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Li T, Bo F, Meng X, Wang D, Ma J, Dai Z. The effect of perioperative antithrombin supplementation on blood conservation and postoperative complications after cardiopulmonary bypass surgery: A systematic review, meta-analysis and trial sequential analysis. Heliyon 2023; 9:e22266. [PMID: 38053853 PMCID: PMC10694320 DOI: 10.1016/j.heliyon.2023.e22266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023] Open
Abstract
Study objective Antithrombin (AT) activity is reduced during cardiopulmonary bypass (CPB) surgery. Guidelines has demonstrated that perioperative AT supplementation contributed to blood conservation and prevent perioperative thrombotic complications and target organ injury owing to its role in reducing thrombin generation. But these recommends is lack of support of meta-analysis in the guidelines. This meta-analysis aims to include all the relevant randomized controlled trails (RCT) on patients who experienced cardiac surgeries with CPB and investigate the effect of perioperative AT on blood conservation and complications after cardiac surgery. Methods Standard published RCTs were searched from bibliographic databases to identify all evidence reporting perioperative AT supplementation for patients undergoing cardiovascular surgeries. The primary outcome was postoperative blood loss, the secondary outcomes were blood component transfusion (red blood cell (RBC), fresh frozen plasma (FFP), platelet and autologous blood), postoperative morbidity and in hospital mortality. The relative risk (RR) for dichotomous outcomes and the standardized mean difference (SMD) for continuous outcomes were estimated using a random-effects model. Trial sequential analysis (TSA) was performed using TSA software 0.9.5.10. Results 13 RCTs with 996 participants undergoing different cardiovascular surgeries were included. Meta-analysis showed AT did not decrease postoperative blood loss (SMD -0.01, 95%CI -0.2 to 0.19). Subgroup analysis showed the effect of AT on postoperative blood loss was not associated with age, RCT type, surgery type, injection time of AT and AT deficiency. TSA further suggested that no additional studies were required for the stable result. Perioperative AT also did not reduce RBC ((SMD 0.10, 95%CI -0.66 to 0.85), (RR 0.99, 95%CI 0.83 to 1.19)), FFP ((SMD 0.11, 95%CI -0.19 to 0.41), (RR 1.30, 95%CI 0.90 to 1.87)), platelet (RR 1.10, 95%CI 0.83 to 1.46) and autologous blood (SMD 0.46, 95%CI -0.12 to 1.8504) transfusions. Perioperative AT significantly increased in hospital mortality (RR 2.53, 95%CI 1.02 to 6.28) and acute kidney injury (AKI) (RR 3.72, 95%CI 1.73 to 8.04) incidence. There was no significant difference in postoperative reexploration, thromboembolism, ECMO/IABP support, and stroke incidence between AT and non-AT group. Conclusions With the improvement of AT level and heparin sensitivity, perioperative AT has no significant effect on blood conservation. And it is noteworthy that the treatment increased in hospital mortality and the incidence of AKI after cardiac surgery.
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Affiliation(s)
- Tao Li
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - FengShan Bo
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - XiangRui Meng
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - Di Wang
- Department of Internal Medicine, Yantai Haigang Hospital, Yantai, 264000, Shandong, China
| | - Jiahai Ma
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
| | - Zhao Dai
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, 264000, Shandong, China
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Moront MG, Woodward MK, Essandoh MK, Avery EG, Reece TB, Brzezinski M, Spiess B, Shore-Lesserson L, Chen J, Henriquez W, Barceló M, Despotis G, Karkouti K, Levy JH, Ranucci M, Mondou E. A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial of Preoperative Antithrombin Supplementation in Patients at Risk for Antithrombin Deficiency After Cardiac Surgery. Anesth Analg 2022; 135:757-768. [PMID: 35877927 DOI: 10.1213/ane.0000000000006145] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Antithrombin (AT) activity is reduced during cardiac operations with cardiopulmonary bypass (CPB), which is associated with adverse outcomes. Preoperative AT supplementation, to achieve >58% and <100% AT activity, may potentially reduce postoperative morbidity and mortality in cardiac operations with CPB. This prospective, multicenter, randomized, double-blind, placebo-controlled study was designed to evaluate the safety and efficacy of preoperative treatment with AT supplementation in patients at risk for low AT activity after undergoing cardiac surgery with CPB. METHODS A total of 425 adult patients were randomized (1:1) to receive either a single dose of AT (n = 213) to achieve an absolute increase of 20% above pretreatment AT activity or placebo (n = 212) before surgery. The study duration was approximately 7 weeks. The primary efficacy end point was the percentage of patients with any component of a major morbidity composite (postoperative mortality, stroke, acute