Wuelton Marcelo Monteiro
- Tropical Medicine Graduate Program, Amazonas State University, Manaus, AM, Brazil.,Carlos Borborema Clinical Research Institute, Doutor Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, AM, Brazil
| | - Elisa Maria de Sousa Russo
- Department of Clinical Analysis, Toxicology and Food Science, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil.,Center for Cell-Based Therapy and Regional Blood Center of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Fabiani Gai Frantz
- Department of Clinical Analysis, Toxicology and Food Science, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Suely Vilela Sampaio
- Department of Clinical Analysis, Toxicology and Food Science, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Marco Aurelio Sartim
- Department of Clinical Analysis, Toxicology and Food Science, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil.,Basic and Applied Immunology Graduate Program, Institute of Biological Sciences, Federal University of Amazonas, Manaus, AM, Brazil
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6
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Meyer AD, Rishmawi AR, Kamucheka R, Lafleur C, Batchinsky AI, Mackman N, Cap AP. Effect of blood flow on platelets, leukocytes, and extracellular vesicles in thrombosis of simulated neonatal extracorporeal circulation. J Thromb Haemost 2020; 18:399-410. [PMID: 31628728 PMCID: PMC7350929 DOI: 10.1111/jth.14661] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 10/10/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has frequent and sometimes lethal thrombotic complications. The role that activated platelets, leukocytes, and small (0.3-micron to 1-micron) extracellular vesicles (EVs) play in ECMO thrombosis is not well understood. OBJECTIVES To test the effect of blood flow rate on the generation of activated platelets, leukocytes, and EVs in a simulated neonatal ECMO circuit using heparinized human whole blood. METHODS Simulated neonatal roller pump circuits circulated whole blood at low, nominal, and high flow rates (0.3, 0.5, and 0.7 L/min) for 6 h. Coagulopathy was defined by thromboelastography (TEG), STA® -procoagulant phospholipid clot time (STA®- Procoag-PPL), and calibrated automated thrombogram. High-resolution flow cytometry measured the cellular expression of prothrombotic phospholipids and proteins on platelets, leukocytes, and EV. RESULTS Despite heparinization, occlusive thrombosis halted flow in two of five circuits at 0.3 L/min and three of five circuits at 0.7 L/min. None of the five circuits at 0.5 L/min exhibited occlusive thrombosis. Phosphatidylserine (PS)-positive platelets and EVs increased at all flow rates more than blood under static conditions (P < .0002). Tissue factor (TF)-positive leukocytes and EVs increased only in low-flow and high-flow circuits (P < .0001). Tissue factor pathway inhibitor (TFPI), at 50 times more than the concentration in healthy adults, failed to suppress thrombin initiation in low-flow and high-flow circuits. CONCLUSIONS This in vitro study informs ECMO specialists to avoid low and high blood flow that increases TF expression on leukocytes and EVs, which likely initiate clot formation. Interventions to decrease TF generated by ECMO may be an effective approach to decrease thrombosis.
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Affiliation(s)
- Andrew D. Meyer
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health, San Antonio, Texas
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Anjana R. Rishmawi
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Health, San Antonio, Texas
| | - Robin Kamucheka
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Crystal Lafleur
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Andriy I. Batchinsky
- Extracorporeal Life Support, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
| | - Nigel Mackman
- Thrombosis and Hemostasis Program, Division of Hematology and Oncology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Andrew P. Cap
- Coagulation and Blood Research, U.S. Army Institute of Surgical Research (USAISR), Ft. Sam Houston, Texas
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7
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Doyle AJ, Hunt BJ. Current Understanding of How Extracorporeal Membrane Oxygenators Activate Haemostasis and Other Blood Components. Front Med (Lausanne) 2018; 5:352. [PMID: 30619862 PMCID: PMC6299009 DOI: 10.3389/fmed.2018.00352] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/30/2018] [Indexed: 12/15/2022] Open
Abstract
Extracorporeal membrane oxygenators are used in critical care for the management of severe respiratory and cardiac failure. Activation of the coagulation system is initiated by the exposure of blood to synthetic surfaces and the shear stresses of the circuit, especially from device pumps. Initial fibrinogen deposition and subsequent activation of coagulation factors and complement allow platelets and leucocytes to adhere to oxygenator surfaces and enhance thrombin generation. These changes and others contribute to higher rates of thrombosis seen in these patients. In addition, bleeding rates are also high. Primary haemostasis is impaired by platelet dysfunction and loss of their key adhesive molecules and shear stress causes an acquired von Willebrand defect. In addition, there is also altered fibrinolysis and lastly, administration of systemic anticoagulation is required to maintain circuit patency. Further research is required to fulyl establish the complexities of the haemostatic changes with these devices, and to elucidate the mechanistic changes that are mainly responsible so that plans can be made to reduce their complications and improve management.
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Affiliation(s)
- Andrew J Doyle
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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8
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Raspé C, Besch M, Charitos EI, Flöther L, Bucher M, Rückert F, Treede H. Rotational Thromboelastometry for Assessing Bleeding Complications and Factor XIII Deficiency in Cardiac Surgery Patients. Clin Appl Thromb Hemost 2018; 24:136S-144S. [PMID: 30198311 PMCID: PMC6714825 DOI: 10.1177/1076029618797472] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
We aimed to detect alterations and deficits in hemostasis during cardiac surgery with
cardiopulmonary bypass (CPB) using point-of-care-supported coagulation analysis
(rotational thromboelastometry, impedance aggregometry), in addition to single factor
assays for the measurement of fibrinogen (FI) and factor XIII (FXIII) levels. Forty-one
patients scheduled for elective cardiac surgery with CPB were enrolled in this
observational study. Perioperative measurement (pre-, postheparin, 30-minutes before the
end of bypass, 1-hourpostoperatively) of standard laboratory variables, additional
rotational thromboelastometry (ROTEM; International GmbH, Munich, Germany), Multiplate
analysis (Roche, Switzerland), and an assay of FXIII activity were performed as well as
the collection of epidemiological data and blood loss. The FI and FXIII levels as well as
the measured ROTEM and Multiplate parameters correlated weakly with the blood loss.
Clotting time and maximum clot firmness (MCF) of the intrinsically activated ROTEM showed
a good correlation (rCT-INTEM = 0.378; P <
.05, rMCF-INTEM = 0.305; P < .05) with
postoperative drainage loss, suggesting a dependence of blood loss on the initial
intrinsic activity. Additionally, perioperative FI or FIBTEM levels and the FXIII levels
correlated with each other. Intrinsically activated ROTEM showed a good correlation with
postoperative drainage loss, thus suggesting a dependence of blood loss on the initial
intrinsic activity and therefore facilitating clinicians to assess postoperative bleeding
complications. Based on the FI level or the MCFFIBTEM measured by ROTEM, it may
also be possible to assess the FXIII concentration. Especially in chronically ill and
massive bleeding cardiac surgery patients with significantly decreased FXIII levels, the
knowledge of FXIII deficiency may help clinicians to treat coagulation disorders more
adequately.
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Affiliation(s)
- Christoph Raspé
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle, Germany
| | - Maximilian Besch
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle, Germany
| | | | - Lilit Flöther
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle, Germany
| | - Michael Bucher
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle, Germany
| | - Florian Rückert
- Department of Anesthesiology and Critical Care Medicine, Halle-Wittenberg University, Halle, Germany
| | - Hendrik Treede
- Department of Cardiac Surgery, Halle-Wittenberg University, Halle, Germany
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Weber M, Steinle H, Golombek S, Hann L, Schlensak C, Wendel HP, Avci-Adali M. Blood-Contacting Biomaterials: In Vitro Evaluation of the Hemocompatibility. Front Bioeng Biotechnol 2018; 6:99. [PMID: 30062094 PMCID: PMC6054932 DOI: 10.3389/fbioe.2018.00099] [Citation(s) in RCA: 313] [Impact Index Per Article: 52.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 06/26/2018] [Indexed: 12/15/2022] Open
Abstract
Hemocompatibility of blood-contacting biomaterials is one of the most important criteria for their successful in vivo applicability. Thus, extensive in vitro analyses according to ISO 10993-4 are required prior to clinical applications. In this review, we summarize essential aspects regarding the evaluation of the hemocompatibility of biomaterials and the required in vitro analyses for determining the blood compatibility. Static, agitated, or shear flow models are used to perform hemocompatibility studies. Before and after the incubation of the test material with fresh human blood, hemolysis, cell counts, and the activation of platelets, leukocytes, coagulation and complement system are analyzed. Furthermore, the surface of biomaterials are evaluated concerning attachment of blood cells, adsorption of proteins, and generation of thrombus and fibrin networks.
