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Raymond PD, Radel M, Ray MJ, Hinton-Bayre AD, Marsh NA. Investigation of factors relating to neuropsychological change following cardiac surgery. Perfusion 2016; 22:27-33. [PMID: 17633132 DOI: 10.1177/0267659107077952] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. An analysis of neuropsychological impairment following cardiopulmonary bypass was performed in 55 patients undergoing elective coronary artery bypass grafting. Methods. Neurocognitive function was measured preoperatively using the MicroCog: Assessment of Cognitive Functioning computer-based testing tool. Testing was repeated in the postoperative period immediately prior to discharge from hospital. Analysis of significant score decline was performed using the standardised regression-based technique. A patient was classified as overall impaired when ≥20% of test scores were significantly impaired. The proposed marker of neurological damage S-100β was also used. Prothrombin Fragment 1+2 (F1+2) was measured as a marker of thrombin development to test the hypothesis that excessive haemostatic activation may lead to thromboembolic damage to the brain. Results and Conclusions. 32.7% of patients were classified as significantly impaired. No relationship was detected between F1+2 and any neuropsychological test score; however, the study was limited due to small sample size. F1+2 levels were higher in patients undergoing prolonged bypass times. Neuropsychological decline was significantly correlated with patient age, suggesting a degree of caution is warranted when operating on an elderly cohort. An unexpected relationship was detected between higher heparin concentrations and increased risk of neuropsychological impairment; however, this requires re-evaluation. Perfusion (2007) 22, 27—33.
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Affiliation(s)
- Paul D Raymond
- Research Concentration in Biological and Medical Sciences, School of Life Sciences, Queensland University of Technology, Brisbane, Australia.
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2
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Bel A, Borik W, Davidson S, Helies JM, Stimmer L, Fremes S, Zelenkofske S, Rusconi C, Alexander J, Alexander D, Menasché P, Pepper J. Inhibition of factor IXa by the pegnivacogin system during cardiopulmonary bypass: a potential substitute for heparin. A study in baboons. Eur J Cardiothorac Surg 2015; 49:682-9. [PMID: 25953802 DOI: 10.1093/ejcts/ezv159] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/24/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Heparin and protamine are standard for anticoagulation and reversal for cardiopulmonary bypass (CPB). The REGADO biosciences protocol 1 (REG1) anticoagulant system, consisting of the Factor IXa (FIXa)-inhibitor pegnivacogin and its reversal agent (anivamersen), has been studied in patients undergoing coronary catheterization and in CPB in sheep and pigs. Prior to first human use in CPB, we wanted to test the safety and efficacy of REG1 in a primate model. METHODS Fourteen baboons undergoing 2 h of CPB followed by 1 h of reperfusion were studied. Three received heparin/protamine and 11 received 1 of 2 doses of pegnivacogin followed by anivamersen. Thrombin-generating capacity was tested in additional in vitro experiments. RESULTS Targeted drug levels and near-complete FIXa inhibition were achieved. Bypass was run uneventfully in all animals without any clotting in the circuit and bleeding was minimal in the two groups. However, in contrast to heparin-treated baboons, those receiving pegnivacogin/anivamersen displayed thrombi in the bypass cannulae upon cannulation and kidney cortical infarcts. Inter-species comparisons revealed that in the presence of high levels of FIXa inhibition, tissue factor-mediated thrombin generation in baboons was much higher than that in other species. CONCLUSIONS These data highlight the limitations of the baboon model for assessing factor-specific coagulation inhibitors during CPB. The justification for Phase 1 human studies using REG1 for CPB is unclear.