kidney injury [AKI], surgical reexploration, arterial or venous thromboembolic events, prolonged mechanical ventilation, and infection) in the 2 groups. Secondary end points included AT activity, blood loss, transfusion requirements, duration of intensive care unit (ICU), and hospital stays. Safety was also assessed. RESULTS Overall, 399 patients (men, n = 300, 75.2%) with a mean (standard deviation [SD]) age of 66.1 (11.7) years, with the majority undergoing complex surgical procedures (n = 266, 67.9%), were analyzed. No differences in the percentage of patients experiencing morbidity composite outcomes between groups were observed (AT-treated 68/198 [34.3%] versus placebo 58/194 [29.9%]; P = .332; relative risk, 1.15). After AT infusion, AT activity was significantly higher in the AT group (108% [42-143]) versus placebo group (76% [40-110]), and lasted up to postoperative day 2. At ICU, the frequency of patients with AT activity ≥58% in the AT group (81.5%) was significantly higher (P < .001) versus placebo group (43.2%). Secondary end point analysis did not show any advantage of AT over placebo group. There were significantly more patients with AKI (P < .001) in the AT group (23/198; 11.6%) than in the placebo group (5/194, 2.6%). Safety results showed no differences in treatment-emergent adverse events nor bleeding events between groups. CONCLUSIONS AT supplementation did not attenuate adverse postoperative outcomes in our cohort of patients undergoing cardiac surgery with CPB.
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Affiliation(s)
- Michael George Moront
- From the, Department of Cardiothoracic Sugery, Promedical Toledo Hospital, Toledo, Ohio
| | | | - Michael K Essandoh
- Department of Anesthesiology' Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Edwin G Avery
- Department of Anesthesiology and Perioperative Medicine, University Hospital Case Medical Center, Cleveland, Ohio
| | - T Brett Reece
- Department of Surgery' Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Marek Brzezinski
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco, California.,San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Bruce Spiess
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | | | - Junliang Chen
- Bioscience Research Group, Grifols, Barcelona, Spain
| | | | | | - George Despotis
- Departments of Pathology, Immunology and Anesthesiology, Washington University School of Medicine, St. Louis, Missouri
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCSS Policlinico San Donato, Milan, Italy
| | - Elsa Mondou
- Bioscience Research Group, Grifols, Barcelona, Spain
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Stammers AH, Francis SG, Miller R, Nostro A, Tesdahl EA, Mongero LB. Application of goal-directed therapy for the use of concentrated antithrombin for heparin resistance during cardiac surgery. Perfusion 2020; 36:171-182. [PMID: 32536326 DOI: 10.1177/0267659120926089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The maintenance of anticoagulation in adult patients undergoing cardiopulmonary bypass is dependent upon a number of factors, including heparin concentration and adequate antithrombin activity. Inadequate anticoagulation increases the risk of thrombosis and jeopardizes both vascular and extracorporeal circuit integrity. The purpose of this study was to evaluate a goal-directed approach for the use of antithrombin in patients who were resistant to heparin. Following institutional review board approval, data were obtained from quality improvement records. A goal-directed protocol for antithrombin was established based upon heparin dosing (400 IU kg-1 body weight) and achieving an activated clotting time of ⩾500 seconds prior to cardiopulmonary bypass. Two groups of patients were identified as those receiving antithrombin and those not receiving antithrombin. Outcome measures included activated clotting time values and transfusion rates. Consecutive patients (n = 140) were included in the study with 10 (7.1%) in the antithrombin group. The average antithrombin dose was 1,029.0 ± 164.5 IU and all patients had restoration to the activated clotting time levels. Patients in the antithrombin group were on preoperative heparin therapy (80.0% vs. 24.6%, p = 0.001). Prior to cardiopulmonary bypass the activated clotting time values were lower in the antithrombin group (417.7 ± 56.1 seconds vs. 581.1 ± 169.8 seconds, p = 0.003). Antithrombin patients had a lower heparin sensitivity index (0.55 ± 0.17 vs. 1.05 ± 0.44 seconds heparin-1 IU kg-1, p = 0.001), received more total heparin (961.3 ± 158.5 IU kg-1 vs. 677.5 ± 199.0 IU kg-1, p = 0.001), more cardiopulmonary bypass heparin (22,500 ± 10,300 IU vs. 12,100 ± 13,200 IU, p = 0.016), and more protamine (5.4 ± 1.2 vs. 4.1 ± 1.1 mg kg-1, p = 0.003). The intraoperative transfusion rate was higher in the antithrombin group (70.0% vs. 35.4%, p = 0.035), but no differences were seen postoperatively. Utilization of a goal-directed algorithm for the administration of antithrombin for the treatment of heparin resistance is effective in patients undergoing cardiac surgery.