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Affiliation(s)
| | | | | | | | | | | | - Meltem Avci-Adali
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
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10
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Targeting Circulating Leukocytes and Pyroptosis During Ex Vivo Lung Perfusion Improves Lung Preservation. Transplantation 2017; 101:2841-2849. [PMID: 28452921 DOI: 10.1097/tp.0000000000001798] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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11
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Hudák R, Debreceni IB, Deák I, Szabó GG, Hevessy Z, Antal-Szalmás P, Osterud B, Kappelmayer J. Laboratory characterization of leukemic cell procoagulants. Clin Chem Lab Med 2017; 55:1215-1223. [PMID: 28593927 DOI: 10.1515/cclm-2017-0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/30/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND In acute myeloid leukemias, there is an increased chance to develop thrombotic disorders. We hypothesized that in addition to leukemic promyelocytes, monocytic leukemia cells may also have a higher procoagulant activity. METHODS Fibrin formation was assessed by a one-stage clotting assay using a magnetic coagulometer. The thrombin generation test (TGT) of magnetically isolated normal human monocytes, intact leukemic cells and their isolated microparticles was performed by a fluorimetric assay. Phosphatidylserine (PS) expression of leukemic cells and microparticle number determinations were carried out by flow cytometry. RESULTS All cell lines displayed a significant procoagulant potential compared to isolated normal human monocytes. In the TGT test, the mean of lagtime and the time to peak parameters were significantly shorter in leukemic cells (3.9-4.7 and 9.9-10.3 min) compared to monocytes (14.9 and 26.5 min). The mean of peak thrombin in various monocytic leukemia cell lines was 112.1-132.9 nM vs. 75.1 nM in monocytes; however, no significant difference was observed in the ETP parameter. Factor VII-deficient plasma abolished all procoagulant activity, whereas factor XII-deficient plasma did not affect the speed of fibrin formation and thrombin generation but modulated the amount of thrombin. Factor XI-deficient plasma affected the time to peak values in one leukemic cell line and also attenuated peak thrombin. Leukemia cell-derived microparticles from all three cell lines exerted a procoagulant effect by significantly shortening the lagtime in TGT; there was a nonsignificant difference in case of ETP parameter. CONCLUSIONS All investigated monocytic leukemia cell lines exhibited significant thrombin generation. This phenomenon was achieved by the procoagulants on the surface of leukemic cells as well as by their microparticles.
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Millar JE, Fanning JP, McDonald CI, McAuley DF, Fraser JF. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:387. [PMID: 27890016 PMCID: PMC5125043 DOI: 10.1186/s13054-016-1570-4] [Citation(s) in RCA: 420] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a technology capable of providing short-term mechanical support to the heart, lungs or both. Over the last decade, the number of centres offering ECMO has grown rapidly. At the same time, the indications for its use have also been broadened. In part, this trend has been supported by advances in circuit design and in cannulation techniques. Despite the widespread adoption of extracorporeal life support techniques, the use of ECMO remains associated with significant morbidity and mortality. A complication witnessed during ECMO is the inflammatory response to extracorporeal circulation. This reaction shares similarities with the systemic inflammatory response syndrome (SIRS) and has been well-documented in relation to cardiopulmonary bypass. The exposure of a patient’s blood to the non-endothelialised surface of the ECMO circuit results in the widespread activation of the innate immune system; if unchecked this may result in inflammation and organ injury. Here, we review the pathophysiology of the inflammatory response to ECMO, highlighting the complex interactions between arms of the innate immune response, the endothelium and coagulation. An understanding of the processes involved may guide the design of therapies and strategies aimed at ameliorating inflammation during ECMO. Likewise, an appreciation of the potentially deleterious inflammatory effects of ECMO may assist those weighing the risks and benefits of therapy.
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Affiliation(s)
- Jonathan E Millar
- Critical Care Research Group, University of Queensland, Brisbane, Australia. .,Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Queensland, 4032, Australia.
| | - Jonathon P Fanning
- Critical Care Research Group, University of Queensland, Brisbane, Australia
| | - Charles I McDonald
- Critical Care Research Group, University of Queensland, Brisbane, Australia
| | - Daniel F McAuley
- Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - John F Fraser
- Critical Care Research Group, University of Queensland, Brisbane, Australia
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13
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Vukicevic P, Mikic A, Kotur-Stevuljevic J, Bogavac-Stanojevic N, Milic N, Nikolic L, Martinovic J. Oxidative stress and platelet activation during on-pump and off-pump coronary artery bypass grafting in patients with double grafted vessels. BIOTECHNOL BIOTEC EQ 2016. [DOI: 10.1080/13102818.2016.1217168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Petar Vukicevic
- Department for Cardiac Surgery, Military Medical Academy , Belgrade, Serbia
| | - Aleksandar Mikic
- Clinic for Cardiac Surgery, UC Clinical Centre , Belgrade, Serbia
- Department of Surgery with Anesthesiology, Faculty of Medicine, University of Belgrade , Belgrade, Serbia
| | - Jelena Kotur-Stevuljevic
- Faculty of Pharmacy, Department for Medical Biochemistry, University of Belgrade , Belgrade, Serbia
| | | | - Natasa Milic
- Department of Surgery with Anesthesiology, Faculty of Medicine, University of Belgrade , Belgrade, Serbia
- Department for Medical Statistics and Informatics , Belgrade, Serbia
| | - Ljubinka Nikolic
- Department for Hematology and Transfusion Laboratory, Clinic for Gynecology and Obstetrics, UC Clinical Centre , Belgrade, Serbia
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Becs G, Hudák R, Fejes Z, Debreceni IB, Bhattoa HP, Balla J, Kappelmayer J. Haemodiafiltration elicits less platelet activation compared to haemodialysis. BMC Nephrol 2016; 17:147. [PMID: 27737645 PMCID: PMC5064778 DOI: 10.1186/s12882-016-0364-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 10/11/2016] [Indexed: 11/20/2022] Open
Abstract
Background Mortality in patients with end-stage renal disorders is often a consequence of cardiovascular complications. Renal replacement therapies may contribute to this morbidity by promoting cellular activation. In renal failure patients peripheral blood samples were investigated for platelet and endothelial cell activation markers to compare the effects of haemodiafiltration (HDF) and haemodialysis (HD). Methods Overall 28 patients were included in the study. Platelet P-selectin and leukocyte - platelet heterotypic aggregates were studied by flow cytometry. Soluble P- and E-selectin values were determined by ELISA, while von Willebrand factor (vWF) antigen levels were measured by immunoturbidimetry. Statistical analysis was done by the SPSS v22 software. Results Platelet surface P-selectin was below 3.0 % in healthy controls, but it was higher during the dialysis after 4 h, 8 % and 14.3 % in HDF and HD, respectively. Monocyte-platelet heterotypic aggregates were significantly elevated after 4 h in both treatments, up to 69.2 % in HDF and to 82.9 % in HD. Soluble P-selectin levels were also significantly elevated by the end of both treatment procedures (p < 0.001), vWF antigen values, however, showed elevation only during HD treatment. Conclusions The attenuated platelet activating effects of HDF compared to HD may contribute to a less unfavourable vascular effect in this treatment modality. Electronic supplementary material The online version of this article (doi:10.1186/s12882-016-0364-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gergely Becs
- Department of Nephrology, University of Debrecen, Debrecen, Hungary
| | - Renáta Hudák
- Department of Laboratory Medicine, University of Debrecen, Nagyerdei krt. 98, Debrecen, Hungary
| | - Zsolt Fejes
- Department of Laboratory Medicine, University of Debrecen, Nagyerdei krt. 98, Debrecen, Hungary
| | - Ildikó Beke Debreceni
- Department of Laboratory Medicine, University of Debrecen, Nagyerdei krt. 98, Debrecen, Hungary
| | - Harjit Pal Bhattoa
- Department of Laboratory Medicine, University of Debrecen, Nagyerdei krt. 98, Debrecen, Hungary
| | - József Balla
- Department of Nephrology, University of Debrecen, Debrecen, Hungary.,MTA-DE Vascular Biology, Thrombosis and Hemostasis Research Group, Hungarian Academy of Sciences, Debrecen, Hungary
| | - János Kappelmayer
- Department of Laboratory Medicine, University of Debrecen, Nagyerdei krt. 98, Debrecen, Hungary.
