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Levy JH, Sniecinski RM, Maier CL, Despotis GJ, Ghadimi K, Helms J, Ranucci M, Steiner ME, Tanaka KA, Connors JM. Finding a common definition of heparin resistance in adult cardiac surgery: communication from the ISTH SSC subcommittee on perioperative and critical care thrombosis and hemostasis. J Thromb Haemost 2024; 22:1249-1257. [PMID: 38215912 DOI: 10.1016/j.jtha.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 01/14/2024]
Abstract
Ensuring adequate anticoagulation for patients requiring cardiac surgery and cardiopulmonary bypass (CPB) is important due to the adverse consequences of inadequate anticoagulation with respect to bleeding and thrombosis. When target anticoagulation is not achieved with typical doses, the term heparin resistance is routinely used despite the lack of uniform diagnostic criteria. Prior reports and guidance documents that define heparin resistance in patients requiring CPB and guidance documents remain variable based on the lack of standardized criteria. As a result, we conducted a review of clinical trials and reports to evaluate the various heparin resistance definitions employed in this clinical setting and to identify potential standards for future clinical trials and clinical management. In addition, we also aimed to characterize the differences in the reported incidence of heparin resistance in the adult cardiac surgical literature based on the variability of both target-activated clotting (ACT) values and unfractionated heparin doses. Our findings suggest that the most extensively reported ACT target for CPB is 480 seconds or higher. Although most publications define heparin resistance as a failure to achieve this target after a weight-based dose of either 400 U/kg or 500 U/kg of heparin, a standardized definition would be useful to guide future clinical trials and help improve clinical management. We propose the inability to obtain an ACT target for CPB of 480 seconds or more after 500 U/kg as a standardized definition for heparin resistance in this setting.
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Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Roman M Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - George J Despotis
- Departments of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Clinical Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Julie Helms
- University Hospital, Medical Intensive Care Unit, Nouvel Hôpital Civil, Strasbourg, France; French National Institute of Health and Medical Research, Regenerative Nanomedicine, Strasbourg, France
| | - Marco Ranucci
- Department of Cardiothoracic, Anesthesia and Intensive Care, Policlinico San Donato, Milan, Italy
| | - Marie E Steiner
- Department of Pediatrics, Divisions of Hematology/Oncology and Critical Care, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Jean M Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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2
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Yamashiro T, Takami Y, Takagi Y. Contributing factors to heparin resistance during cardiopulmonary bypass. J Artif Organs 2024:10.1007/s10047-024-01435-1. [PMID: 38367099 DOI: 10.1007/s10047-024-01435-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 01/18/2024] [Indexed: 02/19/2024]
Abstract
Since the risk factors for heparin resistance (HR) before cardiopulmonary bypass (CPB) have not been fully clarified, this study investigated the contributing factors for HR after the initial unfractionated heparin (UFH) dose of 500 IU/kg. We retrospectively analyzed the data of 371 patients who underwent CPB surgery, with the initial UFH dose of 500 IU/kg, between May 2017 and December 2021. We defined HR as the failure to achieve activated clotting time (ACT) of > 480 s after the initial UFH dose of 500 IU/kg. HR was observed in 36 patients (9.7%) (HR group), while HR was not observed in 335 patients (control group). The HR group included significantly more patients with preoperative use of UFH, with significantly higher white blood cell counts, fibrinogen, fibrinogen degradation products, D-dimer, and C-reactive protein, and lower hemoglobin and albumin. The multivariable logistic regression analysis identified albumin (OR: 3.09, 95% CI 1.3504-7.0845, p = 0.0075) and fibrinogen (OR: 0.99, 95% CI 0.9869-0.9963, p = 0.0003) as independent predictors for HR. Using the Youden index, the cutoffs of albumin and fibrinogen were calculated as 3.8 g/dL and 303 mg/dL, respectively. The receiver operating characteristic curves showed the predictive performance of albumin (area under the curve (AUC): 0.78, sensitivity: 65%, specificity: 81%) and fibrinogen (AUC: 0.77, sensitivity: 56%, specificity: 88%). The incidence of HR after the initial UFH dose of 500 IU/kg was 9.7%. The preoperative albumin < 3.8 g/dL and fibrinogen > 303 mg/dL were independent predictors for HR.