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Affiliation(s)
| | | | | | - Anthony Nostro
- Department of Anesthesia, Pocono Medical Center, East Stroudsburg, PA, USA
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Sorial MN, Greene RA, Zullo AR, Berard-Collins C, Willis S. Exogenous supplementation of antithrombin III in adult and pediatric patients receiving extracorporeal membrane oxygenation. Int J Artif Organs 2019; 43:315-322. [DOI: 10.1177/0391398819888932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Antithrombin III deficiency can occur with heparin anticoagulation during extracorporeal membrane oxygenation leading to heparin resistance. Antithrombin III supplementation has been shown to improve anticoagulation; however, there is no consensus on appropriate administration. We described the effect of antithrombin III supplementation on coagulation parameters in adult and pediatric extracorporeal membrane oxygenation patients. Methods: We conducted a retrospective cohort study using electronic medical records of patients who received ⩾1 dose of antithrombin III during extracorporeal membrane oxygenation while on continuous heparin. Endpoints included the change in anti-Xa levels and antithrombin III activity at −6 versus 6 h relative to antithrombin III supplementation, and heparin infusion rates at 6 versus 12 h after antithrombin III supplementation. Results: Eighteen patients receiving 36 antithrombin III administrations were analyzed. Mean (standard deviation) anti-Xa values at −6 versus 6 h were 0.15 (0.07) versus 0.24 (0.15) IU/mL ( p-value: 0.250) for pediatrics and 0.19 (0.22) versus 0.31 (0.27) IU/mL ( p-value: 0.052) for adults. Mean (standard deviation) plasma antithrombin III activity at the same intervals were 32% (14.2%) versus 66.8% (25.1%; p-value: 0.062) for pediatrics and 30.3% (14%) versus 52.8% (8.1%; p-value: 0.094) for adults. Mean (standard deviation) heparin rates at 6 versus 12 h after antithrombin III for pediatrics were 23.6 (6) versus 23.5 (6.5) units/kg/h ( p-value: 0.728), and 15.3 (6.6) versus 13.5 (8) units/kg/h ( p-value: 0.188) for adults. Conclusion: Administration of antithrombin III improved anti-Xa levels in both populations, however, did not significantly reduce heparin rates. Our findings suggest that the use of antithrombin III restores heparin responsiveness in patients with low antithrombin III activity and low anti-Xa activity.
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Affiliation(s)
- Mark N Sorial
- Department of Pharmacy, Lifespan–Rhode Island Hospital & Hasbro Children’s Hospital, Providence, RI, USA
| | - Rebecca A Greene
- Department of Pharmacy, Lifespan–Rhode Island Hospital & Hasbro Children’s Hospital, Providence, RI, USA
| | - Andrew R Zullo
- Department of Pharmacy, Lifespan–Rhode Island Hospital & Hasbro Children’s Hospital, Providence, RI, USA
- School of Public Health, Brown University, Providence, RI, USA
| | - Christine Berard-Collins
- Department of Pharmacy, Lifespan–Rhode Island Hospital & Hasbro Children’s Hospital, Providence, RI, USA
| | - Steve Willis
- Department of Pharmacy, Lifespan–Rhode Island Hospital & Hasbro Children’s Hospital, Providence, RI, USA
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Right Sided Intracardiac Thrombosis during Veno-Arterial Extracorporeal Membrane Oxygenation: A Case Report and Literature Review. Case Rep Crit Care 2019; 2019:8594681. [PMID: 30723555 PMCID: PMC6339751 DOI: 10.1155/2019/8594681] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/24/2018] [Indexed: 11/17/2022] Open
Abstract
Veno-Arterial Extracorporeal Membrane Oxygenation is a common technology of the modern era used as a bridge in severe refractory cardiac and respiratory failure until definitive management is planned. However, early recognition and management of one of the most challenging complications, intracardiac thrombus, continue to remain a conundrum. The incidence of the clinical scenario is very rare. Therefore, due to the lack of literature, there are no guidelines for risk stratification, prevention, or management of intracardiac thrombus. We describe a case of massive pulmonary embolism, who developed a sudden right sided intra-cardiac thrombosis while being optimally anticoagulated on VA ECMO. We also review the literature to describe the pathophysiology, risk stratification, prevention, and management of this rare entity.