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15
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Choi SJ, Jang KJ, Lim JA, Kim HS. Human coagulation factor VIII domain-specific recombinant polypeptide expression. Blood Res 2015; 50:103-8. [PMID: 26157780 PMCID: PMC4486152 DOI: 10.5045/br.2015.50.2.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/22/2015] [Accepted: 05/27/2015] [Indexed: 11/17/2022] Open
Abstract
Background Hemophilia A is caused by heterogeneous mutations in F8. Coagulation factor VIII (FVIII), the product of F8, is composed of multiple domains designated A1-A2-B-A3-C1-C2. FVIII is known to interact with diverse proteins, and this characteristic may be important for hemostasis. However, little is known about domain-specific functions or their specific binding partners. Methods To determine F8 domain-specific functions during blood coagulation, the FVIII domains A1, A2, A3, and C were cloned from Hep3B hepatocytes. Domain-specific recombinant polypeptides were glutathione S-transferase (GST)- or polyhistidine (His)-tagged, over-expressed in bacteria, and purified by specific affinity chromatography. Results Recombinant polypeptides of predicted sizes were obtained. The GST-tagged A2 polypeptide interacted with coagulation factor IX, which is known to bind the A2 domain of activated FVIII. Conclusion Recombinant, domain-specific polypeptides are useful tools to study the domain-specific functions of FVIII during the coagulation process, and they may be used for production of domain-specific antibodies.
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Affiliation(s)
- Su Jin Choi
- Department of Biological Science, College of Natural Sciences, Ajou University, Suwon, Korea
| | - Ki Jung Jang
- Department of Biological Science, College of Natural Sciences, Ajou University, Suwon, Korea
| | - Jeong-A Lim
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Hye Sun Kim
- Department of Biological Science, College of Natural Sciences, Ajou University, Suwon, Korea
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16
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Probing the coagulation pathway with aptamers identifies combinations that synergistically inhibit blood clot formation. ACTA ACUST UNITED AC 2014; 21:935-44. [PMID: 25065530 DOI: 10.1016/j.chembiol.2014.05.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/03/2014] [Accepted: 05/30/2014] [Indexed: 11/21/2022]
Abstract
Coordinated enzymatic reactions regulate blood clot generation. To explore the contributions of various coagulation enzymes in this process, we utilized a panel of aptamers against factors VIIa, IXa, Xa, and prothrombin. Each aptamer dose-dependently inhibited clot formation, yet none was able to completely impede this process in highly procoagulant settings. However, several combinations of two aptamers synergistically impaired clot formation. One extremely potent aptamer combination was able to maintain human blood fluidity even during extracorporeal circulation, a highly procoagulant setting encountered during cardiopulmonary bypass surgery. Moreover, this aptamer cocktail could be rapidly reversed with antidotes to restore normal hemostasis, indicating that even highly potent aptamer combinations can be rapidly controlled. These studies highlight the potential utility of using sets of aptamers to probe the functions of proteins in molecular pathways for research and therapeutic ends.
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Abstract
The contact of any biomaterial with blood gives rise to multiple pathophysiologic defensive mechanisms such as activation of the coagulation cascade, platelet adhesion and activation of the complement system and leukocytes. The reduction of these events is of crucial importance for the successful clinical performance of a cardiovascular device. This can be achieved by improving the hemocompatibility of the device materials or by pharmacologic inhibition of the key enzymes responsible for the activation of the cascade reactions, or a combination of both. Different strategies have been developed during the last 20 years, and this article attempts to review the most significant, by dividing them into three main categories: bioinert or biopassive, biomimetic and bioactive strategies. With regard to bioactive strategies, particular attention is given to heparin immobilization and recent related technologies. References from both scientific literature and commercial sites are provided. Future development and studies are suggested.
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Affiliation(s)
- Maria Cristina Tanzi
- Politecnico di Milano, Bioengineering Department, P.zza L. da Vinci, Milano, Italy.
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18
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Brekke OL, Waage C, Christiansen D, Fure H, Qu H, Lambris JD, Østerud B, Nielsen EW, Mollnes TE. The effects of selective complement and CD14 inhibition on the E. coli-induced tissue factor mRNA upregulation, monocyte tissue factor expression, and tissue factor functional activity in human whole blood. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 735:123-36. [PMID: 23402023 DOI: 10.1007/978-1-4614-4118-2_8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The complement pathway and CD14 play essential roles in inflammation, but little is known about the relative roles of complement and CD14 in E. coli-induced tissue factor (TF) mRNA upregulation, expression by monocytes, and functional activity in human whole blood. METHODS Whole E. coli bacteria were incubated for up to 4 h in human whole blood containing the anticoagulant lepirudin, which does not affect complement activation. TF mRNA levels were analyzed using reverse transcription, quantitative real-time PCR (RT-qPCR), and the expression of TF on the cell surface was analyzed using flow cytometry. Complement was selectively inhibited using the C3 convertase inhibitor compstatin or a C5a receptor antagonist (C5aRa), while CD14 was blocked by an anti-CD14 F(ab')2 monoclonal antibody. RESULTS The E. coli-induced TF mRNA upregulation was reduced to virtually background levels by compstatin, whereas anti-CD14 had no effect. Monocyte TF expression and TF activity in plasma microparticles were significantly reduced by C5aRa. Anti-CD14 alone only slightly reduced E. coli-induced monocyte TF expression but showed a modest additive effect when combined with the complement inhibitors. Inhibiting complement and CD14 efficiently reduced the expression of the E. coli-induced cytokines IL-1beta, IL-6, IL-8, and platelet-derived growth factor bb. CONCLUSION Our results indicate that E. coli-induced TF mRNA upregulation is mainly dependent on complement activation, while CDI4 plays a modest role in monocyte TF expression and the plasma TF activity in human whole blood.
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Affiliation(s)
- O L Brekke
- Department of Laboratory Medicine, Nordland Hospital, Bodø, N-8092, Norway
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19
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Benkwitz C, Hammer GB. Thrombotic endotracheal tube occlusion after administration of recombinant factor VIIa. J Cardiothorac Vasc Anesth 2012; 27:1330-3. [PMID: 22959153 DOI: 10.1053/j.jvca.2012.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Claudia Benkwitz
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA.
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20
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Schetz M, Van Cromphaut S, Dubois J, Van den Berghe G. Does the surface-treated AN69 membrane prolong filter survival in CRRT without anticoagulation? Intensive Care Med 2012; 38:1818-25. [PMID: 22773036 DOI: 10.1007/s00134-012-2633-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 06/06/2012] [Indexed: 11/27/2022]
Abstract
PURPOSE The need for continuous anticoagulation remains a significant drawback in continuous renal replacement therapy (CRRT), especially in patients with increased bleeding risk. Polyethyleneimine treatment of the AN69 membrane (AN69ST) reduces thrombogenicity through decreased contact activation and promotion of heparin binding. The aim of this study is to evaluate whether this membrane prolongs filter survival in CRRT without anticoagulation. METHODS A single-center, prospective, randomized, double-blind controlled trial with cross-over design comparing filter survival with the AN69ST membrane and the original AN69 membrane in 39 patients treated with continuous venovenous hemofiltraton (CVVH) without additional heparin. RESULTS Filter survival with the AN69ST membrane (n = 75) was 14.2 ± 8.2 h, which is not significantly different from the 13.3 ± 10.3 h for the original AN69 membrane (n = 76; p = 0.59). Limiting the analysis to those treatments that were interrupted for filter clotting yielded similar results: 14.4 ± 8.2 h for the AN69 ST membrane (n = 62) versus 14.1 ± 7.5 h for the original AN69 membrane (n = 56) (p = 0.93). CONCLUSIONS Compared with the original AN69 membrane, the surface-treated AN69ST membrane does not prolong filter survival during CVVH without systemic anticoagulation and with the CRRT settings used in this study.
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Affiliation(s)
- Miet Schetz
- Department of Intensive Care Medicine, University Hospital of the Catholic University Leuven, Herestraat 49, 3000, Leuven, Belgium.