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Affiliation(s)
- Alain Bel
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou Department of Cardiovascular Surgery, Paris, France
| | - Wasseem Borik
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou Department of Cardiovascular Surgery, Paris, France
| | - Simon Davidson
- Department of Haematology, Royal Brompton Hospital, London, UK
| | - Jean-Marie Helies
- Molecular Imaging Research Center, Commissariat à l'Energie Atomique, Fontenay-aux-Roses, France
| | - Lev Stimmer
- Molecular Imaging Research Center, Commissariat à l'Energie Atomique, Fontenay-aux-Roses, France CEA-INSERM U986, Commissariat à l'Energie Atomique, Fontenay-aux-Roses, France
| | - Stephen Fremes
- Department of Cardiovascular Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | | | - John Alexander
- Cardiovascular Thrombosis, Duke Clinical Research Institute, Durham, NC, USA
| | - David Alexander
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, UK
| | - Philippe Menasché
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou Department of Cardiovascular Surgery, Paris, France Université Paris Descartes, Sorbonne Paris Cité; INSERM U 970, Paris, France
| | - John Pepper
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, UK
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3
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Inflammatory response and extracorporeal circulation. Best Pract Res Clin Anaesthesiol 2015; 29:113-23. [PMID: 26060024 DOI: 10.1016/j.bpa.2015.03.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 02/11/2015] [Accepted: 03/19/2015] [Indexed: 02/06/2023]
Abstract
Patients undergoing cardiac surgery with extracorporeal circulation (EC) frequently develop a systemic inflammatory response syndrome. Surgical trauma, ischaemia-reperfusion injury, endotoxaemia and blood contact to nonendothelial circuit compounds promote the activation of coagulation pathways, complement factors and a cellular immune response. This review discusses the multiple pathways leading to endothelial cell activation, neutrophil recruitment and production of reactive oxygen species and nitric oxide. All these factors may induce cellular damage and subsequent organ injury. Multiple organ dysfunction after cardiac surgery with EC is associated with an increased morbidity and mortality. In addition to the pathogenesis of organ dysfunction after EC, this review deals with different therapeutic interventions aiming to alleviate the inflammatory response and consequently multiple organ dysfunction after cardiac surgery.
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Davidson S. State of the Art - How I manage coagulopathy in cardiac surgery patients. Br J Haematol 2014; 164:779-89. [DOI: 10.1111/bjh.12746] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Simon Davidson
- Department of Haematology; Royal Brompton Hospital; London UK
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5
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DAVIDSON SJ, WOODHAMS B. Factor VIIa-Antithrombin complexes during cardiac surgery using cardiopulmonary bypass. Int J Lab Hematol 2011; 33:614-6. [DOI: 10.1111/j.1751-553x.2011.01331.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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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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Baufreton C, Pinaud F, Corbeau JJ, Chevailler A, Jolivot D, Ter Minassian A, Henrion D, de Brux JL. Increased cerebral blood flow velocities assessed by transcranial Doppler examination is associated with complement activation after cardiopulmonary bypass. Perfusion 2010; 26:91-8. [DOI: 10.1177/0267659110392439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The role of complement activation on the cerebral vasculature after cardiopulmonary bypass (CPB) is unclear. The goal of the study was to assess whether heparin-coated CPB reduces complement activation, and influences cerebral blood flow velocities (CBFV). Twenty-four patients undergoing coronary surgery were randomly allocated to non-coated (NC-group) or heparin-coated (HC-group) CPB. Complement activation was assessed by measuring sC5b-9. Transcranial Doppler (TCD) was performed on middle cerebral arteries before and after CPB. Systolic (SV), diastolic (DV) and mean (MV) CBFV were measured. Significant increase of sC5b-9 (p=0.003) was observed in the NC-group and CBFV increased after CPB (SV by 27%, p=0.05; DV by 40%, p=0.06; MV by 33%, p=0.04) whereas no changes were detected in the HC-group. TCD values were higher in the NC-group than in the HC-group (SV, p=0.04; DV, p=0.03; MV, p=0.03) although cardiac index, systemic vascular resistance, haematocrit and pCO2 were similar. Postoperative SV, DV and MV were significantly correlated with sC5b-9 (r=0.583, p=0.009; r=0.581, p=0.009; r=0.598, p=0.007, respectively). Increased CBFV after CPB are correlated to the level of complement activation and may be controlled by heparin-coated circuits.
