Heparin monitoring during cardiac surgery. Part 1: validation of whole-blood heparin concentration and activated clotting time

The impact of heparin and direct thrombin inhibitors on cell-penetrating polymer siRNA transfection

Gene therapy using siRNA has become a promising strategy to achieve targeted gene knockdown for treatment of cardiovascular pathologies. However, efficient siRNA transfection often relies on cationic delivery vectors such as synthetic cell-penetrating polymers which are susceptible to interference by negatively charged molecules. Anticoagulants such as heparin, which is negatively charged and widely used in cardiovascular applications, may pose a significant barrier to effective siRNA delivery. We therefore conducted in vitro studies utilizing human smooth muscle and endothelial cells transfected with glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and β2-microglobulin (B2M) siRNA in the presence of heparin, argatroban, and bivalirudin in order to determine which anticoagulant therapy is most compatible for siRNA delivery. We observed that while heparin, at clinical doses, decreases the efficiency of siRNA targeted mRNA knockdown, mRNA knockdown is not inhibited in the presence of either argatroban or bivalirudin. Our data suggests that heparin should be avoided during siRNA therapy with cationic transfection agents, and argatroban and bivalirudin should be used in its stead.

Pleiotropic Effects of Heparin and its Monitoring in the Clinical Practice

Unfractionated heparin (UFH) was uncovered in 1916, has been used as an anticoagulant since 1935, and has been listed in the World Health Organization's Model List of Essential Medicines. Despite the availability of many other anticoagulants, the use of heparin (either low molecular weight heparin [LMWH] or UFH) is still substantial. Heparin has pleotropic effects including anticoagulant and several nonanticoagulant properties such as antiproliferative, anti-inflammatory activity, and anticomplement effects. Although UFH has been widely replaced by LMWH, UFH is still the preferred anticoagulant of choice for patients undergoing cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, and patients with high-risk mechanical cardiac valves requiring temporary bridging with a parenteral anticoagulant. UFH is a highly negatively charged molecule and binds many positively charged molecules, hence has unpredictable pharmacokinetics, and variable anticoagulant effect on an individual patient basis. Therefore, anticoagulant effects of UFH may not be proportional to the dose of UFH given to any individual patient. In this review, we discuss the anticoagulant and nonanticoagulant activities of UFH, differences between UFH and LMWH, when to use UFH, different methods of monitoring the anticoagulant effects of UFH (including activated partial thromboplastin time, heparin anti-Xa activity level, and activated clotting time), while discussing pros and cons related to each method and comparison of clinical outcomes in patients treated with UFH monitored with different methods based on available evidence.

Evaluation of the use of a heparin dose-response test in dogs to determine the optimal heparin dose during intravascular procedures and assessment of the in vitro heparin response in healthy dogs

BACKGROUND

No guidelines for administering and monitoring anticoagulants intraprocedurally are currently available in dogs, despite the prevalence of procedures necessitating systemic anticoagulation with heparin.

OBJECTIVES

To evaluate an activated clotting time (ACT)-based heparin dose-response (HDR) test to predict the individual required heparin dose in dogs during intravascular procedures, and to investigate both the in vitro heparin - ACT and in vitro heparin - factor anti-Xa activity (anti-Xa) relationships in dogs.

METHODS

Blood was collected from eight healthy beagles undergoing a cardiac procedure and utilised to establish baseline ACT and for in vitro evaluation. Subsequently, 100 IU/kg heparin was administered intravenously (IV) and ACT was remeasured (HDR test). The required heparin dose for an ACT target response ≥300 s was calculated for each individual and ACT was remeasured after administration of this dose. For in vitro testing, a serial heparin blood dilution (0-0.5-1-2-4 international unit (IU)/mL) was prepared and ACT and anti-Xa were determined using whole blood and frozen plasma, respectively.

RESULTS

The HDR test overestimated the required heparin dose in 3/7 dogs. In vitro, ACT and anti-Xa increased significantly with increasing blood heparin concentration. Heparin - ACT was nonlinear in 4/8 dogs at heparin concentrations >2 IU/mL, whereas heparin - anti-Xa remained linear throughout the tested range.

CONCLUSIONS

The HDR test poorly estimated the required heparin dose in dogs. This is most likely attributed to a nonlinear heparin - ACT relationship, as observed in vitro. Anti-Xa is a promising alternative for ACT; however, unavailability as a point-of-care test and lack of in vivo target values restrict its current use.