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21
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Inflammatory response induced by candidate biomaterials of an implantable microfabricated sensor. J Biomed Mater Res A 2012; 100:1142-50. [DOI: 10.1002/jbm.a.34054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 11/01/2011] [Accepted: 11/29/2011] [Indexed: 11/07/2022]
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22
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Fischer M, Sperling C, Tengvall P, Werner C. The ability of surface characteristics of materials to trigger leukocyte tissue factor expression. Biomaterials 2010; 31:2498-507. [DOI: 10.1016/j.biomaterials.2009.12.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 12/03/2009] [Indexed: 11/17/2022]
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23
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Patchipulusu S, Turturro M, Hall CL. Monocyte-derived macrophage microparticles impart tissue factor activity to biomaterial surfaces. J Biomed Mater Res A 2010; 92:724-32. [DOI: 10.1002/jbm.a.32320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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24
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Mueller SW, MacLaren R, Fish DN, Kiser TH. Prefilter Bivalirudin for Preventing Hemofilter Occlusion in Continuous Renal Replacement Therapy. Ann Pharmacother 2009; 43:1360-5. [DOI: 10.1345/aph.1m179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To describe a case of successful bivalirudin use as a prefilter anticoagulant in continuous venovenous hemofiltration (CVVH). Case Summary: A 30-year-old male was brought to the hospital by ambulance with an anterior communicating artery subarachnoid hemorrhage, signs of intraparenchymal hemorrhage, and hydrocephalus. During the patient's complicated hospital course, he developed acute renal failure requiring CVVH, as well as hepatic insufficiency (Child-Pugh class B). Unfractionated heparin was used as a prefilter anticoagulant. After he had a positive heparin-induced thrombocytopenia (HIT) antibody test, prefilter heparin was discontinued in favor of bivalirudin. Filter survival and systemic activated partial thromboplastin time (aPTT) values were compared between prefilter heparin (n = 5) and bivalirudin (n = 4). Filter survival was similar (median 26 h with heparin vs 37 h with bivalirudin; p = 0.52). Prefilter bivalirudin 1–2.5 mg/hour (0.009–0.023 mg/kg/h) was effective in maintaining systemic aPTTs that were 1–1.4 times the reference range. Serotonin release assay and subsequent HIT antibodies were negative. The patient's renal function improved and CVVH was discontinued. Discussion: Critically ill patients requiring CVVH often need regional or systemic anticoagulation to prevent filter occlusion. In some patient populations, such as those with HIT or liver failure, prefilter heparin and regional citrate, respectively, may not be options. Alternative anticoagulants may be needed to avoid complications of frequent filter occlusions. The direct thrombin inhibitors (DTIs) lepirudin and argatroban have been used to maintain hemofilter patency, in small studies. Bivalirudin may have pharmacokinetic advantages over other DTIs when used in patients with hepatic and renal impairment. In our patient, bivalirudin provided a safe alternative to heparin therapy and was effective in maintaining hemofilter patency during CVVH. Conclusions: Prefilter bivalirudin may be an option to prevent filter occlusion in patients requiring continuous renal replacement therapy. Future studies are needed to validate the safety and efficacy of bivalirudin as a prefilter anticoagulant.
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Affiliation(s)
- Scott W Mueller
- Critical Care Specialty Resident, Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Denver, Aurora, CO
| | - Robert MacLaren
- Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Denver
| | | | - Tyree H Kiser
- Department of Clinical Pharmacy, School of Pharmacy, University of Colorado Denver
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25
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26
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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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27
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Oudemans-van Straaten HM. Anticoagulation in CRRT: Systemic or Regional? Intensive Care Med 2007. [DOI: 10.1007/0-387-35096-9_64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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28
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Abstract
Factor XII (FXII), a clotting enzyme that can initiate coagulation in vitro, has long been considered dispensable for normal blood clotting in vivo because hereditary deficiencies in FXII are not associated with spontaneous or excessive bleeding. However, new studies show that mice lacking FXII are protected against arterial thrombosis (obstructive clot formation) and stroke. Thus, FXII could be a unique drug target that could be blocked to prevent thrombosis without the side effect of increased bleeding.
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Affiliation(s)
- Robert W Colman
- Sol Sherry Thrombosis Research Center and Hematology Division, Department of Medicine, Temple University School of Medicine, Philadelphia, PA 19140, USA.
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29
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Oudemans-van Straaten HM, Wester JPJ, de Pont ACJM, Schetz MRC. Anticoagulation strategies in continuous renal replacement therapy: can the choice be evidence based? Intensive Care Med 2006; 32:188-202. [PMID: 16453140 DOI: 10.1007/s00134-005-0044-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2005] [Accepted: 12/13/2005] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Critical illness increases the tendency to both coagulation and bleeding, complicating anticoagulation for continuous renal replacement therapy (CRRT). We analyzed strategies for anticoagulation in CRRT concerning implementation, efficacy and safety to provide evidence-based recommendations for clinical practice. METHODS We carried out a systematic review of the literature published before June 2005. Studies were rated at five levels to create recommendation grades from A to E, A being the highest. Grades are labeled with minus if the study design was limited by size or comparability of groups. Data extracted were those on implementation, efficacy (circuit survival), safety (bleeding) and monitoring of anticoagulation. RESULTS Due to the quality of the studies recommendation grades are low. If bleeding risk is not increased, unfractionated heparin (activated partial thromboplastin time, APTT, 1-1.4 times normal) or low molecular weight heparin (anti-Xa 0.25-0.35 IU/l) are recommended (grade E). If facilities are adequate, regional anticoagulation with citrate may be preferred (grade C). If bleeding risk is increased, anticoagulation with citrate is recommended (grade D(-)). CRRT without anticoagulation can be considered when coagulopathy is present (grade D(-)). If clotting tendency is increased predilution or the addition of prostaglandins to heparin may be helpful (grade C(-)). CONCLUSION Anticoagulation for CRRT must be tailored to patient characteristics and local facilities. The implementation of regional anticoagulation with citrate is worthwhile to reduce bleeding risk. Future trials should be randomized and should have sufficient power and well defined endpoints to compensate for the complexity of critical illness-related pro- and anticoagulant forces. An international consensus to define clinical endpoints is advocated.
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Affiliation(s)
| | - J P J Wester
- Department of Intensive Care Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - A C J M de Pont
- Adult Intensive Care Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - M R C Schetz
- Department of Intensive Care Medicine, University Hospital Gasthuisberg, Leuven, Belgium
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30
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Sperling C, Schweiss RB, Streller U, Werner C. In vitro hemocompatibility of self-assembled monolayers displaying various functional groups. Biomaterials 2005; 26:6547-57. [PMID: 15939466 DOI: 10.1016/j.biomaterials.2005.04.042] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2004] [Accepted: 04/15/2005] [Indexed: 11/17/2022]
Abstract
Self-assembled monolayers (SAMs) of alkanethiols with various terminating groups (-OH, -CH3, -COOH) and binary mixtures of these alkanethiols were studied with respect to their hemocompatibility in vitro by means of freshly taken human whole blood. The set of smooth monomolecular films with graded surface characteristics was applied to scrutinize hypotheses on the impact of surface chemical-physical properties on distinct blood activation cascades, i.e. to analyze -OH surface groups vs. complement activation, acidic surface sites vs. contact activation/coagulation and surface hydrophobicity vs. thrombogenicity. Blood and model surfaces were analyzed after incubation for the related hemocompatibility parameters. Our results show that the adhesion of leukocytes is abolished on a -CH3 surface and greatly enhanced on surfaces with -OH groups. The opposite was detected for the adhesion of platelets. A strong correlation between the activation of the complement system and the adhesion of leukocytes with the content of -OH groups could be observed. The contact activation for hydrophilic surfaces was found to scale with the amount of acidic surface sites. However, the coagulation and platelet activation did not simply correlate with any surface property and were therefore concluded to be determined by a superposition of contact activation and platelet adhesion.
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Affiliation(s)
- Claudia Sperling
- Department of Biocompatible Materials, Leibniz Institute of Polymer Research Dresden, The Max Bergmann Center of Biomaterials Dresden, 01069 Dresden, Germany
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31
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Hattori T, Khan MMH, Colman RW, Edmunds LH. Plasma Tissue Factor Plus Activated Peripheral Mononuclear Cells Activate Factors VII and X in Cardiac Surgical Wounds. J Am Coll Cardiol 2005; 46:707-13. [PMID: 16098440 DOI: 10.1016/j.jacc.2005.05.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Revised: 04/28/2005] [Accepted: 05/03/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The purpose of this study was to test the hypothesis that activated monocytes with soluble plasma tissue factor (pTF) activate factors VII and X to generate thrombin. BACKGROUND Despite heparin, thrombin is progressively generated during cardiac surgery with cardiopulmonary bypass (CPB), produces intravascular fibrin and fibrinolysis, and causes serious thromboembolic and nonsurgical bleeding complications. Thrombin is primarily produced in the surgical wound, but mechanisms are unclear. METHODS In 13 patients, interactions of mononuclear cells, platelets, pTF, and pTF fractions to activate factors VII and X were evaluated in pre-bypass, perfusate, and pericardial wound blood before and during CPB. RESULTS Monocytes are activated in wound, but not in pre-bypass or perfusate plasma (monocyte chemotactic protein-1 = 29.5 +/- 2.1 pmoles/l vs. 2.8 +/- 1.2 pmoles/l and 3.3 +/-1.4 pmoles/l, respectively). Wound pTF is substantially elevated compared to other locations (3.64 +/- 0.45 pmoles/l vs. 0.71 +/- 0.65 pmoles/l and 1.31 +/- 1.4 pmoles/l). Supernatant wound pTF contains 81.7% of TF antigen; wound microparticle pTF contains 18.3%. Wound monocytes and all C5a-stimulated monocytes (but not activated platelets) completely convert factor VII to factor VIIa with wound pTF. Activated monocytes more efficiently activate factor X with wound supernatant TF/factor VII(VIIa) complex than with wound microparticle TF/factor VII(fVIIa). The correlation coefficient (r) between wound thrombin generation (F1.2) and wound pTF concentration is 0.944 (p = 0.0004). CONCLUSIONS During cardiac surgery with CPB, wound monocytes plus wound pTF or wound microparticle-free supernatant pTF preferentially accelerate activation of factor VII and factor X. This system represents a novel mechanism for thrombin generation via the TF coagulation pathway.