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Muedra V, Moreno L, Rodilla V, Arce C, Montó F, Blázquez Á, Pérez P, D’Ocón P. Dexamethasone Preconditioning in Cardiac Procedures Reduces Decreased Antithrombin Activity and Is Associated to Beneficial Outcomes: Role of Endothelium. Front Pharmacol 2018; 9:1014. [PMID: 30319401 PMCID: PMC6167415 DOI: 10.3389/fphar.2018.01014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 08/20/2018] [Indexed: 01/07/2023] Open
Abstract
Introduction: Decreased antithrombin (AT) activity in patients scheduled for cardiovascular surgery under cardiopulmonary bypass (CPB) is related to increased postoperative complications and hospitalization time. Indirect evidence suggests that glucocorticoids mitigate this decreased AT activity. To better understand the beneficial effects of AT we have analyzed: (i) the clinical relevance of acute dexamethasone (DX) administration before cardiac surgery on AT activity, (ii) the modulation by DX of AT expression in human endothelial cells (hECs), (iii) the activity of AT on migration and angiogenesis of hECs, or on angiogenesis of rat aorta. Methods: A retrospective cohort study in patients undergoing aortic valve replacement surgery was designed to evaluate the effect of DX administration on AT activity at five separate time points: preoperatively, during CPB, at intensive care unit admission and at 12 and 24 h post-intervention. We have analyzed also clinical differences in postoperative outcomes as safety and the length of stay in hospitalization. Changes in mRNA levels of AT induced by DX were determined by qRT-PCR in human coronary (hCEC), aorta (hAEC) and cardiac microvasculature (hCMEC) endothelial cells. AT activity on migration and angiogenesis were also assayed. Angiogenic growth of rat aortic rings incubated in Matrigel® was determined in presence and absence of AT. Results: The cohort comprised 51 patients in the control group and 29 patients in the group receiving dexamethasone. Preoperative DX supplementation reduced intraoperative decrease of AT activity (67.71 ± 10.49% DX treated vs. 58.12 ± 9.11% untreated, p < 0.001) that could be related to a decrease in the hospitalization time (7.59 ± 4.08 days DX treated vs. 13.59 ± 16.00 days untreated, p = 0.014). Treatment of hECs with 500 nM DX slightly increased AT expression. Incubation with 0.5 and 1 IU/mL of AT increased migration and angiogenesis in hCAECs and hAECs, but not in hCMECs. The same concentrations of AT potentiated angiogenic sprouting of new vessels from rat aorta. Conclusion: Preoperative DX supplementation could be an interesting procedure to avoid excessive decrease in AT levels during cardiac surgery. Positive outcomes associated with maintaining adequate AT levels could be related to its potential beneficial effect on endothelial function (migration and angiogenesis).