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Affiliation(s)
- C. Baufreton
- Department of Cardiac Surgery, University Hospital, Angers, France,
| | - F. Pinaud
- Department of Cardiac Surgery, University Hospital, Angers, France, Department of Anaesthesiology, University Hospital, Angers, France, Laboratory of Immunology University Hospital, Angers, France, UMR-CNRS 6214, INSERM 771, University of Angers, Angers, France
| | - JJ Corbeau
- Department of Anaesthesiology, University Hospital, Angers, France
| | - A. Chevailler
- Laboratory of Immunology University Hospital, Angers, France
| | - D. Jolivot
- Department of Cardiac Surgery, University Hospital, Angers, France
| | - A. Ter Minassian
- Department of Anaesthesiology, University Hospital, Angers, France
| | - D. Henrion
- UMR-CNRS 6214, INSERM 771, University of Angers, Angers, France
| | - JL de Brux
- Department of Cardiac Surgery, University Hospital, Angers, France
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Al-Ruzzeh S, Navia JL. The “Off-Label” Role of Recombinant Factor VIIa in Surgery: Is the Problem Deficient Evidence or Defective Concept? J Am Coll Surg 2009; 209:659-67. [DOI: 10.1016/j.jamcollsurg.2009.07.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Revised: 07/20/2009] [Accepted: 07/22/2009] [Indexed: 01/31/2023]
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Warren OJ, Smith AJ, Alexiou C, Rogers PLB, Jawad N, Vincent C, Darzi AW, Athanasiou T. The inflammatory response to cardiopulmonary bypass: part 1--mechanisms of pathogenesis. J Cardiothorac Vasc Anesth 2008; 23:223-31. [PMID: 18930659 DOI: 10.1053/j.jvca.2008.08.007] [Citation(s) in RCA: 219] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Indexed: 01/17/2023]
Affiliation(s)
- Oliver J Warren
- Department of BioSurgery and Surgical Technology, Imperial College London, London, United Kingdom
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Al-Ruzzeh S, Ibrahim K, Navia JL. Con: The Role of Recombinant Factor VIIa in the Control of Bleeding After Cardiac Surgery. J Cardiothorac Vasc Anesth 2008; 22:783-5. [DOI: 10.1053/j.jvca.2008.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Indexed: 11/11/2022]
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Comparison of Blood Activation in the Wound, Active Vent, and Cardiopulmonary Bypass Circuit. Ann Thorac Surg 2008; 86:537-41. [DOI: 10.1016/j.athoracsur.2008.02.076] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2007] [Revised: 02/19/2008] [Accepted: 02/22/2008] [Indexed: 11/19/2022]
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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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Donahue BS, Gailani D, Mast AE. Disposition of tissue factor pathway inhibitor during cardiopulmonary bypass. J Thromb Haemost 2006; 4:1011-6. [PMID: 16689752 DOI: 10.1111/j.1538-7836.2006.01896.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The tissue factor (TF) factor (F) VIIa complex activates coagulation FIX and FX to initiate coagulation, and also cleaves protease activated receptors (PARs) to initiate inflammatory processes in vascular cells. Tissue factor pathway inhibitor (TFPI) is the only specific inhibitor of the TF-FVIIa complex, regulating both its procoagulant and pro-inflammatory properties. Upon heparin infusion during cardiopulmonary bypass (CPB), a heparin releasable pool of endothelial associated TFPI circulates in plasma. Following protamine neutralization of heparin, the plasma TFPI level decreases, but does not return completely to baseline, suggesting that during CPB a fraction of the plasma TFPI becomes heparin-independent. We have investigated the structural and functional properties of plasma TFPI during CPB to further characterize how TFPI is altered during this procedure. METHODS We enrolled 17 patients undergoing first-time cardiac surgery involving CPB. Plasma samples were obtained at baseline, 5 min and 1 h after start of CPB (receiving heparin), 10 min after protamine administration (off CPB) and 24 h following surgery. Samples were analyzed for full-length