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Affiliation(s)
- Takashi Hattori
- Harrison Department of Surgical Research, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Johnell M, Larsson R, Siegbahn A. The influence of different heparin surface concentrations and antithrombin-binding capacity on inflammation and coagulation. Biomaterials 2005; 26:1731-9. [PMID: 15576147 DOI: 10.1016/j.biomaterials.2004.05.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2004] [Accepted: 05/12/2004] [Indexed: 11/15/2022]
Abstract
The corline heparin surface (CHS) used in the extracorporeal circuit during coronary artery bypass grafting is shown to decrease the activation of inflammation and coagulation. Synchrotron radiation studies have shown that a single layer of the CHS may not completely cover the substrate surface. However, a double layer of CHS results in a uniform surface. We investigated the effect of surfaces with different surface concentrations of heparin on cell activation and coagulation compared to an uncoated surface. The CHS is prepared by a conditioning layer of polymeric amine onto which a macromolecular heparin conjugate is attached. We used PVC tubing, uncoated or modified with a single or double layer of the CHS, and circulated fresh whole blood from healthy volunteers in a loop model system at 37 degrees C up to 4 h. Blood was drawn from the loops at different times and activation of inflammation and coagulation was studied by real-time PCR, flow cytometry and ELISA. The activation of leukocytes and platelets and formation of leukocyte-platelet aggregates were reduced by use of the single-layered CHS compared to the uncoated surface. Use of double-layered CHS resulted in significantly reduced cell activation and thrombin generation. Development of the CHS obtained by the double layer of the coating has improved the biocompatibility of the surface.
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Affiliation(s)
- M Johnell
- Laboratory for Coagulation Research, Clinical Chemistry, Department of Medical Sciences, Uppsala University, Akademiska Hospital, SE-751 85 Uppsala, Sweden
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33
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Bull BS, Hay K, Razzouk AJ, Huse WM. Reinfusion of aspirated pericardial blood during CPB. Part II. Laparotomy sponges are hazardous parts of the CPB circuit? Blood Cells Mol Dis 2005; 34:144-50. [PMID: 15727897 DOI: 10.1016/j.bcmd.2004.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Indexed: 10/26/2022]
Abstract
Usually, cotton laparotomy sponges are discarded when they become blood soaked. During bypass surgery, however, they are often wrung out into the pericardial sac and the contents of the sac are aspirated into the cardiopulmonary bypass (CPB) circuit. After cardiopulmonary bypass, many patients give evidence of mental confusion, excessive bleeding, and systemic inflammatory response syndrome (SIRS). We believe that a possible cause is reinfusion of blood that has been activated by contact with laparotomy sponges and contains fibrin microemboli and thrombin. Thrombin production, soluble fibrin (SF) development, and fibrinogen disappearance were measured, over time, in model systems composed of increasing amounts (0-10-20 microL) of tissue factor (TF) in 4 ml of anticoagulated blood distributed through the interstices of a 49-cm(2) laparotomy sponge. Clotting occurred in all of the sponges. Clotting was accelerated by the presence of TF. Without TF, clotting occurred in an average of 28 min (range 17-39). With 10 and 20 microl TF, clotting occurred in 20 (range 11-27) and 13 (range 10-16) min, respectively. Thrombin at a level of approximately 16 NIHU/ml whole blood was present in several donors for 10-20 min after clotting was complete. If 120 ml of blood was to be wrung from a full-sized laparotomy sponge at this point in time, it could contain as much as 2000 units of thrombin.
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Affiliation(s)
- Brian S Bull
- Department of Pathology and Human Anatomy, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA.
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Kappelmayer J, Nagy B, Miszti-Blasius K, Hevessy Z, Setiadi H. The emerging value of P-selectin as a disease marker. Clin Chem Lab Med 2005; 42:475-86. [PMID: 15202782 DOI: 10.1515/cclm.2004.082] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Activated platelets are key components in many arterial disorders. P-selectin is an activation-dependent platelet receptor, which is also identified in endothelial cells. Together with E- and L-selectin it constitutes the selectin family. These transmembrane proteins have continued to attract great interest as they support rapid and reversible cell adhesion in flow systems and thus play an essential role in multicellular interactions during thrombosis and inflammation. Similarly to other lectins, selectins bind to different glycoconjugates with varying affinities. Protein ligands, equipped with the appropriate carbohydrate and sulfate moieties for P-selectin binding, have been identified in normal peripheral blood leukocytes and several non-hematopoietic organs, as well as on cancer cells. For diagnostic purposes, P-selectin can readily be detected on the platelet surface by flow cytometry and by ELISA as a soluble ligand in the plasma. Along with other markers, these data can be used in the assessment of platelet activation status. Such results bear clinical significance since P-selectin has been implicated in the pathogenesis of wide-spread disorders including coronary artery disease, stroke, diabetes and malignancy.
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Affiliation(s)
- János Kappelmayer
- Department of Clinical Biochemistry and Molecular Pathology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary.
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Gorbet MB, Sefton MV. Biomaterial-associated thrombosis: roles of coagulation factors, complement, platelets and leukocytes. Biomaterials 2005; 25:5681-703. [PMID: 15147815 DOI: 10.1016/j.biomaterials.2004.01.023] [Citation(s) in RCA: 857] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2003] [Accepted: 01/19/2004] [Indexed: 01/18/2023]
Abstract
Our failure to produce truly non-thrombogenic materials may reflect a failure to fully understand the mechanisms of biomaterial-associated thrombosis. The community has focused on minimizing coagulation or minimizing platelet adhesion and activation. We have infrequently considered the interactions between the two although we are generally familiar with these interactions. However, we have rarely considered in the context of biomaterial-associated thrombosis the other major players in blood: complement and leukocytes. Biomaterials are known agonists of complement and leukocyte activation, but this is frequently studied only in the context of inflammation. For us, thrombosis is a special case of inflammation. Here we summarize current perspectives on all four of these components in thrombosis and with biomaterials and cardiovascular devices. We also briefly highlight a few features of biomaterial-associated thrombosis that are not often considered in the biomaterials literature: The importance of tissue factor and the extrinsic coagulation system. Complement activation as a prelude to platelet activation and its role in thrombosis. The role of leukocytes in thrombin formation. The differing time scales of these contributions.