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Affiliation(s)
- Tomoaki Yamashiro
- Department of Clinical Engineering, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
| | - Yoshiyuki Takami
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan.
| | - Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake, Toyoake, Aichi, 470-1192, Japan
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Ito K, Sasaki K, Ono M, Suzuki T, Sakamoto K, Okamoto H, Katori N, Momose N, Araki Y, Tojo K, Ieko M, Komiyama Y, Saiki Y. Investigation of real-world heparin resistance and anticoagulation management prior to cardiopulmonary bypass: report from a nationwide survey by the Japanese Association for Thoracic Surgery heparin resistance working group. Gen Thorac Cardiovasc Surg 2024; 72:8-14. [PMID: 37195584 PMCID: PMC10766675 DOI: 10.1007/s11748-023-01936-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/14/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE Heparin resistance is often encountered during cardiopulmonary bypass. Heparin dose and activated clotting time target values for the initiation of cardiopulmonary bypass are not yet universally standardized; further no consensus exists on the management of heparin resistance. This study aimed to investigate the current real-world practice on heparin management and anticoagulant treatment for heparin resistance in Japan. METHODS A questionnaire survey was conducted at medical institutions nationwide with which The Japanese Society of Extra-Corporeal Technology in Medicine members are affiliated, targeting surgical cases with cardiopulmonary bypass performed from January 2019 through December 2019. RESULTS Among 69% (230/332) of the participating institutions, the criterion for heparin resistance was defined as "the target activated clotting time value not reached even with an additional dose of heparin administration". Cases of heparin resistance were reported in 89.8% (202/225) of the responded institutions. Of note, 75% (106/141) of the responded institutions reported heparin resistance associated with antithrombin activity ≥ 80%. Antithrombin concentrate was used in 38.4% (238/619 responses) or third dose of heparin in 37.8% (234/619 responses) for advanced heparin resistance treatment. Antithrombin concentrate was found to be effective in resolving heparin resistance in patients having normal, as well as lower antithrombin activity. CONCLUSION Heparin resistance has occurred in many cardiovascular centers, even among patients with normal antithrombin activities. Interestingly, the administration of antithrombin concentrate resolved heparin resistance, regardless of the baseline antithrombin activity value.
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Affiliation(s)
- Koki Ito
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan
| | - Konosuke Sasaki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo, Tokyo, Japan
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Kisaburo Sakamoto
- Department of Cardiovascular Surgery, Mt. Fuji Shizuoka Children's Hospital, Shizuoka, Japan
| | - Hirotsugu Okamoto
- Department of Anesthesiology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Nobuyuki Katori
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoki Momose
- Department of Medical Center, Jichi Medical University, Saitama, Japan
| | - Yasuyuki Araki
- Department of Clinical Engineering, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Keiichi Tojo
- Department of Medical Engineering, Kitasato University Hospital, Sagamihara, Japan
| | - Masahiro Ieko
- Department of Hematology, Iwate Prefectural Chubu Hospital, Kitakami, Japan
| | - Yutaka Komiyama
- Faculty of Health and Medical Sciences, Hokuriku University, Kanazawa, Japan
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryomachi, Aoba-ku, Sendai, 980-8574, Japan.
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Nakatani H, Ida M, Kotani T, Kawaguchi M. Relationship between estimated and observed heparin sensitivity indices in cardiac and thoracic aortic surgery. JA Clin Rep 2023; 9:50. [PMID: 37541982 PMCID: PMC10403474 DOI: 10.1186/s40981-023-00642-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Little evidence exists on the relationship between the estimated heparin sensitivity index (HSI) based on commonly available clinical and laboratory data and observed HSI in the adult population. This retrospective study assessed the relationship between the observed and estimated HSIs. METHODS This study was conducted in an academic, single-institution setting. Patients aged ≥ 20 years who underwent cardiac and thoracic aortic surgery and requiring cardiopulmonary bypass were included. Clinical and laboratory data, including age, sex, and platelet count, were collected. The fibrinogen-albumin ratio index was calculated by dividing the fibrinogen value by the albumin value, multiplied by 10.The HSI was calculated using the formula: (activated clotting time after initial heparin administration-baseline activated clotting time)/initial heparin dose (IU/kg). The estimated HSI was based on the results of multiple regression analysis that included clinically relevant factors. The intraclass correlation coefficient between the observed and estimated HSIs was used to assess. RESULTS In total, 560 patients with valid activated clotting time (ACT) values after initial heparin administration were included in the final analysis to explore associated factors using the estimated HSI. Multiple regression analysis revealed that hemodialysis, platelet count, fibrinogen-to-albumin ratio index, baseline activated clotting time, and initial heparin dose were significantly associated with the HSI. The mean (standard deviation) observed and estimated HSIs were 1.38 (0.43) and 1.55 (0.13), respectively, with an intra-class correlation coefficient of 0.10. CONCLUSIONS The correlation between the observed and estimated HSIs was low, and a formula with high accuracy for estimating the HSI is needed.