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Affiliation(s)
- Vicente Muedra
- Departamento de Anestesiología, Cuidados Críticos y Terapéutica del Dolor, Hospital Universitario de La Ribera, Valencia, Spain
- Departamento de Cirugía, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, Valencia, Spain
| | - Lucrecia Moreno
- Departamento de Farmacia, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, Valencia, Spain
| | - Vicente Rodilla
- Departamento de Farmacia, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, Valencia, Spain
| | - Cristina Arce
- Departamento de Farmacología, Facultad de Farmacia, Universitat de València, Valencia, Spain
- Estructura de Recerca Interdisciplinar en Biotecnologia i Biomedicina (ERI BIOTECMED), Universitat de València, Valencia, Spain
| | - Fermi Montó
- Departamento de Farmacología, Facultad de Farmacia, Universitat de València, Valencia, Spain
- Estructura de Recerca Interdisciplinar en Biotecnologia i Biomedicina (ERI BIOTECMED), Universitat de València, Valencia, Spain
| | - Águeda Blázquez
- Departamento de Farmacología, Facultad de Farmacia, Universitat de València, Valencia, Spain
| | - Paloma Pérez
- Instituto de Biomedicina de Valencia-Consejo Superior de Investigaciones Científicas (IBV-CSIC), Valencia, Spain
| | - Pilar D’Ocón
- Departamento de Farmacología, Facultad de Farmacia, Universitat de València, Valencia, Spain
- Estructura de Recerca Interdisciplinar en Biotecnologia i Biomedicina (ERI BIOTECMED), Universitat de València, Valencia, Spain
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Ornaghi S, Barnhart KT, Frieling J, Streisand J, Paidas MJ. Clinical syndromes associated with acquired antithrombin deficiency via microvascular leakage and the related risk of thrombosis. Thromb Res 2014; 133:972-84. [PMID: 24593911 DOI: 10.1016/j.thromres.2014.02.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 01/25/2014] [Accepted: 02/11/2014] [Indexed: 12/17/2022]
Abstract
Antithrombin (AT) is a 65kDa glycoprotein belonging to a group of inhibitory factors known as serpins (serine protease inhibitors). It plays a critical role in the inhibition of coagulation and inflammation processes within the environment of the vascular endothelium. Inadequate levels of functional AT in plasma results in an increased risk of thrombotic events, both venous and arterial. AT deficiency can be inherited or acquired. Congenital AT deficiency is the most severe inherited thrombophilic condition with an odds ratio of 20 for the increased risk of venous thrombosis. Acquired AT deficiency occurs in a variety of physiologic and pathologic medical conditions with similar risks of increased thrombosis. In this article, we review clinical settings characterized by an acquired AT deficiency largely or partly subsequent to protein microvascular leakage. Other different mechanisms of AT depletion are implied in some clinical conditions together with endothelial loss, and, therefore, outlined. In addition, we provide a description of the current knowledge on the specific mechanisms underlying endothelial AT leakage and on the consequences of this protein decrease, specifically looking at thrombosis. We identify potential directions of research that might prove useful in patients with acquired AT deficiency.
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Affiliation(s)
- Sara Ornaghi
- Yale Women and Children's Center For Blood Disorders, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, USA; Department of Obstetrics and Gynecology, University of Milan-Bicocca, via Pergolesi 33, Monza, MB, Italy.
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Johan Frieling
- rEVO Biologics 175 Crossing Boulevard, Framingham, MA 01702, USA
| | - James Streisand
- rEVO Biologics 175 Crossing Boulevard, Framingham, MA 01702, USA
| | - Michael J Paidas
- Yale Women and Children's Center For Blood Disorders, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, USA
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Krajewski S, Krauss S, Kurz J, Neumann B, Schlensak C, Wendel HP. Real-time measurement of free thrombin: evaluation of the usability of a new thrombin assay for coagulation monitoring during extracorporeal circulation. Thromb Res 2013; 133:455-63. [PMID: 24359968 DOI: 10.1016/j.thromres.2013.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/16/2013] [Accepted: 12/03/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION In patients undergoing cardiac surgery with heart-lung machine support, adequate anticoagulation to mitigate blood clotting caused by the artificial surfaces of the extracorporeal circulation (ECC) system is essential. These patients routinely receive heparin, whose effectiveness is monitored by measurements of the activated clotting time (ACT). However, ACT values only poorly correlate with the actual hemostatic status. The aim of our study was to evaluate the detection of free thrombin in heparinized human blood as a monitor of anticoagulation during ECC. MATERIALS AND METHODS Human whole blood was anticoagulated with different concentrations of heparin (0.75, 1, 2 or 3 IU/ml) and circulated in the Chandler-loop model for up to 240 min at 37 °C. Next to ACT, ECC-mediated changes in free active thrombin, prothrombin fragment 1+2 (F1+2) and thrombin-antithrombin-III (TAT) levels were measured before and during circulation. Platelet activation and cell count parameters were further investigated. RESULTS Our study shows that detection of ECC-mediated changes in free thrombin is possible in blood anticoagulated with 0.75 or 1 IU/ml heparin, whereas no thrombin was detectable at higher heparin concentrations. Thrombin generation during 240 min of ECC is comparable to F 1+2 and TAT plasma levels during ECC. CONCLUSIONS Thrombin is the key enzyme in the coagulation cascade and hence represents a promising marker for monitoring the coagulation status of patients. Although detection of free thrombin was not feasible at high heparin concentrations, the employed test represents an additional test to current laboratory methods investigating blood coagulation at low heparin concentrations.