Efficacy of the Hepcon system in reducing hemorrhagic and thrombotic complications in antiphospholipid syndrome patients undergoing cardiac surgery

INTRODUCTION

Patients with Antiphospholipid Syndrome (APS) undergoing cardiopulmonary bypass (CPB) surgery are at increased risk for thrombotic and hemorrhagic complications. Anticoagulation during CPB is typically monitored with activated clotting time (ACT) which may be falsely prolonged in patients with APS. The Hepcon Hemostasis Management System quantitatively determines the whole blood heparin concentration through heparin/protamine titration.

METHODS

This was a retrospective study of APS patients who underwent cardiac surgery requiring CPB at the Cleveland Clinic between April 2013, and July 2020. The primary endpoint was the composite rate of hemorrhagic or thromboembolic complications per surgical case in patients monitored by Hepcon versus patients monitored by ACT. Secondary endpoints were median volume of chest tube output and packed red blood cell (PRBC) transfusion within the first three post-operative days.

RESULTS

43 patients were included. 20 (47%) patients were monitored using Hepcon while 23 (53%) were monitored using ACT. For the primary endpoint of rate of thromboembolic or hemorrhagic complications per surgical case, there was no statistically significant difference between the Hepcon and ACT groups (HMS, 6/20 [30%]; ACT, 7/23 [30%]; p = >0.99). For the secondary endpoints, there was no statistically significant difference in median post-operative chest tube output (780 mL vs. 850 mL; p = 0.88) and median post-operative PRBC transfusion (1 unit vs. 0 unit; p = 0.28) between the Hepcon and ACT groups, respectively.

CONCLUSION

There was no difference in the composite outcome of thrombotic or hemorrhagic complications in patients monitored by Hepcon versus those monitored by ACT.

Accurate protamine:heparin matching (not just smaller protamine doses) decreases postoperative bleeding in cardiac surgery; results from a high-volume academic medical center

BACKGROUND

A multidisciplinary Quality Assurance/Performance Improvement study to identify the incidence of "heparin rebound" in our adult cardiac surgical population instead detected a thromboelastometry pattern suggestive of initial protamine overdose in 34% despite Hepcon-guided anticoagulation management. Analysis of our practice led to an intervention that made an additional lower-range Hepcon cartridge available to the perfusionists.

METHODS

One year later, an IRB-approved retrospective study was conducted in >500 patients to analyze the effects of the intervention, specifically focusing on the impact of the initial protamine dose accuracy and 18-h mediastinal chest tube drainage (MCTd).

RESULTS

No differences were observed between group demographics, surgical procedures, duration of CPB or perioperative blood product transfusion. Both groups were managed using the same perfusion and anesthesia equipment, strategies, and protocols. The median initial protamine dose decreased by 19% (p < .001) in the intervention group (170 [IQR 140-220] mg; n = 295) versus the control group (210 [180-250] mg; n = 257). Mean 18-h MCTd decreased by 13% (p < .001) in the intervention group (405.15 ± 231.54 mL; n = 295) versus the control group (466.13 ± 286.73 mL; n = 257). Covariate-adjusted mixed effects model showed a significant reduction of MCTd in the intervention group, starting from hour 11 after surgery (group by time interaction p = .002).

CONCLUSION

Though previous investigators have associated lower protamine doses with less MCTd, this study demonstrates that more accurately matching the initial protamine dose to the remaining circulating heparin concentration reduces postoperative bleeding.

Heparin Rebound: An In-Depth Review

The common conception of "heparin rebound" invokes heparin returning to circulation in the postoperative period after apparently adequate intraoperative reversal with protamine. This is believed to portend increased postoperative bleeding and provides the rationale for administering additional empiric doses of protamine in response to prolonged coagulation tests and/or bleeding. However, the relevant literature of the last 60+ years provides only a weak level of evidence that "rebounded" heparin itself is a significant etiology of postoperative bleeding after cardiac surgery with cardiopulmonary bypass. Notably, many of the most frequently cited heparin rebound investigators ultimately concluded that although exceedingly low levels of heparin activity could be detected by anti-Xa assay in some (but not all) patients postoperatively, there was no correlation with actual bleeding. An understanding of the literature requires a careful reading of the details because the investigators lacked standardized definitions for "heparin rebound" and "adequate reversal" while studying the phenomenon with significantly different experimental methodologies and laboratory tests. This review was undertaken to provide a modern understanding of the "heparin rebound" phenomenon to encourage an evidence-based approach to postoperative bleeding. Literature searches were conducted via PubMed using the following MeSH terms: heparin rebound, heparin reversal, protamine, platelet factor 4, and polybrene. Relevant English language articles were reviewed, with subsequent references obtained from the internal citations. Perspective is provided for both those who use HepCon-guided management and those who do not, as are practical recommendations for the modern era based on the published data and conclusions of the various investigators.