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Affiliation(s)
- Hitomi Nakatani
- Department Resource Nurse Center, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- Department of Anesthesiology, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Mitsuru Ida
- Department of Anesthesiology, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan.
| | - Taichi Kotani
- Department of Anesthesiology, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
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5
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Taneja R, Szoke DJ, Hynes Z, Jones PM. Minimum protamine dose required to neutralize heparin in cardiac surgery: a single-centre, prospective, observational cohort study. Can J Anaesth 2023; 70:219-227. [PMID: 36471142 DOI: 10.1007/s12630-022-02364-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Excess protamine contributes to coagulopathy following cardiopulmonary bypass (CPB) and may increase blood loss and transfusion requirements. The primary aim of this study was to find the least amount of protamine necessary to neutralize residual heparin following CPB using the gold standard assays of anti-IIa and anti-Xa activity. Secondary objectives were to evaluate whether the post-CPB activated clotting time could be used as a surrogate marker for quantifying heparin neutralization. METHODS Twenty-eight consecutive patients undergoing elective cardiac surgery were enrolled. Protamine administration was standardized through an infusion pump at 25 mg·min-1. Blood samples were withdrawn prior to and following administration of 150, 200, 250, and 300 mg protamine and analyzed for activated clotting time and anti-IIa and -Xa activity. RESULTS Following a mean (standard deviation) cumulative heparin dose of 67,700 (19,400) units and a CPB duration of 113 (71) min, protamine requirements varied widely. Eight out of 25 (32%) patients showed complete neutralization of anti-IIa and -Xa activity at the first sampling point (150 mg protamine; protamine:heparin ratio, 0.3 [0.1]). A protamine:heparin ratio of 0.5 (0.2) was sufficient for heparin neutralization in > 90% of patients. After CPB, a low to mid-range activated clotting time correlated well with anti-IIa and -Xa activity. CONCLUSIONS The protamine:heparin ratio required to neutralize residual unfractionated heparin (UFH) following CPB is variable. A protamine:heparin ratio of 0.3 was sufficient to neutralize UFH in some patients, while a ratio of 0.5 is sufficient to neutralize both residual anti-IIa and -Xa activity in most patients. Larger studies are necessary to confirm these findings and evaluate their clinical implications. STUDY REGISTRATION ClinicalTrials.gov (NCT03787641); registered 26 December 2018.
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Affiliation(s)
- Ravi Taneja
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada.
- Division of Critical Care, Department of Medicine, London Health Sciences Centre, University Hospital, B2-223, 339 Windermere Road, London, ON, N6A 5A5, Canada.
| | - Daniel J Szoke
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
| | - Zachary Hynes
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
| | - Philip M Jones
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
- Department of Epidemiology & Biostatistics, University of Western Ontario, London, ON, Canada
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Rodgers GM, Mahajerin A. Antithrombin Therapy: Current State and Future Outlook. Clin Appl Thromb Hemost 2023; 29:10760296231205279. [PMID: 37822179 PMCID: PMC10571690 DOI: 10.1177/10760296231205279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 10/13/2023] Open
Abstract
Antithrombin (AT) is a natural anticoagulant pivotal in inactivating serine protease enzymes in the coagulation cascade, making it a potent inhibitor of blood clot formation. AT also possesses anti-inflammatory properties by influencing anticoagulation and directly interacting with endothelial cells. Hereditary AT deficiency is one of the most severe inherited thrombophilias, with up to 85% lifetime risk of venous thromboembolism. Acquired AT deficiency arises during heparin therapy or states of hypercoagulability like sepsis and premature infancy. Optimization of AT levels in individuals with AT deficiency is an important treatment consideration, particularly during high-risk situations such as surgery, trauma, pregnancy, and postpartum. Here, we integrate the existing evidence surrounding the approved uses of AT therapy, as well as potential additional patient populations where AT therapy has been considered by the medical community, including any available consensus statements and guidelines. We also describe current knowledge regarding cost-effectiveness of AT concentrate in different contexts. Future work should seek to identify specific patient populations for whom targeted AT therapy is likely to provide the strongest clinical benefit.