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Affiliation(s)
- Maud B Gorbet
- Department of Chemical Engineering and Applied Chemistry, Institute of Biomaterials and Biomedical Engineering, University of Toronto, 4 Taddle Creek Road, Room 407D, Toronto, Ont., Canada M5S 3G9
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Kaminishi Y, Hiramatsu Y, Watanabe Y, Yoshimura Y, Sakakibara Y. Effects of nafamostat mesilate and minimal-dose aprotinin on blood-foreign surface interactions in cardiopulmonary bypass. Ann Thorac Surg 2004; 77:644-50. [PMID: 14759453 DOI: 10.1016/s0003-4975(03)01513-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2003] [Indexed: 11/25/2022]
Abstract
BACKGROUND The pharmacological inhibition of blood-foreign surface interactions is an attractive strategy for reducing the morbidity associated with cardiopulmonary bypass. We compared the inhibitory effects of nafamostat mesilate (a broad-spectrum synthetic protease inhibitor) and minimal-dose aprotinin on blood-surface interactions in clinical cardiopulmonary bypass. METHODS Eighteen patients undergoing coronary surgery were divided into three groups: (1) the control group (heparin, 4 mg/kg; n = 6), (2) the nafamostat mesilate group (heparin plus nafamostat, 0.2 mg/kg bolus followed by 2.0 mg/kg/h during cardiopulmonary bypass; n = 6), and (3) the aprotinin group (heparin plus aprotinin, 2.0 x 10(4) KIU/kg; n = 6). Platelet count, platelet aggregation, beta-thromboglobulin, prothrombin fragment F1.2, thrombin-antithrombin complex, plasminogen activator inhibitor-1, alpha2-plasmin inhibitor-plasmin complex, D-dimer, neutrophil elastase, and interleukin-6 were measured before, during, and after bypass. Bleeding times and blood loss were recorded. RESULTS There were no significant differences between groups in platelet count, beta-thromboglobulin, plasminogen activator inhibitor-1, interleukin-6, bleeding times, or blood loss. Platelet aggregation was better preserved at 12 hours after surgery in the nafamostat and aprotinin groups than in the control group. Prothrombin fragment F1.2, thrombin-antithrombin complex and neutrophil elastase levels were significantly reduced by aprotinin, but not by nafamostat as compared with the control group. The alpha2-plasmin inhibitor-plasmin complex and D-dimer were significantly lower with either of the drugs. Aprotinin showed better control of D-dimer than did nafamostat. CONCLUSIONS Nafamostat mesilate fails to reduce thrombin formation and neutrophil elastase release, whereas minimal-dose aprotinin inhibits both. Neither nafamostat nor aprotinin inhibits platelet activation. Nafamostat reduces fibrinolysis during cardiopulmonary bypass, although its effect is not as potent as aprotinin.
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Affiliation(s)
- Yuichiro Kaminishi
- Division of Cardiovascular Surgery, Jichi Medical School, Tochigi, Japan
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Maslow A, Schwartz C. Cardiopulmonary Bypass-Associated Coagulopathies and Prophylactic Therapy. Int Anesthesiol Clin 2004; 42:103-33. [PMID: 15205643 DOI: 10.1097/00004311-200404230-00010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, 02903, USA
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Streller U, Sperling C, Hübner J, Hanke R, Werner C. Design and evaluation of novel blood incubation systems for in vitro hemocompatibility assessment of planar solid surfaces. J Biomed Mater Res B Appl Biomater 2003; 66:379-90. [PMID: 12808598 DOI: 10.1002/jbm.b.10016] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Success in the development of hemocompatible biomaterials depends on adequate equipment and procedures for standardized analysis of blood-materials interactions in vitro. In view of the limited standard of knowledge on that important aspect, two novel incubation systems were designed, built, and evaluated for the in vitro assessment of the hemocompatibility of planar solid surfaces: A screening setup was introduced for the comparison of up to 12 different samples. A perfusion setup was developed to model the directed blood flow in the vascular system during incubation by a recirculation circuit, allowing the variation of the wall shear rate at the sample surface. The incubation procedures utilized freshly drawn, heparinized whole human blood. Hemocompatibility in terms of selected aspects of coagulation, thrombogenicity, and immune responses was quantified through plasma levels of characteristic molecules (immunoassays), cell counting, and analysis of adherent cells and fibrin formation (scanning electron microscopy), respectively. Prevention of blood-air contact and mechanical stress, constant temperature and blood pH during incubation, and the suitable choice of reference materials were found to be crucial for reliable testing. Considering those requirements, screening and perfusion system both provided sensitive discrimination between a given set of planar solid surfaces. In conclusion, the suggested methods for an in vitro hemocompatibility assessment permit versatile, sensitive, and efficient analysis of important blood-material interactions despite the unavoidable variability of blood characteristics in different experiments.
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Affiliation(s)
- U Streller
- Institute of Polymer Research, Dresden and The Max Bergmann Center of Biomaterials, Dresden, Germany
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Morgan EN, Pohlman TH, Vocelka C, Farr A, Lindley G, Chandler W, Griscavage-Ennis JM, Verrier ED. Nuclear factor kappaB mediates a procoagulant response in monocytes during extracorporeal circulation. J Thorac Cardiovasc Surg 2003; 125:165-71. [PMID: 12539000 DOI: 10.1067/mtc.2003.99] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this study was to examine the mechanism of procoagulant activity and inhibition in whole blood during extracorporeal circulation. METHODS In this study we examine the development of procoagulant activity and monocyte activation in heparinized whole blood passing through a closed circuit consisting of a pump and silicone envelope membrane oxygenator for 6 hours. RESULTS Anaphylatoxins, C3a and C5a, determined by means of enzyme-linked immunosorbant assay, appeared in the blood within 30 minutes of circulation. Circulated blood developed a marked potential for coagulation demonstrated in a 1-step clotting assay that reached maximal activity by 4 hours of circulation. This procoagulant activity was neutralized by anti-tissue factor antibody, suggesting a prominent role for the extrinsic pathway in pump-induced intravascular coagulation. Isolation of monocytes from circulated blood revealed that tissue factor expression is upregulated on the cell surface. Furthermore, we observed nuclear factor kappaB nuclear translocation in monocytes from blood passing through the circuit, suggesting that tissue factor expression was due to monocyte stimulation and transcriptional activation of the tissue factor gene. Tissue factor expression resulted in an approximately 30-fold increase in thrombin generation. Monocyte nuclear factor kappaB activation, monocyte tissue factor expression, thrombin generation, and the procoagulant activity of blood in extracorporeal circulation were all blocked by the proteasome inhibitor MG132. CONCLUSIONS We conclude that intravascular tissue factor expression during extracorporeal circulation of blood is due to nuclear factor kappaB-mediated activation of monocytes (possibly by complement), which can be controlled pharmacologically.
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Affiliation(s)
- Elizabeth N Morgan
- Department of Surgery, Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Wash. 98104, USA
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Gorbet MB, Sefton MV. Material-induced tissue factor expression but not CD11b upregulation depends on the presence of platelets. ACTA ACUST UNITED AC 2003; 67:792-800. [PMID: 14613227 DOI: 10.1002/jbm.a.10155] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Biomaterials activate leukocytes as well as platelets when exposed to blood. One feature of leukocyte activation at least at times beyond a few hours is tissue factor expression, contributing to a procoagulant state. We show here that platelet activation and specifically platelet-monocyte aggregate formation appears to be a precondition for tissue factor expression. Material-induced Tissue Factor (TF) expression by isolated leukocytes (6 x 10(6) cells/mL) resuspended in increasing concentrations of platelets in plasma was elevated when the platelet concentration was 50 x 10(6) platelets/mL or more; at lower platelet concentrations (1-25 x 10(6). cells/mL) the TF expression remained at background levels. On the other hand, significant CD11b upregulation was observed on leukocytes, in bulk and adherent to beads, at all platelet concentrations. This platelet effect on material-induced TF expression appeared to be mediated by the formation of platelet-monocyte aggregates. Anti-P-selectin, which blocked the association between platelets and leukocytes, reduced monocyte adhesion and material-induced TF expression for bulk monocytes. Anti-GPIIb/IIIa, a GPIIb/IIIa platelet antagonist, also reduced monocyte adhesion and material-induced TF expression in the bulk, most likely due to its inhibiting effect on the formation of platelet-monocyte aggregates, secondary to platelet activation. However, the antibody-associated reductions for bulk leukocytes (mainly neutrophils) were small and incomplete. Similar levels of TF expression, in the bulk, were observed with both polystyrene (PS), a strong platelet activator, and polyethylene glycol-modified PEG (PS-PEG), a mild platelet activator. The role of platelets in material-induced TF expression appears to be mediated in part via the formation of platelet-monocyte aggregates, although other mechanisms are likely also involved.
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Affiliation(s)
- M B Gorbet
- Department of Chemical Engineering and Applied Chemistry, Institute of Biomaterials and Biomedical Engineering, University of Toronto, 4 Taddle Creek Road, Room 407D, Toronto, Canada M5S 3G9
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Johnell M, Elgue G, Thelin S, Larsson R, Siegbahn A. Cell adhesion and tissue factor upregulation in oxygenators used during coronary artery bypass grafting are modified by the Corline Heparin Surface. SCAND CARDIOVASC J 2002; 36:351-7. [PMID: 12626202 DOI: 10.1080/140174302762659076] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass (CPB) is associated with inflammatory response and activation of coagulation. We investigated the influence of a new heparin surface on the activation of cells retrieved from oxygenators used during coronary artery bypass grafting (CABG). DESIGN Sixty patients undergoing CABG with CPB were randomly assigned to either uncoated or completely Corline Heparin Surface (CHS)-coated circuits with one of three different levels of systemic heparin: standard, high or low. At end of surgery adhered cells were retrieved from the oxygenators and cell count, tissue factor (TF)- and CD11b-expression on monocytes and monocytic TFmRNA were analysed. RESULTS The heparin coating of the oxygenator prevented adhesion of granulocytes, monocytes and platelets. TF-expression on monocytes from the oxygenators was significantly higher than on circulating cells in all groups. Monocytes from the uncoated oxygenators showed low levels of TF-expression with high levels of TFmRNA. The coated group with high level of heparin showed higher surface-expression of TF with low levels of TFmRNA. CONCLUSION The CHS was most biocompatible with the standard level of heparin used during CABG whereas elevation of systemic heparin rather increased the activation and TF upregulation in monocytes from oxygenators.