Titrated versus conventional anticoagulation management for thrombin generation in cardiac surgery: a randomized controlled trial

PURPOSE

Optimal heparin titration during cardiopulmonary bypass (CPB) may reduce coagulation system activation and preserve hemostatic function post-CPB. Our objective was to assess if the Heparin Management System (HMS) Plus improves heparin titration, thereby leading to higher thrombin generation post-CPB compared with activated clotting time (ACT)-guided management.

METHODS

We conducted a randomized controlled trial of 100 patients undergoing cardiac surgery with CPB at a single center. A total of 50 patients were randomized to conventional ACT-guided management, and 50 to the HMS Plus system. The primary outcome was change in thrombin generation post-CPB compared with baseline, as assessed by calibrated automated thrombography. Secondary outcomes included intraoperative blood loss, chest drain output up to 72 hr, and transfusions. In an exploratory analysis, we compared the quintile of patients with the highest average heparin concentration on CPB (≥ 4.0 mg⋅kg-1) with the rest of the cohort.

RESULTS

A total of 100 patients were included in an intent-to-treat analysis. We observed no difference in post-CPB thrombin generation or secondary outcomes. However, patients in the HMS Plus group had higher average heparin concentrations while on CPB than patients in the conventional management group did (mean difference, -0.21; 95% confidence interval, -0.42 to -0.01). The quintile of patients with the highest average heparin concentration (4.0 mg⋅kg-1) had higher thrombin generation post-CPB than the rest of the cohort did.

CONCLUSIONS

The HMS Plus system did not show significant benefits in thrombin generation, bleeding outcomes, or transfusion in patients undergoing cardiac surgery with CPB. Higher average heparin concentrations on CPB were associated with higher post-CPB thrombin generation.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT03347201); first submitted 12 October 2017.

An indicator displacement assay-based optical chemosensor for heparin with a dual-readout and a reversible molecular logic gate operation based on the pyranine/methyl viologen

We have reported an optical indicator displacement assay (IDA) for heparin with a UV-vis absorbance and fluorescence dual-readout based on pyranine/methyl viologen (MV²⁺). Upon introducing heparin, pyranine/MV²⁺ shows a clearly observable increase in UV-vis absorbance and a turn-on of the fluorescence signal. We have demonstrated that the ionic nature of buffers significantly affects the pyranine displacement and the zwitterionic HEPES was most suitable for heparin sensing. After careful screening of experimental conditions, the pyranine/MV²⁺-based optical chemosensor exhibits a fast, sensitive, and selective response toward heparin. It shows dynamic linear concentration of heparin in the ranges of 0.1-40 U·mL^-1 and 0.01-20 U·mL^-1 for the absorptive and fluorescent measurements, respectively, which both cover the clinically relevant levels of heparin. As with the animal experiments, the optical chemosensor has been demonstrated to be selective and effective for heparin level qualification in rat plasma. The chemosensor is readily accessible, cost-effective, and reliable, which holds a great promise for potential application on clinical and biological studies. Furthermore, this IDA system can serve as an IMPLICATION logic gate with a reversible and switchable logical manner.

Anticoagulation Monitoring for Perioperative Physicians

From preoperative medications to intraoperative needs to postoperative thromboprophylaxis, anticoagulants are encountered throughout the perioperative period. This review focuses on coagulation testing clinicians utilize to monitor the effects of these medications.

Fluorescence sensing of heparin and heparin-like glycosaminoglycans by stabilizing intramolecular charge transfer state of dansyl acid-labeled AG73 peptides with glutathione-capped gold nanoclusters

Sensors that can specifically and accurately detect glycosaminoglycans are rare. Here, a dual-mode platform for fluorescence intensity and lifetime sensing of plasma heparin and fluorescence imaging of heparan sulfate proteoglycan-expressed cancer cells was developed by stabilizing the intramolecular charge transfer (ICT) state of dansyl acid-labeling AG73 (DA-AG73) peptide with glutathione-capped gold nanoclusters (GSH-AuNCs). DA-AG73 peptides, including an electron-donor dimethylamino group and an electron-withdrawing sulfonamide moiety in the labeled DA molecules, emitted weak fluorescence due to the formation of the twisted ICT excited state. The complexation of heparin with DA-AG73 peptides followed by interacting with the GSH-AuNCs could restrict the rotation of the dimethylamino groups of the labeled DA molecules, triggering the transition from their twisted ICT state to ICT excited state. As a result, the fluorescence intensity and lifetime of the labeled DA molecules in DA-AG73 peptides were gradually enhanced with increasing the heparin concentration. The proposed platform provided excellent selectivity toward heparin and heparan sulfate and exhibited two linear calibration curves for quantifying 20-800 nM and 20-1000 nM heparin in the fluorescence intensity and lifetime modes, respectively. The proposed platform was practically applied for the fluorescence intensity and lifetime determination of plasma heparin and for the selective imaging of heparan sulfate proteoglycan-expressed cells.