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Affiliation(s)
- George M. Rodgers
- Division of Hematology, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Arash Mahajerin
- Division of Hematology, Children's Hospital of Orange County, Orange, CA, USA
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7
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Chen Y, Phoon PHY, Hwang NC. Heparin Resistance During Cardiopulmonary Bypass in Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:4150-4160. [PMID: 35927191 PMCID: PMC9225936 DOI: 10.1053/j.jvca.2022.06.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/09/2022] [Accepted: 06/17/2022] [Indexed: 12/15/2022]
Abstract
The use of heparin for anticoagulation has changed the face of cardiac surgery by allowing a bloodless and motionless surgical field throughout the introduction of cardiopulmonary bypass (CPB). However, heparin is a drug with complex pharmacologic properties that can cause significant interpatient differences in terms of responsiveness. Heparin resistance during CPB is a weighty issue due to the catastrophic consequences stemming from inadequate anticoagulation, and the treatment of it necessitates a rationalized stepwise approach due to the multifactorial contributions toward this entity. The widespread use of activated clotting time (ACT) as a measurement of anticoagulation during CPB is examined, as it may be a false indicator of heparin resistance. Heparin resistance also has been repeatedly reported in patients infected with COVID-19, which deserves further exploration in this pandemic era. This review aims to examine the variability in heparin potency, underlying mechanisms, and limitations of using ACT for monitoring, as well as provide a framework towards the current management of heparin resistance.
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Affiliation(s)
- Yufan Chen
- Department of Anaesthesiology, Singapore General Hospital, Singapore,Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore
| | - Priscilla Hui Yi Phoon
- Department of Anaesthesiology, Singapore General Hospital, Singapore,Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anesthesia, National Heart Centre, Singapore.
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Fernandez-Turizo MJ, Benavidez-Zora D, Anaya-Hoyos AE, Portillo-Gómez S, Castro-Arias HD. The addition of Tirofiban infusion to heparin for intraoperative heparin resistance associated with Marfan Syndrome. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.5554/22562087.e1035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Marfan syndrome classically presents with aortic root aneurysms. Aortic ectasia causes diverse blood flow alterations, influencing the behavior of coagulation factors and platelet activity. Heparin resistance has also been reported associated with Marfan Syndrome in a small number of patients, probably due to antithrombin III (ATIII) deficiency or various mutations. The ascending aorta and the aortic valve are replaced with prosthetic material during Bentall- de Bonno procedures. Resistance to anticoagulation during extracorporeal circulation, represents a significant challenge for both anesthesiologists and the surgical team. Resistance to heparin was observed in a patient with Marfan syndrome undergoing a Bentall procedure. ATIII concentrate was not available, and ACT did not increase despite high doses of heparin. An alternate anticoagulation approach was used successfully.
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Abstract
The management of infective endocarditis is complex and inherently requires multidisciplinary cooperation. About half of all patients diagnosed with infective endocarditis will meet the criteria to undergo cardiac surgery, which regularly takes place in urgent or emergency settings. The pathophysiology and clinical presentation of infective endocarditis make it a unique disorder within cardiac surgery that warrants a thorough understanding of specific characteristics in the perioperative period. This includes, among others, echocardiography, coagulation, bleeding management, or treatment of organ dysfunction. In this narrative review article, the authors summarize the current knowledge on infective endocarditis relevant for the clinical anesthesiologist in perioperative management of respective patients. Furthermore, the authors advocate for the anesthesiologist to become a structural member of the endocarditis team.