and free (non-lipoprotein bound) TFPI antigen by enzyme-linked immunosorbent assay (ELISA) and for TFPI anticoagulant activity using an amidolytic assay. Western blot analysis was used to identify TFPI species of varying molecular weights in three additional patients. Dunnett's test for post hoc comparisons was used for statistical analysis. RESULTS The ELISA and Western blot data indicated that an increase in full-length TFPI accounted for most of the heparin releasable TFPI. Following heparin neutralization with protamine, the full-length TFPI antigen returned to baseline levels while the free TFPI antigen and the total plasma TFPI activity remained elevated. This was associated with the appearance of a new 38 kDa form of plasma TFPI identified by Western blot analysis. The 38 kDa form of TFPI did not react with an antibody directed against the C-terminal region of TFPI indicating it has undergone proteolysis within this region. All TFPI measurements returned to baseline 24 h following CPB. CONCLUSIONS During CPB the full-length form of TFPI is the predominant form in plasma because of its prompt release from the endothelial surface following heparin administration. Upon heparin neutralization with protamine, full-length TFPI redistributes back to the endothelial surface. However, a new 38 kDa TFPI fragment is generated during CPB and remains circulating in plasma, indicating that TFPI undergoes proteolytic degradation during CPB. This degradation may result in a decrease in endothelium-associated TFPI immediately post-CPB, and may contribute to the procoagulant and proinflammatory state that often complicates CPB.
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Affiliation(s)
- B S Donahue
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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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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Kalweit G, Bach J, Huwer H, Winning J, Hellstern P. The impact of cardiac ischemia and reperfusion on markers of activated haemostasis and fibrinolysis during cardiopulmonary bypass: comparison of plasma levels in arterial and coronary venous blood. Thromb Res 2005; 116:33-9. [PMID: 15850606 DOI: 10.1016/j.thromres.2004.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2004] [Revised: 09/30/2004] [Accepted: 10/07/2004] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Activation of coagulation and fibrinolysis is common among patients undergoing cardiopulmonary bypass (CPB) surgery. Little is known, however, about the impact of myocardial ischemia and reperfusion on coagulation activation and fibrinolysis in this clinical setting. STUDY DESIGN AND METHODS We determined the levels of coagulation activation and fibrinolysis markers (CAFM) in 19 patients with severe coronary heart disease (CHD) during CPB surgery. FXIIa, tissue factor (TF), FVIIa, tissue plasminogen activator/plasminogen activator inhibitor-1 complexes (tPA/PAI-1), prothrombin fragments 1+2 (F1+2), D-dimers (DD) and plasmin-plasmin inhibitor complexes (PPI) were measured at baseline, prior to and after cardioplegic myocardial ischemia. Simultaneous blood samples were drawn from the aorta and the coronary sinus to evaluate arteriovenous CAFM plasma level gradients. RESULTS Myocardial ischemia induced significant increases in gradients of FXIIa and F1+2 levels across the coronary circulation without influencing systemic levels of these markers significantly. Systemic levels of FXIIa, tPA/PAI-1, F1+2, DD and PPI increased significantly during CPB operation. There was a significant linear correlation between FXIIa, FVIIa, F1+2, DD and PPI. CONCLUSIONS Myocardial ischemia induces contact activation and thrombin generation rather than release of tPA and might thus contribute to postoperative thromboembolic complications. Surgery itself and CPB cause activation of coagulation and fibrinolysis as already described. A significant association between FXIIa, FVIIa, F1+2, DD and PPI suggests a relationship between contact activation, thrombin generation, fibrin formation and fibrinolysis.