Lead halide perovskites with aggregation-induced emission feature coupled with gold nanoparticles for fluorescence detection of heparin

Herein, a new kind of lead halide perovskite (LHP, (C₁₂H₂₅NH₃)₂PbI₄) with aggregation-induced emission (AIE) feature is developed as a fluorescent probe for heparin (Hep). The LHPs exhibit high emission when they aggregate in water. Interestingly, a few picomoles of dispersed gold nanoparticles (AuNPs) can quench the emission of LHPs, but the aggregated AuNPs are invalid. When protamine (Pro) is mixed with AuNPs at first, the negatively charged AuNPs aggregate through electrostatic interaction, producing the AIE recovery. Nevertheless, Hep disturbs the interaction between AuNPs and Pro due to its strong electrostatic interaction with Pro. Therefore, the dispersed AuNPs quench the fluorescence of LHPs again. A response linear range of Hep of 0.8-4.2 ng ml^-1is obtained, and the detection limit is 0.29 ng ml^-1. Compared with other probes for determination of Hep with AuNPs, this strategy exhibits better sensitivity due to the small quantity of AuNPs used. Finally, it is also successfully applied to detect Hep in human serum samples with satisfactory recoveries.

A rolling circle amplification based platform for ultrasensitive detection of heparin

Heparin has a variety of pharmacological uses, including applications for anti-tumor metastasis, anti-inflammatory and anti-viral activities and is widely used as a clinical anticoagulant. Due to its widespread applications in the clinical procedures, monitoring heparin levels is critically important to ensure the safe use of heparin and to prevent overdose and complications, such as hemorrhage and thrombocytopenia. However, traditional heparin detection relies on the measurements of the activated clotting time or activated partial thromboplastin time, which are not sufficiently reliable or accurate measurements for certain clinical settings. In this work, we describe a dumbbell probe-aided strategy for ultrasensitive and isothermal detection of heparin based on a uniquely strong protamine-heparin interaction and rolling circle amplification driven signal amplification. The detection limit for heparin is 12.5 ng mL-1 (0.83 nM), which is much lower than the therapeutic level of heparin in cardiovascular surgery (17-67 μM) and in postoperative and long-term treatment (1.7-10 μM). Additionally, the proposed sensing platform works well for heparin monitoring in human plasma samples. This simple and ultrasensitive heparin biosensor has potential application in diagnostics, therapeutics, and in biological research.

A cationic on–off fluorescent sensor with AIE properties for heparin and protamine detection

In this research, a distyryl-anthracene derivative (DSAI) with two quaternary ammonium groups was synthesized for highly sensitive detection of heparin and protamine.

Activated Coagulation Time and Hepcon Protamine Titration Device to Manage Unfractionated Heparin During Cardiopulmonary Bypass in a Hemophilia A Patient on Emicizumab

In the perioperative management of patients with hemophilia A, emicizumab prevents the accurate measurement of common clotting assays, including the activated clotting time (ACT), which is essential for high-dose heparin monitoring during cardiopulmonary bypass surgery. The authors describe the successful perioperative management of a hemophilia A patient on maintenance emicizumab who, following a non-ST myocardial infarction, underwent cardiopulmonary bypass grafting surgery with heparin monitoring using both the ACT and heparin levels from the Hepcon protamine titration device. Postoperatively, the patient was transitioned to recombinant factor VIII replacement therapy. In hemophilia A patients on emicizumab who require heparin titration on cardiopulmonary bypass surgery, the ACT, combined with Hepcon heparin levels, may be used to complete the surgery successfully without excessive bleeding or morbidity.

Use of Coagulation Point-of-Care Tests in the Management of Anticoagulation and Bleeding in Pediatric Cardiac Surgery: A Systematic Review

Bleeding and coagulation management are essential aspects in the management of neonates and children undergoing cardiac surgery. The use of point-of-care tests (POCTs) in a pediatric setting is not as widely used as in the adult setting. This systematic review aims to summarize the evidence showed by the literature regarding the use of POCTs in children undergoing cardiac surgery. We included all studies examining the pediatric population (<18 years old) undergoing cardiac surgery in which the coagulation profile was assessed with POCTs. Three electronic databases (PubMed, Embase, and the Cochrane Controlled Clinical Trials register) were searched. Tests involved were heparin effect tests, viscoelastic tests, and platelet function tests. Due to the wide heterogeneity of the patients and tests studied, a formal meta-analysis was impossible, and the results are therefore presented through a systematic review. Eighty articles were found, of which 47 are presented in this review. At present, literature data are too weak to define POCTs as a "gold standard" for the treatment of perioperative bleeding in pediatric cardiac surgery. Nevertheless, introduction of POCTs into postoperative algorithms has shown to improve bleeding management, patient outcome, and cost efficiency.