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10
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Zhang X, Guo F, Wang Q, Bai W, Zhao A. Management of heparin resistance due to antithrombin deficiency in a Chinese pregnant woman: a case report. J Int Med Res 2021; 49:3000605211058355. [PMID: 34851773 PMCID: PMC8647273 DOI: 10.1177/03000605211058355] [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] [Indexed: 11/17/2022] Open
Abstract
Untreated individuals with antithrombin (AT) deficiency are at higher risk of thrombosis and adverse pregnancy outcomes. The present recommendations are mostly empirical for treating patients with AT deficiency during pregnancy because of the absence of guidelines. We report a rare case of heparin resistance due to AT deficiency in a pregnant 32-year-old Chinese woman. We also reviewed the English medical literature for AT deficiency and its association with thromboembolism and treatment. This patient suffered two early miscarriages because of thrombosis due to AT deficiency. The patient was administered the combination of adequate low molecular weight heparin with fresh frozen plasma and warfarin because of her heparin resistance. She delivered a healthy female newborn without any adverse effects of the anticoagulation therapy. Our findings suggest that the combination of adequate low molecular weight heparin with fresh frozen plasma and warfarin is effective for preventing thrombus during pregnancy.
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Affiliation(s)
- Xiaoxin Zhang
- Department of Obstetrics and Gynecology, School of Medicine, Renji Hospital, Shanghai JiaoTong University, Shanghai, China.,Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
| | - Feng Guo
- Department of Obstetrics and Gynecology, School of Medicine, Renji Hospital, Shanghai JiaoTong University, Shanghai, China
| | - Qiaohong Wang
- Department of Obstetrics and Gynecology, School of Medicine, Renji Hospital, Shanghai JiaoTong University, Shanghai, China
| | - Wenxin Bai
- Department of Obstetrics and Gynecology, School of Medicine, Renji Hospital, Shanghai JiaoTong University, Shanghai, China
| | - Aimin Zhao
- Department of Obstetrics and Gynecology, School of Medicine, Renji Hospital, Shanghai JiaoTong University, Shanghai, China.,Shanghai Key Laboratory of Gynecologic Oncology, Shanghai, China
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11
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Barga K, Smith A, Faherty M, Crawford K. Evaluation of heparin infusion rates in patients with intravenous drug misuse. J Thromb Thrombolysis 2021; 53:959-964. [PMID: 34807373 PMCID: PMC8607219 DOI: 10.1007/s11239-021-02615-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 01/21/2023]
Abstract
To evaluate the hypothesis that patients with a history of intravenous drug misuse (IVDM) initiated on weight-based heparin infusions require higher than expected infusion rates to achieve therapeutic activated partial thromboplastin time (aPTT). This study is a multicenter, retrospective chart review of patients with a history of IVDM who were admitted to an acute care site between 10/1/2015 and 9/30/2020 and treated with continuous heparin infusions. Patients were identified using ICD9 and ICD10 codes and included if they had a documented history of IVDM within the past six months. Variables of particular interest included: median heparin infusion rates to maintain therapeutic aPTT, average time to reach therapeutic aPTT, and International Society of Thrombosis and Haemostasis Criteria for moderate to severe bleeding. Of the 41 patients who met the inclusion and exclusion criteria, 39 achieved therapeutic aPTT while on a weight-based heparin infusion. All heparin infusions were initiated at a rate of 18 units/kg/hr then titrated per institutional heparin infusion protocols. The mean time to therapeutic aPTT was 38.48 h ± 26.4 h with a mean infusion rate of 27.64 ± 7.14 units/kg/hr. To maintain therapeutic anticoagulation, infusion rates 150% higher than the initial rate were required. Of the 39 patients who achieved therapeutic aPTT, 85% (33) met criteria for heparin resistance, defined as greater than 35,000 units of heparin daily. No statistical significance could be derived from this retrospective chart review as therapeutic heparin rates were evaluated in comparison to initial infusion rate, rather than a control group. The findings in this study demonstrate a possible clinical association of the reduced antithrombin activity previously described in opiate misusers. To efficiently achieve therapeutic anticoagulation, it may be appropriate to consider use of heparin antiXa monitoring in place of aPTT or utilization of increased initial heparin infusion rates.