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Affiliation(s)
- Gerhard Kalweit
- Clinic of Cardiac and Thoracic Surgery, Voelklingen Heart Centre, Voelklingen, Germany
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Sturk-Maquelin KN, Nieuwland R, Romijn FPHTM, Eijsman L, Hack CE, Sturk A. Pro- and non-coagulant forms of non-cell-bound tissue factor in vivo. J Thromb Haemost 2003; 1:1920-6. [PMID: 12941032 DOI: 10.1046/j.1538-7836.2003.00361.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Concentrations of non-cell-bound (NCB; soluble) tissue factor (TF) are elevated in blood collecting in the pericardial cavity of patients during cardiopulmonary bypass (CPB). Previously, we reported microparticles supporting thrombin generation in such blood samples. In this study we investigated the extent of microparticle association of the NCB form of TF in pericardial and systemic blood, and whether this microparticle-associated form is active in thrombin generation compared with non-microparticle-bound, (fluid-phase) TF. METHODS Systemic and pericardial blood samples were collected before and during CPB from six patients undergoing cardiac surgery. Microparticles were isolated by differential centrifugation and their thrombin-generating capacity measured in a chromogenic assay. Microparticle-associated and fluid-phase forms of NCB TF were measured by ELISA. Microparticle-associated TF was visualized by flow cytometry. RESULTS In pericardial samples, 45-77% of NCB TF was microparticle-associated, and triggered factor VII (FVII)-mediated thrombin generation in vitro. Microparticles from systemic samples triggered thrombin generation independently of FVII, except at the end of bypass (P = 0.003). The fluid-phase form of TF did not initiate thrombin generation. Both forms of NCB TF were, at least in part, antigenically cryptic. CONCLUSIONS We demonstrate the occurrence of two forms of NCB TF. One form, which is microparticle-associated, supports thrombin generation via FVII. The other form, which is fluid-phase, does not stimulate thrombin formation. We hypothesize that the microparticle-associated form of NCB TF may be actively involved in postoperative thromboembolic processes when pericardial blood is returned into the patients.
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Affiliation(s)
- K N Sturk-Maquelin
- Department of Cardiothoracic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Weerwind PW, Lindhout T, Caberg NEH, de Jong DS. Thrombin generation during cardiopulmonary bypass: the possible role of retransfusion of blood aspirated from the surgical field. Thromb J 2003; 1:3. [PMID: 12904260 PMCID: PMC179879 DOI: 10.1186/1477-9560-1-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2003] [Accepted: 07/15/2003] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND: In spite of using heparin-coated extracorporeal circuits, cardiopulmonary bypass (CPB) is still associated with an extensive thrombin generation, which is only partially suppressed by the use of high dosages of heparin. Recent studies have focused on the origins of this thrombotic stimulus and the possible role of retransfused suctioned blood from the thoracic cavities on the activation of the extrinsic coagulation pathway. The present study was designed to find during CPB an association between retransfusion of suctioned blood from the pericardium and pleural space, containing activated factor VIIa and systemic thrombin generation. METHODS: Blood samples taken from 12 consenting patients who had elective cardiac surgery were assayed for plasma factor VIIa, prothrombin fragment 1+2 (F1+2), and thrombin-antithrombin (TAT) concentrations. Blood aspirated from the pericardium and pleural space was collected separately, assayed for F1+2, TAT, and factor VIIa and retransfused to the patient after the aorta occlusion. RESULTS: After systemic heparinization and during CPB thrombin generation was minimal, as indicated by the lower than base line plasma levels of F1+2, and TAT after correction for hemodilution. In contrast, blood aspirated from the thoracic cavities had significantly higher levels of factor VIIa, F1+2, and TAT compared to the simultaneous samples from the blood circulation (P < 0.05). Furthermore, after retransfusion of the suctioned blood (range, 200-1600 mL) circulating levels of F1+2, and TAT rose significantly from 1.6 to 2.9 nmol/L (P = 0.002) and from 5.1 to 37.5 μg/L (P = 0.01), respectively. The increase in both F1+2, and TAT levels correlated significantly with the amount of retransfused suctioned blood (r = 0.68, P = 0.021 and r = 0.90, P = 0.001, respectively). However, the circulating factor VIIa levels did not correlate with TAT and F1+2 levels. CONCLUSIONS: These data suggest that blood aspirated from the thoracic cavities during CPB is highly thrombogenic. Retransfusion of this blood may, therefore, promote further systemic thrombin generation during CPB.