Are We Able to Dose Protamine Accurately Yet? A Review of the Protamine Conundrum

Without anticoagulation, cardiopulmonary bypass would not have developed over the last nearly 60 years into one of the most influential innovations in medicine; without the ability to reverse anticoagulation, cardiac surgery might not have become the common intervention, which is now practiced globally. Despite the recent breathtaking developments in extracorporeal technology, heparin and protamine remain the pillars of anticoagulation and its reversal until this day. However, there is still much controversy in particular about protamine dosing regimens. A number of recent publications investigating various approaches to dosing protamine have rekindled this debate. This review is seeking to capture the current thinking about protamine dosing after cessation of cardiopulmonary bypass.

Patient Blood Management in Pediatric Cardiac Surgery: A Review

Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.

Reversible fluorescence modulation of BSA stabilised copper nanoclusters for the selective detection of protamine and heparin

Depicting fluorescence sensing of protamine and heparin based on aggregation and disaggregation of copper nanoclusters.

Benefits and Pitfalls of Point-of-Care Coagulation Testing for Anticoagulation Management: An ACLPS Critical Review

Objectives

Point-of-care (POC) testing is generally less precise and has higher reagent costs per test than laboratory-based assays. However, POC hemostasis testing can offer significant advantages in particular situations: patient-managed warfarin therapy as well as rapid turnaround time heparin management for intraoperative patients. Of note, POC hemostasis testing is generally approved for the purposes of anticoagulation monitoring and is inferior to laboratory coagulation testing for the diagnosis of congenital or acquired coagulopathy.

Methods

The frequently used POC coagulation instruments for POC international normalized ratio and activated clotting time are reviewed, as well as their typical performance relative to central laboratory testing (where available).

Results

Several cases are discussed that highlight the benefits, as well as pitfalls, of POC coagulation testing.

Conclusions

POC coagulation testing for anticoagulation monitoring offers advantages in particular situations. Clear policies and protocols must be developed to guide proper use of POC versus central laboratory hemostasis testing.

A ratiometric fluorometric heparin assay based on the use of CdTe and polyethyleneimine-coated carbon quantum dots

CdTe quantum dots (QDs) were integrated with polyethyleneimine-coated carbon dots (PEI-CDs) to form a dually emitting probe for heparin. The red fluorescence of the CdTe QDs is quenched by the PEI-CDs due to electrostatic interactions. In the presence of heparin, the blue fluorescence of PEI-CDs remains unaffected, while its quenching effect on the fluorescence of CdTe QDs is strongly reduced. A ratiometric fluorometric assay was worked out. The ratio of the fluorescences at 595 and 436 nm serves as the analytical signal. Response is linear in the concentration range of 50-600 ng·mL^-1 (0.1-1.2 U·mL^-1) of heparin. The limit of detection is 20 ng·mL^-1 (0.04 U·mL^-1). This makes the method a valuable tool for heparin monitoring during postoperative and long-term care. This assay is relatively free from the interference by other analogues which commonly co-exist with heparin in samples, and it is more robust than single-wavelength based assays. Graphical abstract In the presence of heparin, the fluorescence of polyethyleneimine-coated carbon dots (PEI-CDs) at 436 nm remains unaffected, while its quenching effect on the fluorescence of CdTe at 595 nm is strongly reduced.

A ratiometric detection of heparin with high sensitivity based on aggregation-enhanced emission of gold nanoclusters triggered by silicon nanoparticles

Heparin (Hep) is a widely applied anticoagulant and the quantification of heparin concentration is pivotal for clinical use. In this work, silicon nanoparticles (SiNPs) modified by the amino groups and glutathione-capped gold nanoclusters (GSH-AuNCs) are able to self-assemble into spherical particle structures via the electrostatic interaction, resulting in the aggregation-enhanced emission (AEE) of GSH-AuNCs. However, Hep, a highly sulfated glycosaminoglycan with much more negative charges, can bind with the SiNPs and inhibit the aggregation. As a result, it causes the AEE quenching of GSH-AuNCs at 570 nm but the SiNPs keep their own blue fluorescence at 450 nm. Thus, the SiNPs can act as an internal reference and the GSH-AuNCs are used as a signal probe in this process. The ratiometric fluorescent signal (I₅₇₀/I₄₅₀) change of the nanohybrid probe is positively correlated with Hep concentrations in the range from 6.44 ng/mL to 96.6 ng/mL with the detection limit of 3.29 ng/mL. As expected, this strategy shows good sensitivity and selectivity, and it is also successfully applied to detect Hep in Hep sodium injection and human serum samples with good recoveries.