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Affiliation(s)
- Stefanie Krajewski
- Department of Thoracic, Cardiac and Vascular Surgery, Clinical Research Laboratory, University Hospital Tuebingen Germany.
| | - Sabrina Krauss
- Department of Thoracic, Cardiac and Vascular Surgery, Clinical Research Laboratory, University Hospital Tuebingen Germany
| | - Julia Kurz
- Department of Thoracic, Cardiac and Vascular Surgery, Clinical Research Laboratory, University Hospital Tuebingen Germany
| | - Bernd Neumann
- Department of Thoracic, Cardiac and Vascular Surgery, Clinical Research Laboratory, University Hospital Tuebingen Germany
| | - Christian Schlensak
- Department of Thoracic, Cardiac and Vascular Surgery, Clinical Research Laboratory, University Hospital Tuebingen Germany
| | - Hans P Wendel
- Department of Thoracic, Cardiac and Vascular Surgery, Clinical Research Laboratory, University Hospital Tuebingen Germany
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Muedra V, Barettino D, D'Ocón P. [Role of antithrombin iii in cardiac surgery]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2013; 60:519-527. [PMID: 23228672 DOI: 10.1016/j.redar.2012.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 09/18/2012] [Accepted: 09/26/2012] [Indexed: 06/01/2023]
Abstract
Coagulation of blood is of multidisciplinary interest. Cardiac surgery produces major changes in the delicate balance between pro-and anti-coagulant serum factors. The role of antithrombin iii has been analysed after finding evidence that associated decreased levels of protein activity to postoperative morbidity and mortality. Supplementing exogenous antithrombin is considered with the aim of optimising outcomes. Its intrinsic anticoagulant and anti-inflammatory properties have stimulated a growing interest, and suggests new lines of research.
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Affiliation(s)
- V Muedra
- Departamento de Anestesiología-Reanimación y Terapéutica del Dolor, Hospital Universitario La Ribera, Alzira, Valencia, España.
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Antithrombin activity and outcomes in patients undergoing cardiac surgery with cardiopulmonary bypass. Blood Coagul Fibrinolysis 2013; 24:454-7. [DOI: 10.1097/mbc.0b013e32835d5422] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Muedra V, Llau JV, Llagunes J, Paniagua P, Veiras S, Fernández-López AR, Diago C, Hidalgo F, Gil J, Valiño C, Moret E, Gómez L, Pajares A, de Prada B. Postoperative Costs Associated With Outcomes After Cardiac Surgery With Extracorporeal Circulation: Role of Antithrombin Levels. J Cardiothorac Vasc Anesth 2013; 27:230-7. [DOI: 10.1053/j.jvca.2012.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Indexed: 11/11/2022]
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Bosch YP, Weerwind PW, Nelemans PJ, Maessen JG, Mochtar B. An Evaluation of Factors Affecting Activated Coagulation Time. J Cardiothorac Vasc Anesth 2012; 26:563-8. [DOI: 10.1053/j.jvca.2012.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Indexed: 11/11/2022]
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13
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Muedra V. [Acquired antithrombin III deficiency in cardiac surgery: an update]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:347-349. [PMID: 22749326 DOI: 10.1016/j.redar.2012.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 05/03/2012] [Accepted: 05/08/2012] [Indexed: 06/01/2023]
Affiliation(s)
- V Muedra
- Grupo de Investigación Multidisciplinar de la Antitrombina y Cirugía Cardiaca, Hospital Universitario La Ribera, Alzira, Valencia, España
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Sniecinski RM, Chandler WL. Activation of the Hemostatic System During Cardiopulmonary Bypass. Anesth Analg 2011; 113:1319-33. [DOI: 10.1213/ane.0b013e3182354b7e] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Muedra V, Bonanad S, Gómez M, Villalonga V, Sánchez F, Llopis JE. Relationships between antithrombin activity, anticoagulant efficacy of heparin therapy and perioperative variables in patients undergoing cardiac surgery requiring cardiopulmonary bypass. Perfusion 2011; 26:487-95. [PMID: 21665912 DOI: 10.1177/0267659111412999] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION A study on 149 cardiopulmonary bypass (CPB) patients was performed to elucidate possible relationships between antithrombin (AT) activity and a subject's clinical profile or surgery characteristics. METHODS An initial dose (300 IU/kg) of heparin was administered before CPB. Additional boluses (100 IU/kg) were administered if the activated clotting time (ACT)≤460 s. AT activity and hematological parameters were determined preoperatively, during and after CPB, and at 12, 24, 36, and 48 hours post-intervention. RESULTS 29.5% patients required an additional dose of heparin during CPB. Preoperative AT was 96.5 ± 13.9% in all but 4 patients. AT was significantly lower during CPB and upon leaving the operating room (59.7%-80.0%). A small, but significant, inverse correlation was observed between AT at the end of CPB and the patient's age, as well as between basal preoperative AT and total heparin administered. CONCLUSIONS Patient's age could be a moderate indicator of AT activity drop and low preoperative AT activity could be a sign of reduced anticoagulant efficacy of heparin during CPB.