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Affiliation(s)
- M Johnell
- Laboratory for Coagulation Research, Department of Medical Sciences, Clinical Chemistry, University Hospital, SE-751 85 Uppsala, Sweden
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Abstract
John Gibbon conceived cardiopulmonary bypass (CPB) and performed the first intracardiac repair using extracorporeal perfusion in 1953. This achievement stimulated rapid development of the knowledge base and equipment necessary for accurate diagnoses and successful intracardiac operations. In the early 60s increasing evidence indicated that exposure of blood to nonendothelial cell surfaces produced bleeding and thrombotic complications and a massive inflammatory response. Early efforts to discover a synthetic, nonthrombogenic surface gave way to efforts to control the 'whole-body inflammatory response' by pharmacological means. These efforts are ongoing; progress is slow; and heparin is still required for most applications of extracorporeal perfusion technology. Nevertheless, CPB now enables over one million cardiac surgical operations each year. Future progress and the development of artificial internal organs that process blood depend upon control of the blood-surface interface without anticoagulants.
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Affiliation(s)
- L Henry Edmunds
- Harrison Department of Surgical Research, School of Medicine, University of Pennsylvania, Philadelphia 19104-4283, USA.
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Raymond PD, Marsh NA. Alterations to haemostasis following cardiopulmonary bypass and the relationship of these changes to neurocognitive morbidity. Blood Coagul Fibrinolysis 2001; 12:601-18. [PMID: 11734660 DOI: 10.1097/00001721-200112000-00001] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cardiopulmonary bypass (CPB) is routinely utilized to provide circulatory support during cardiac surgical procedures. The morbidity of CPB has been significantly reduced since its introduction 50 years ago; however, cerebral injury remains a potentially serious consequence of otherwise successful surgery. The risk of stroke postoperatively is approximately 1-5%. Incidence rates for neurocognitive deficit, however, vary markedly depending on the detection method, although typically it is reported in at least 50% of patients. The aetiology of this cerebral injury remains open to debate, although evidence shows that ischaemia secondary to microembolism may be the principal factor. Emboli originate from bubbles of air, atheroemboli released on aortic manipulation and thromboemboli generated as a result of haemostatic activation. Significant generation of thrombin occurs during CPB resulting in fibrin formation, although the trigger of this activation is not fully understood. Rather than originating from contact activation as previously thought, the primary trigger may be via the activated factor VII/tissue factor pathway of coagulation, with an additional role of contact activation in amplification of coagulation as well as the fibrinolytic response to CPB. Haemostatic activation is inhibited with systemic heparin therapy. The relationship between haemostatic activation and emboli formation during CPB is not known. Interventions to reduce cerebral injury in the context of cardiac surgery depend, in large part, on the minimization of emboli. This review investigates cerebral injury after cardiac surgery and evidence showing that microembolism is the principal causative agent. Fibrin emboli are postulated to be an important source of cerebral embolism. The mechanism of haemostatic activation during CPB is therefore also discussed.
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Affiliation(s)
- P D Raymond
- Research Concentration in Biological and Medical Sciences, School of Life Sciences, Queensland University of Technology, Brisbane, Australia
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Frank RD, Weber J, Dresbach H, Thelen H, Weiss C, Floege J. Role of contact system activation in hemodialyzer-induced thrombogenicity. Kidney Int 2001; 60:1972-81. [PMID: 11703617 DOI: 10.1046/j.1523-1755.2001.00009.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The contact system is generally believed to be the main trigger of the coagulation cascade during extracorporeal circulation. However, the extent of contact activation, its role for intradialytic thrombin generation as well as the influence of different dialyzer membranes have not been well established. METHODS In a novel full-scale ex vivo recirculation dialysis model, we investigated the thrombogenicity of three widely used hemodialyzers (Cuprophan Renak RA15-U, Polysulfone F6HPS and AN69XT Nephral 200). The activation of the contact system was evaluated using a newly developed ELISA for factor XIIa-C1-inhibitor complexes. Additionally, we determined free FXIIa (ELISA), thrombin-antithrombin (TAT) complexes, platelet factor 4 (PF4), complement activation (C5a), granulocyte elastase and blood cell counts. The findings in blood from normal volunteers were compared with factor XII-deficient blood. RESULTS With normal blood AN69 exhibited the highest thrombogenicity in comparison to Cuprophan and Polysulfone, as assessed by TAT generation and platelet consumption. AN69 caused a rapid increase of the FXIIa-C1-inhibitor complexes and of free FXIIa. Despite significant TAT generation with Cuprophan and Polysulfone free FXIIa remained unchanged and the FXIIa-C1-inhibitor complexes stayed below the detection limit. With factor XII-deficient blood Polysulfone exhibited the same TAT generation, whereas the thrombogenicity of AN69 was greatly reduced. CONCLUSIONS Our data challenge the common assumption that activation of the contact system with generation of FXIIa is the main trigger for coagulation and thrombus formation in hemodialysis. Only the negatively charged AN69 membrane with enhanced thrombogenicity strongly induced contact activation.
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Affiliation(s)
- R D Frank
- Department of Nephrology and Clinical Immunology, IZKF "Biomat.," University Hospital RWTH Aachen, Pauwelsstrasse 30, 52057 Aachen, Germany.
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Kottke-Marchant K, Sapatnekar S. Hemostatic Abnormalities in Cardiopulmonary Bypass: Pathophysiologic and Transfusion Considerations. Semin Cardiothorac Vasc Anesth 2001. [DOI: 10.1053/scva.2001.26125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac surgical procedures typically use cardiopulmo nary bypass (CPB), a technique that diverts blood from the heart and lungs, where it is oxygenated and pumped back into the circulation. CPB is associated with significant pathophysiologic changes leading to an increased bleeding risk. Bleeding during CPB occurs for multiple reasons; the primary reason is the expo sure of blood to the material components of the CPB system, with intense systemic coagulation and platelet, fibrinolytic, and endothelial activation. To counteract the coagulation activation, extremely high levels of heparin anticoagulation are required to prevent sys temic thrombosis. Thrombin generation through tissue factor pathway activation is now thought to be the predominant mechanism of coagulation activation in CPB. The stimulus for tissue factor exposure to blood is thought to be a systemic activation of tissue factor on monocytes and endothelial cells caused by comple ment activation by the CPB materials and circulating inflammatory mediators. Despite improvements in the CPB system, surgical techniques, and blood conserva tion methods, the demand for blood in such procedures remains sustantial. Optimal blood use can be achieved by combining blood conservation measures with the transfusion of blood components according to strict guidelines. Blood is a limited resource and must be used wisely and cautiously. The risks and costs associ ated with transfusion are compelling reasons to mini mize unnecessary exposure to blood. However, the bene fits of transfusion are well established, and the risks are reasonably low. New developments in the surfaces of the CPB system, use of established and new protease inhibitors, and new blood conservation measures offer promise in decreasing the bleeding risk associated with CPB.