Changes in heparin dose response slope during cardiac surgery: possible result in inaccuracy in predicting heparin bolus dose requirement to achieve target ACT

Introduction:

The substantial interpatient variability in heparin requirement has led to the use of a heparin dose response (HDR) technique. The accuracy of Hepcon-based heparin administration in achieving a target activated clotting time (ACT) using an HDR slope remains controversial.

Methods:

We prospectively studied 86 adult patients scheduled for cardiac surgery requiring cardiopulmonary bypass. The total dose of calculated heparin required for patient and pump priming was administered simultaneously to achieve a target ACT of 450 s for HDR on the Hepcon HMS system. Blood samples were obtained after the induction of anesthesia, at 3 min after heparin administration and after the initiation of CPB to measure kaolin ACT, HDR slope, whole-blood heparin concentration based on the HDR slope and anti-Xa heparin concentration, antithrombin and complete blood count.

Results:

The target ACT of 450 s was not achieved in 68.6% of patients. Compared with patients who achieved the target ACT, those who failed to achieve their target ACT had a significantly higher platelet count at baseline. Correlation between the HDR slope and heparin sensitivity was poor. Projected heparin concentration and anti-Xa heparin concentration are not interchangeable based on the Bland–Altman analysis.

Conclusion:

It can be hypothesized that the wide discrepancy in HDR slope versus heparin sensitivity may be explained by an inaccurate prediction of the plasma heparin level and/or the change in HDR of individual patients, depending on in vivo factors such as extravascular sequestration of heparin, decreased intrinsic antithrombin activity level and platelet count and/or activity.

A luminescent and colorimetric probe based on the functionalization of gold nanoparticles by ruthenium(ii) complexes for heparin detection

A colorimetric and luminescent bifunctional Ru(ii) complex-modified gold nanoprobe for the sensing of heparin in Tris-HCl buffer (pH 7.4) and 1% fetal bovine serum (FBS) was developed.

Pyrene-based heparin sensors in competitive aqueous media – the role of self-assembled multivalency (SAMul)

Simple functionalised pyrene derivatives can achieve ratiometric sensing of heparin with the precise sensing mechanism depending on whether the sensor self-assembles into a multivalent ligand display.

A portable blood plasma clot micro-elastometry device based on resonant acoustic spectroscopy

Abnormal blood clot stiffness is an important indicator of coagulation disorders arising from a variety of cardiovascular diseases and drug treatments. Here, we present a portable instrument for elastometry of microliter volume blood samples based upon the principle of resonant acoustic spectroscopy, where a sample of well-defined dimensions exhibits a fundamental longitudinal resonance mode proportional to the square root of the Young's modulus. In contrast to commercial thromboelastography, the resonant acoustic method offers improved repeatability and accuracy due to the high signal-to-noise ratio of the resonant vibration. We review the measurement principles and the design of a magnetically actuated microbead force transducer applying between 23 pN and 6.7 nN, providing a wide dynamic range of elastic moduli (3 Pa-27 kPa) appropriate for measurement of clot elastic modulus (CEM). An automated and portable device, the CEMport, is introduced and implemented using a 2 nm resolution displacement sensor with demonstrated accuracy and precision of 3% and 2%, respectively, of CEM in biogels. Importantly, the small strains (<0.13%) and low strain rates (<1/s) employed by the CEMport maintain a linear stress-to-strain relationship which provides a perturbative measurement of the Young's modulus. Measurements of blood plasma CEM versus heparin concentration show that CEMport is sensitive to heparin levels below 0.050 U/ml, which suggests future applications in sensing heparin levels of post-surgical cardiopulmonary bypass patients. The portability, high accuracy, and high precision of this device enable new clinical and animal studies for associating CEM with blood coagulation disorders, potentially leading to improved diagnostics and therapeutic monitoring.

Bivalirudin as an adjunctive anticoagulant to heparin in the treatment of heparin resistance during cardiopulmonary bypass-assisted cardiac surgery

Heparin resistance (unresponsiveness to heparin) is characterized by the inability to reach acceptable activated clotting time values following a calculated dose of heparin. Up to 20% of the patients undergoing cardiothoracic surgery with cardiopulmonary bypass using unfractionated heparin (UFH) for anticoagulation experience heparin resistance. Although UFH has been the "gold standard" for anticoagulation, it is not without its limitations. It is contraindicated in patients with confirmed heparin-induced thrombocytopenia (HIT) and heparin or protamine allergy. The safety and efficacy of the use of the direct thrombin inhibitor bivalirudin for anticoagulation during cardiac surgery has been reported. However, there have been no reports on the treatment of heparin resistance with bivalirudin during CPB. In this review, we report the favorable outcome of our single-center experience with the alternative use of bivalirudin in the management of anticoagulation of heparin unresponsive patients undergoing coronary artery bypass graft surgery.