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Affiliation(s)
- V Muedra
- Department of Anesthesia, Critical Care and Pain Therapy, La Ribera University Hospital, Alzira, Valencia, Spain.
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Ferraris V, Ferraris S. Thrombin and cardiopulmonary bypass – A paradigm for evaluation of the regulation of hemostasis. Int J Angiol 2011. [DOI: 10.1007/s00547-005-2016-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Garvin S, Muehlschlegel JD, Perry TE, Chen J, Liu KY, Fox AA, Collard CD, Aranki SF, Shernan SK, Body SC. Postoperative activity, but not preoperative activity, of antithrombin is associated with major adverse cardiac events after coronary artery bypass graft surgery. Anesth Analg 2009; 111:862-9. [PMID: 19820236 DOI: 10.1213/ane.0b013e3181b7908c] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Low levels of antithrombin (AT) have been independently associated with prolonged intensive care unit stay and an increased incidence of neurologic and thromboembolic events after cardiac surgery. We hypothesized that perioperative AT activity is independently associated with postoperative major adverse cardiac events (MACEs) in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS We prospectively studied 1403 patients undergoing primary CABG surgery with cardiopulmonary bypass (CPB) (http://clinicaltrials.gov/show/NCT00281164). The primary clinical end point was occurrence of MACE, defined as a composite outcome of any one or more of the following: postoperative death, reoperation for coronary graft occlusion, myocardial infarction, stroke, pulmonary embolism, or cardiac arrest until first hospital discharge. Plasma AT activity was measured before surgery, after post-CPB protamine, and on postoperative days (PODs) 1-5. Multivariate logistic regression modeling was performed to estimate the independent effect of perioperative AT activity upon MACE. RESULTS MACE occurred in 146 patients (10.4%), consisting of postoperative mortality (n = 12), myocardial infarction (n = 108), stroke (n = 17), pulmonary embolism (n = 8), cardiac arrest (n = 16), or a subsequent postoperative or catheter-based treatment for graft occlusion (n = 6). AT activity at baseline did not differ between patients with (0.91 ± 0.13 IU/mL; n = 146) and without (0.92 ± 0.13 IU/mL; n = 1257) (P = 0.18) MACE. AT activity in both groups was markedly reduced immediately after CPB and recovered to baseline values over the ensuing 5 PODs. Postoperative AT activity was significantly lower in patients with MACE than those without MACE. After adjustment for clinical predictors of MACE, AT activity on PODs 2 and 3 was associated with MACE. CONCLUSIONS Preoperative AT activity is not associated with MACE after CABG surgery. MACE is independently associated with postoperative AT activity but only at time points occurring predominantly after the MACE.