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Affiliation(s)
- Kandice Kottke-Marchant
- Department of Clinical Pathology, The Cleveland Clinic Foundation and American Red Cross Blood Services, Northern Ohio Region, Cleveland, OH
| | - Suneeti Sapatnekar
- Department of Clinical Pathology, The Cleveland Clinic Foundation and American Red Cross Blood Services, Northern Ohio Region, Cleveland, OH
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Fung M, Loubser PG, Undar A, Mueller M, Sun C, Sun WN, Vaughn WK, Fraser CD. Inhibition of complement, neutrophil, and platelet activation by an anti-factor D monoclonal antibody in simulated cardiopulmonary bypass circuits. J Thorac Cardiovasc Surg 2001; 122:113-22. [PMID: 11436043 DOI: 10.1067/mtc.2001.114777] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Patients undergoing cardiopulmonary bypass frequently manifest generalized systemic inflammation and occasionally manifest serious multiorgan failure. Inflammatory responses of bypass are triggered by contact of blood with artificial surfaces of the bypass circuits, surgical trauma, and ischemia-reperfusion injury. We studied the effects of specific inhibition of the alternative complement cascade by using an anti-factor D monoclonal antibody (166-32) in extracorporeal circulation of human whole blood used as a simulated model of cardiopulmonary bypass. METHODS Five healthy blood donors were used in the study. Monoclonal antibody 166-32 was added to freshly collected, heparinized human blood recirculated in a pediatric cardiopulmonary bypass circuit at a final concentration of 18 microg/mL. An irrelevant monoclonal antibody was used as a negative control with the same donor blood in a parallel bypass circuit on the same day. Blood samples were collected at different time points during recirculation for measurement of activation of complement, neutrophils, and platelets by immunofluorocytometric methods and enzyme-linked immunosorbent assays. RESULTS Monoclonal antibody 166-32 inhibited the alternative complement activation and the production of Bb, C3a, sC5b-9, and C5a. Upregulation of CD11b on neutrophils and CD62P on platelets was also significantly inhibited by monoclonal antibody 166-32. This is consistent with the inhibition of the release of neutrophil-specific myeloperoxidase and elastase and platelet thrombospondin. The production of proinflammatory cytokine interleukin 8 was also suppressed by the antibody. CONCLUSIONS The alternative complement cascade is predominantly activated during extracorporeal circulation. Anti-factor D monoclonal antibody 166-32 is effective in inhibiting the activation of complement, neutrophils, and platelets. Inhibition of the alternative complement pathway by targeting factor D could be useful in reducing systemic inflammation in patients undergoing cardiopulmonary bypass.
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Affiliation(s)
- M Fung
- Tanox, Inc, Houston, TX, USA.
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Gorbet MB, Sefton MV. Leukocyte activation and leukocyte procoagulant activities after blood contact with polystyrene and polyethylene glycol-immobilized polystyrene beads. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 2001; 137:345-55. [PMID: 11329532 DOI: 10.1067/mlc.2001.114677] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Beads (45 microm) of polystyrene (PS) and polyethylene glycol modified PS (TentaGel) with an amino or hydroxyl terminal group were incubated with blood to assess the effect of surface area and material chemistry on leukocyte activation. After a 2-hour incubation, blood contact with beads activated leukocytes in the bulk (tissue factor expression, CD11b up-regulation, and association with platelets) independently of material surface chemistry. On the other hand, activation of adherent leukocytes was material dependent. After blood contact with PS, polyethylene glycol-immobilized PS (PS-PEG) and PS-PEG-NH2 beads, CD11b up-regulation in the bulk, platelet-leukocyte aggregates, and leukocyte adhesion were all dependent on surface area, whereas tissue factor (TF) expression was not. Material-induced leukocyte activation in the bulk was also independent of the beads' capacity to activate platelets. However, monocyte adhesion and TF expression on beads appeared to be related to the presence of platelets on the surface. Material-induced TF expression was able to initiate the extrinsic pathway of coagulation, resulting in significant fibrin formation. Although not all of our markers of leukocyte activation varied with material area or chemistry, it was clear that these materials activated leukocytes in a way that resulted in increased procoagulant activity. During blood-material interactions, material-induced leukocyte activation may then contribute to thrombogenesis.
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Affiliation(s)
- M B Gorbet
- Department of Chemical Engineering and Applied Chemistry and the Institute of Biomaterials and Biomedical Engineering, University of Toronto, On, Canada
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Abstract
Anticoagulation during continuous renal replacement therapy should aim for an optimal filter performance allowing the delivery of an adequate dose of renal replacement therapy. On the other hand, the patient's safety should not be endangered. Although numerous options have been proposed, none of them appears to be ideal. Unfractionated heparin is still the most widely used anticoagulant. Reported experience with low-molecular-weight heparin is limited and does not confirm the anticipated increased safety. Regional citrate anticoagulation has been shown to reduce bleeding complications during continuous haemodialysis. A recent report demonstrates the feasibility and safety of citrate anticoagulation during continuous predilution haemofiltration. However, its use is labour intensive and the prevention of side-effects requires meticulous monitoring. Hirudin, a selective thrombin inhibitor, appears to be a suitable, although not completely safe, alternative in patients with heparin-induced thrombocytopenia. Continuous renal replacement therapy without anticoagulation may result in acceptable filter lives in patients with reduced coagulatory potential or an increased risk of bleeding. Although receiving little attention in the literature, the adequate selection of treatment characteristics may also contribute to an improved filter performance.
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Affiliation(s)
- M Schetz
- Department of Intensive Care Medicine, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium.
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Kojima T, Gando S, Kemmotsu O, Mashio H, Goda Y, Kawahigashi H, Watanabe N. Another point of view on the mechanism of thrombin generation during cardiopulmonary bypass: role of tissue factor pathway inhibitor. J Cardiothorac Vasc Anesth 2001; 15:60-4. [PMID: 11254842 DOI: 10.1053/jcan.2001.20278] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the role of tissue factor and tissue factor pathway inhibitor (TFPI) in coagulation activation during cardiopulmonary bypass (CPB). DESIGN Prospective, observational study. SETTING Operating room in a city hospital. PARTICIPANTS Thirty-one patients undergoing cardiac surgery. MEASUREMENTS AND MAIN RESULTS The plasma levels of tissue factor antigen (tissue factor), total and free TFPI, several markers of thrombin generation (prothrombin fragment F1+2, thrombin antithrombin complex, and fibrinopeptide A), and heparin concentration were measured. Blood samples were obtained after induction of anesthesia (baseline level), before and after CPB, and at the end of the surgery. Despite an average heparin concentration of 2.9 +/- 0.2 IU/ mL, markers of thrombin generation, fibrin formation and its degradation (D-dimer) were observed during CPB. Significant increases of total and free TFPI levels (p < 0.0001) were found during CPB associated with lower tissue factor concentration (p < 0.0001) compared with the baseline values. Heparin concentration correlated with levels of total TFPI (r2 = 0.613, p < 0.0001) and free TFPI (r2 = 0.689, p < 0.0001). Tissue factor concentration showed significant negative correlations with levels of total TFPI (r2 = 0.128, p = 0.0003) and free TFPI (r2 = 0.070, p = 0.0078). CONCLUSION These data indicate that TFPI release by heparin probably has an important role in the suppression of the tissue factor-dependent coagulation pathway during CPB. These changes occur along with ongoing thrombin generation and its activation. Either insufficient prevention of thrombin generation by TFPI or indirect activation of the intrinsic coagulation pathway occurs during CPB.
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Affiliation(s)
- T Kojima
- Department of Anesthesiology and Critical Care Medicine, Hokkaido University School of Medicine, Sapporo, Japan
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50
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Gil W. Inflammo-coagulatory response, extrinsic pathway thrombin generation and a new theory of activated clotting time interpretation. Perfusion 2001; 16:27-35. [PMID: 11192304 DOI: 10.1177/026765910101600105] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
When blood is subjected to contact with foreign surfaces, as during cardiopulmonary bypass (CPB), the whole body inflammatory response is initiated, resulting in the expression of procoagulant molecules on the vascular endothelium and white blood cells. These surface bound procoagulants participate in the extrinsic coagulation pathway. It appears that the primary source of thrombin generation during CPB is due to extrinsic pathway activation. Thrombin not only converts fibrinogen to fibrin, it also acts as a proinflammatory agent resulting in a positive feedback loop or the inflammo-coagulatory response. Extrinsic pathway thrombin generation occurs as a membrane bound event. Membrane bound factors are resistant to heparin/ATIII inhibition. Therefore, the anticoagulant effect of heparin/ATIII is due to thrombin inhibition, not the inhibition of thrombin generation. Interpretation of the activated clotting time (ACT) must take into account the thrombin concentration [T]; this results in the coagulatory ratio, ACT is proportional to ([Hep -ATIII]/[T]). Considering this proportionality, it can be seen that the ACT cannot be used to quantitate heparin concentration. Changes in the ACT can reflect changes in [Hep - ATIII], changes in [T], or changes in both concentrations. Anti-inflammatory agents which suppress or inhibit the extrinsic pathway, such as aprotinin, result in decreased thrombin generation. As thrombin generation decreases, the ACT-heparin dose response curve is warped, resulting in a dose response curve resembling a PTT-heparin dose response curve. We can no longer assume that the disproportionate rise in the ACT relative to the [HEP - ATIII] when aprotinin is used as indicative of failure of the ACT to provide a credible indication of anticoagulation.
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Affiliation(s)
- W Gil
- West Penn Allegheny Health System, Pittsburgh, Pennsylvania, USA
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