Perioperative anticoagulation management in antiphospholipid syndrome

Patients with antiphospholipid syndrome are at increased risk of developing thrombotic and hemorrhagic complications after cardiac surgery, and may have abnormal coagulation tests and develop thrombocytopenia after invasive procedures, which can complicate the perioperative management of anticoagulant therapy. We describe a patient with chronic thromboembolic pulmonary hypertension and antiphospholipid syndrome, who presented with prolonged activated partial thromboplastin and activated clotting times, and developed thrombocytopenia after the catheterization workup. We performed pulmonary endarterectomy and successfully managed anticoagulation by restricting heparin use at the time of surgery and monitoring the heparin effect by measuring heparin concentrations during cardiopulmonary bypass.

Resonance Rayleigh scattering detection of heparin with concanavalin A

Stepwise macromolecular interactions observed between conA and heparin, which are accompanied by RRS changes.

A polyadenosine-coralyne complex as a novel fluorescent probe for the sensitive and selective detection of heparin in plasma

This study presents the development of a simple, label-free, sensitive, and selective detection system for heparin based on the use of a complex of 20-repeat adenosine (A20) and coralyne. Coralyne emits relatively weak fluorescence in an aqueous solution. In the presence of A20, coralyne molecules complexed with A20 through A2-coralyne-A2 coordination. An increase in the fluorescence of coralyne was observed because coralyne remained separate from water in the hydrophobic environment of the folded A20. The presence of heparin and the formation of the coralyne-heparin complex caused coralyne to be removed from the A20-corlayne complex. Because heparin promoted coralyne dimerization, the fluorescence of coralyne decreased as a function of the concentration of added heparin. This detection method is effective because the electrostatic attraction between heparin and coralyne is substantially stronger than the coordination between A20 and coralyne in a 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid (HEPES) buffer at pH 7.0. Under optimal conditions (5 μM coralyne, 1 μM poly A20, and 10mM HEPES), this probe exhibited high selectivity (>90-fold) toward heparin over hyaluronic acid and chondroitin sulfate. The probe׳s detection limit for heparin was determined to be 4 nM (75 ng/mL) at a signal-to-noise ratio of 3. This study validates the practicality of using the A20-corlayne complex to determine the concentration of heparin in plasma.

Thin layer coulometry based on ion-exchanger membranes for heparin detection in undiluted human blood

We explore here for the first time a potentially calibration-free methodology for the detection of protamine (and, by titration, heparin) in undiluted human blood in the therapeutic concentration range from 20 to 120 mg L(-1). The use of a thin layer sample (5.8 μL) confined between a tubular protamine selective membrane (inner diameter, 600 μm) and a Ag/AgCl wire (diameter 400 μm) achieves an exhaustive depletion from the sample. Coulometry detection was chosen for the interrogation of the thin layer, employing a double pulse technique with 120 s for each pulse. Protamine calibration curves were recorded at physiological concentrations and in undiluted human blood. A linear relationship was obtained in both cases, but a diminished sensitivity was observed in contact with blood, which is explained with a partial passivation of the inner Ag/AgCl element. Heparin-protamine titrations were performed in undiluted human blood samples, mimicking the final application with patients undergoing critical care. The observed values correlate satisfactorily with those of an alternative technique, so-called flash-chronopotentiometry on planar membranes.

Water-soluble bioprobes with aggregation-induced emission characteristics for light-up sensing of heparin

The AIE probe performs better than the ACQ probe in the heparin assay in terms of sensitivity and selectivity.

Highly sensitive surface-enhanced Raman scattering sensing of heparin based on antiaggregation of functionalized silver nanoparticles

We report a simple and sensitive surface-enhanced Raman scattering (SERS) platform for the detection of heparin, based on antiaggregation of 4-mercaptopyridine (4-MPY) functionalized silver nanoparticles (Ag NPs). Here, protamine was employed as a medium for inducing the aggregation of negatively charged 4-MPY functionalized Ag NPs through surface electrostatic interaction, which resulted in significantly enhanced Raman signal of the Raman reporter. However, in the presence of heparin, the interaction between heparin and protamine decreased the concentration of free protamine, which dissipated the aggregated 4-MPY functionalized Ag NPs and thus decreased Raman enhancement effect. The degree of aggregation and Raman enhancement effect was proportional to the concentration of added heparin. Under optimized assay conditions, good linear relationship was obtained over the range of 0.5-150 ng/mL (R(2) = 0.998) with a minimum detectable concentration of 0.5 ng/mL in standard aqueous solution. Furthermore, the developed method was also successfully applied for detecting heparin in fetal bovine serum samples with a linear range of 1-400 ng/mL.