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Affiliation(s)
- Sean Garvin
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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Raivio P, Lassila R, Petäjä J. Thrombin in Myocardial Ischemia-Reperfusion During Cardiac Surgery. Ann Thorac Surg 2009; 88:318-25. [DOI: 10.1016/j.athoracsur.2008.12.097] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Revised: 12/17/2008] [Accepted: 12/18/2008] [Indexed: 10/20/2022]
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Ranucci M, Ballotta A, Frigiola A, Boncilli A, Brozzi S, Costa E, Mehta RH. Pre-operative homocysteine levels and morbidity and mortality following cardiac surgery. Eur Heart J 2009; 30:995-1004. [PMID: 19224934 PMCID: PMC2668805 DOI: 10.1093/eurheartj/ehp015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Aims Elevated homocysteinaemia is associated not only with an increased risk for cardiovascular disease but also for increased morbidity and mortality in patients with established coronary artery or cerebrovascular disease. Whether elevated homocysteine further increases the morbidity and mortality in patients undergoing cardiac surgery on cardiopulmonary bypass (CPB) (a prothrombotic state itself) remains less known. Methods and results Accordingly, we conducted a prospective observational study with pre-operative measurement of plasma homocysteine levels in 531 consecutive patients undergoing cardiac operations on CPB. The association of pre-operative plasma homocysteine levels with post-operative morbidity and hospital mortality was evaluated. Elevated homocysteine levels (>15 µmol/L) were observed in 209 patients (39.4%), and homocysteinaemia was associated with a higher mortality and perioperative morbidity (major morbidity, low cardiac output, acute renal failure, mesenteric infarction, and thrombo-embolic events). Even after accounting for the differences in baseline clinical features, EuroSCORE, and CPB time, pre-operative homocysteine levels remained independently associated with hospital mortality [odds ratio (OR) 1.06, 95% confidence interval (CI) 1.03–1.11], major morbidity (OR 1.04, 95% CI 1.01–1.07), low cardiac output (OR 1.04, 95% CI 1.02–1.08), mesenteric infarction (OR 1.06, 95% CI 1.01–1.11), and thrombo-embolic events (OR 1.09, 95% CI 1.04–1.13). This association of homocysteine with increased risk of morbidity and mortality was observed particularly in CABG patients. Conclusion Elevated pre-operative homocysteine level is independently associated with increased morbidity and mortality, particularly in patients undergoing CABG. Specific post-operative antithrombotic strategies may be advisable in hyperhomocysteinaemic patients.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic-Vascular Anesthesia and Intensive Care, IRCCS Policlinico S.Donato, Milan, Italy
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Sniecinski R, Szlam F, Chen EP, Bader SO, Levy JH, Tanaka KA. Antithrombin Deficiency Increases Thrombin Activity After Prolonged Cardiopulmonary Bypass. Anesth Analg 2008; 106:713-8, table of contents. [DOI: 10.1213/ane.0b013e3181608f7c] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Maclean PS, Tait RC. Hereditary and acquired antithrombin deficiency: epidemiology, pathogenesis and treatment options. Drugs 2007; 67:1429-40. [PMID: 17600391 DOI: 10.2165/00003495-200767100-00005] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Antithrombin is a glycoprotein critical to the regulation of coagulation. Its primary action is the inhibition of the activated coagulation factors IIa (thrombin) and Xa. In addition there is growing evidence to suggest that antithrombin also plays a role in the inhibition of inflammation within the environment of the vascular endothelium. Reduced plasma antithrombin may result from congenital deficiency or arise secondarily from a range of disorders such as liver dysfunction, premature infancy and sepsis, or as a result of interventions such as major surgery or cardiopulmonary bypass. Congenital antithrombin deficiency is the most clinically important of the inherited thrombophilias resulting in thrombosis in the majority of those affected. The challenge in managing these patients is preventing potentially life-threatening thrombosis, while minimising the equally significant risk of haemorrhage associated with long-term anticoagulation. This is achieved in the first instance by identifying high-risk episodes such as surgery, immobility and pregnancy for which prophylactic anticoagulation can be used in the short term. Prophylaxis for such periods is best provided by the use of low molecular weight heparin (LMWH) with substitution by or addition of antithrombin concentrate in particularly high-risk circumstances. In the case of pregnancy, antithrombin concentrate is often used around the time of birth when LMWH may increase the risk of post-partum haemorrhage. As patients with congenital antithrombin deficiency get older so their thrombotic risk gradually increases and for many patients long-term anticoagulation becomes unavoidable because of recurrent episodes of venous thromboembolism. There has been much interest in the role of antithrombin deficiency in the setting of sepsis and the critically ill patient where there is a clear correlation between severity of illness and degree of antithrombin reduction. It is not clear yet, however, to what extent the depletion of antithrombin affects the clinical condition of such patients. A number of trials have investigated the use of antithrombin as a treatment in the intensive care setting with the overall conclusion being that there is some benefit to its use but only if large supra-physiological doses are used. It has also become clear that the concurrent use of any form of heparin removes whatever benefit may be derived from antithrombin treatment in this setting. Until recently, antithrombin replacement was only available as a pooled plasma-derived product, which despite effective viral inactivation still carries an uncertain risk of transfusion transmitted infection. A recombinant antithrombin product now under investigation, and recently licensed in Europe, may provide a useful alternative treatment option.
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Affiliation(s)
- Peter S Maclean
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, UK.
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Preventing and managing postoperative bleeding in cardiac surgery by controlling disseminated intravascular coagulation. Eur J Anaesthesiol 2007. [DOI: 10.1097/00003643-200706002-00004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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