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Affiliation(s)
- Patrick W Weerwind
- Department of Extracorporeal Circulation, University Medical Center Nijmegen, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| | - Theo Lindhout
- Department of Biochemistry, Maastricht University, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
| | - Nicole EH Caberg
- Department of Cardiothoracic Surgery / Extracorporeal Circulation, University Hospital Maastricht, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands
| | - Dick S de Jong
- Department of Cardiothoracic Surgery / Extracorporeal Circulation, University Hospital Maastricht, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands
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Svenmarker S, Engström KG. The inflammatory response to recycled pericardial suction blood and the influence of cell-saving. SCAND CARDIOVASC J 2003; 37:158-64. [PMID: 12881158 DOI: 10.1080/14017430310001465] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate the inflammatory and cellular response attributed to conventional cardiotomy suction vs cell-saver during cardiac surgery. DESIGN Thirty-three (n = 33) low-risk patients admitted for routine coronary artery bypass grafting were randomly assigned to two groups: cardiotomy suction or cell-saver for salvage of pericardial blood. The groups were compared with reference to proinflammatory cytokines, complement activation, leukocyte pattern, and haemolysis during and after cardiopulmonary bypass. RESULTS Pericardial suction blood contained significantly increased concentrations of free plasma haemoglobin, C3a, IL-6, IL-8, TNF-alpha, eosinophils and basophils compared with the systemic circulation. No differences were found for the terminal complement complex and lymphocytes, whereas overall concentrations of leukocytes, platelets and haemoglobin were decreased. Recycling of pericardial suction blood gave no systemic effects except from that of free plasma haemoglobin, which increased significantly. The cell-saver eliminated plasma haemoglobin, but no other effects could be demonstrated. CONCLUSION Cardiotomy suction is a major cause of haemolysis, but contributes insignificantly to the systemic inflammatory response. Treatment of shed mediastinal blood with a cell-saver reduces haemolysis and may lower the dose load of inflammatory components.
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Affiliation(s)
- Staffan Svenmarker
- Department of Surgical and Perioperative Science, Umeå University Hospital, Sweden
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Johnell M, Elgue G, Larsson R, Larsson A, Thelin S, Siegbahn A. Coagulation, fibrinolysis, and cell activation in patients and shed mediastinal blood during coronary artery bypass grafting with a new heparin-coated surface. J Thorac Cardiovasc Surg 2002; 124:321-32. [PMID: 12167793 DOI: 10.1067/mtc.2002.122551] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Heparin coating of the cardiopulmonary bypass circuit is shown to improve the biocompatibility of the surface. We have studied a new heparin surface, the Corline Heparin Surface, applied to a complete set of an extracorporeal device used during coronary artery bypass grafting in terms of activation of inflammation, coagulation, and fibrinolysis in patients and in shed mediastinal blood. METHODS Sixty patients scheduled for coronary artery bypass grafting were randomized to one of 3 groups with heparin-coated devices receiving either a standard, high, or low dose of systemic heparin or to an uncoated but otherwise identical circuit receiving a standard dose of systemic heparin. Samples were drawn before, during, and after the operation from the pericardial cavity and in shed mediastinal blood. No autotransfusion of shed mediastinal blood was performed. RESULTS The Corline Heparin Surface significantly reduced the activation of coagulation, fibrinolysis, platelets, and inflammation compared with that seen with the uncoated surface in combination with a standard dose of systemic heparin during cardiac surgery with cardiopulmonary bypass. Both a decrease and an increase of systemic heparin in combination with the coated heparin surface resulted in higher activation of these processes. A significantly higher expression of all studied parameters was found in the shed mediastinal blood compared with in systemic blood at the same time. CONCLUSIONS The Corline Heparin Surface used in cardiopulmonary bypass proved to be more biocompatible than an uncoated surface when using a standard systemic heparin dose. The low dose of systemic heparin might not be sufficient to maintain the antithrombotic activity, and the high dose resulted in direct cell activation rather than a further anti-inflammatory and anticoagulatory effect.
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Affiliation(s)
- Matilda Johnell
- Department of Medical Sciences, Clinical Chemistry, Laboratory for Coagulation Research, University Hospital, SE-751 85 Uppsala, Sweden
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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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