pH-independent optical sensing of heparin based on ionic liquid-capped gold nanoparticles

A simple pH-independent optical method for the sensing of heparin, as a biomedically important polyionic drug, based on aggregation of gold nanoparticles (AuNPs) is described. The polyanionic heparin induces the aggregation of positively charged ionic liquid stabilized AuNPs, which results in a shift in the surface plasmon band and a consequent color change of the AuNPs from red to blue. The color change was monitored using UV-vis spectrophotometry and image analysis methods. The aggregation was confirmed by transmission electron microscopic measurements. The degree of aggregation was found to be proportional to the concentration of the added heparin, allowing its quantitative detection. The change in the absorbance and color-value has been used to monitor the concentration of heparin. This optical method can quantify heparin as low as 0.010 μg mL(-1) and the calibration is linear for a wide range of concentration.

Adenosine-based molecular beacons as light-up probes for sensing heparin in plasma

This study presents an adenosine-based molecular beacon (MB) for the selective and sensitive detection of heparin based on the competitive binding between heparin and the MB stem to coralyne.

Impact of protamine dose on activated clotting time and thromboelastography in infants and small children undergoing cardiopulmonary bypass

OBJECTIVES

To study the effect of two protamine-dosing strategies on activated clotting time (ACT) and thromboelastography (TEG).

BACKGROUND

Protamine dosage based on neutralizing heparin present in the combined estimated blood volumes (EBVs) of the patient and cardiopulmonary bypass (CPB) pump may result in excess protamine and contributes toward a coagulopathy that can be detected by ACT and TEG in pediatric patients.

METHODS

A total of 100 pediatric patients 1 month to ≤5 years of age undergoing CPB were included in this retrospective before/after design study. Combined-EBV group consisted of 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the combined EBVs of the patient and the pump. Pt-EBV group consisted of the next 50 consecutive patients whose protamine dose was calculated to neutralize heparin in the patient's EBV.

RESULTS

Baseline and postprotamine ACTs were similar between groups. Postprotamine heparin assay (Hepcon) showed the absence of residual heparin in both groups. Postprotamine kaolin-heparinase TEG showed that R was prolonged by 7.5 min in the Combined-EBV group compared with the Pt-EBV group (mean R of 20.17 vs. 12.4 min, respectively, P < 0.001). Increasing doses of protamine were associated with a corresponding, but nonlinear increase in R. There was no significant difference in the changes for K, alpha, and MA between the groups.

CONCLUSION

Automated protamine titration with a protamine dosage based on Pt-EBV can adequately neutralize heparin as assessed by ACT while minimizing prolonging clot initiation time as measured by TEG.

Time course of haemostatic effects of fibrinogen concentrate administration in aortic surgery

Background

There is currently a contrast between the demonstrated benefits of fibrinogen concentrate in correcting bleeding and reducing transfusion, and its perceived thrombogenic potential. This analysis evaluates the effects of fibrinogen concentrate on coagulation up to 12 days after administration during aortic surgery.

Methods

We performed a post hoc analysis of a prospective, randomized, double-blind, controlled trial of fibrinogen concentrate as first-line haemostatic therapy in aortic surgery. After cardiopulmonary bypass (CPB) and protamine administration, subjects with coagulopathic bleeding received fibrinogen concentrate or placebo. The placebo group received allogeneic blood products, including fresh-frozen plasma (FFP; n=32); the fibrinogen concentrate group received fibrinogen concentrate alone (FC; n=14), or fibrinogen concentrate followed by allogeneic blood products (FC+FFP; n=15). Plasma fibrinogen, fibrin-based clotting (ROTEM^®-based FIBTEM assay), and peri- and postoperative haematological and coagulation parameters were compared.

Results

Plasma fibrinogen and FIBTEM maximum clot firmness (MCF) decreased ∼50% during CPB but were corrected by FC or FC+FFP. At last suture, the highest values for plasma fibrinogen (360 mg dl⁻¹) and FIBTEM MCF (22 mm) were within normal ranges—below the acute phase increases observed after surgery. In patients receiving only FFP as a source of fibrinogen, these parameters recovered marginally by last suture (P<0.001 vs FC and FC+FFP). All groups displayed comparable haemostasis at 24 h post-surgery. Fibrinogen concentrate did not cause alterations of other haemostasis parameters.

Conclusions

Fibrinogen concentrate provided specific, significant, short-lived increases in plasma fibrinogen and fibrin-based clot firmness after aortic surgery.