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Affiliation(s)
- Kenneth Barga
- OhioHealth Riverside Methodist Hospital (Pharmacy Services), Columbus, OH, USA
| | - Adam Smith
- OhioHealth Riverside Methodist Hospital (Pharmacy Services), Columbus, OH, USA
| | - Mallory Faherty
- OhioHealth Riverside Methodist Hospital (OhioHealth Research Institute), Columbus, OH, USA
| | - Katherine Crawford
- OhioHealth Riverside Methodist Hospital (Pharmacy Services), Columbus, OH, USA.
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12
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Abstract
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.
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13
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Chieffo A, Dudek D, Hassager C, Combes A, Gramegna M, Halvorsen S, Huber K, Kunadian V, Maly J, Møller J, Pappalardo F, Tarantini G, Tavazzi G, Thiele H, Vandenbriele C, Van Mieghem NM, Vranckx P, Werner N, Price S. Joint EAPCI/ACVC expert consensus document on percutaneous ventricular assist devices. EUROINTERVENTION 2021; 17:e274-e286. [PMID: 34057071 PMCID: PMC9709772 DOI: 10.4244/eijy21m05_01] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
There has been a significant increase in the use of short-term percutaneous ventricular assist devices (pVADs) as acute circulatory support in cardiogenic shock and to provide haemodynamic support during interventional procedures, including high-risk percutaneous coronary interventions. Although frequently considered together, pVADs differ in their haemodynamic effects, management, indications, insertion techniques, and monitoring requirements. This consensus document summarizes the views of an expert panel by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Association for Acute Cardiovascular Care (ACVC) and appraises the value of short-term pVAD. It reviews the pathophysiological context and possible indications for pVAD in different clinical settings and provides guidance regarding the management of pVAD based on existing evidence and best current practice.
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Affiliation(s)
- Alaide Chieffo
- Interventional Cardiology Unit San Raffaele Scientific Institute - Milan, Italy
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, and Department of Medical Intensive Care Unit, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, F-75013 Paris, France
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål and University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna, and Sigmund Freud University, Medical School, Freudplatz 3, A-1020 Vienna, Austria
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - Jiri Maly
- Cardiac Center, IKEM Prague, Videnska 1958/9, 14021 Prague 4, Czech Republic
| | - Jacob Møller
- Department of Cardiology, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Via Ernesto Triconi 5, 94100 Palermo, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Unit of Anaesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Piazzale Golgi 19, 27100 Pavia, Italy
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Struempellstr 30, 04289 Leipzig, Germany
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium,Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
| | - Nicolas M. Van Mieghem
- Department of Interventional Cardiology, Erasmus University Medical Centre, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium, and Faculty of Medicine and Life Sciences University of Hasselt Martelarenplein 42, 3500 Hasselt, Belgium
| | - Nikos Werner
- Heart Center Trier,Department of Internal Medicine III, Krankenhaus der Barmherzigen Brüder, Nordallee 1, 54292 Trier, Germany
| | - Susanna Price
- Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
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McIlroy DR, Roman B, Billings FT, Bollen BA, Fox A, Geube M, Liu H, Shore-Lesserson L, Zarbock A, Shaw AD. Potential Renoprotective Strategies in Adult Cardiac Surgery: A Survey of Society of Cardiovascular Anesthesiologists Members to Explore the Rationale and Beliefs Driving Current Clinical Decision-Making. J Cardiothorac Vasc Anesth 2021; 35:2043-2051. [PMID: 33674203 PMCID: PMC9933995 DOI: 10.1053/j.jvca.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The authors sought to (1) characterize the rationale underpinning anesthesiologists' use of various perioperative strategies hypothesized to affect renal function in adult patients undergoing cardiac surgery, (2) characterize existing belief about the quality of evidence addressing the renal impact of these strategies, and (3) identify potentially renoprotective strategies for which anesthesiologists would most value a detailed, evidence-based review. DESIGN Survey of perioperative practice in adult patients undergoing cardiac surgery. SETTING Online survey. PARTICIPANTS Members of the Society of Cardiovascular Anesthesiologists (SCA). INTERVENTIONS None. MEASUREMENTS & MAIN RESULTS The survey was distributed to more than 2,000 SCA members and completed in whole or in part by 202 respondents. Selection of target intraoperative blood pressure (and relative hypotension avoidance) was the strategy most frequently reported to reflect belief about its potential renal effect (79%; 95% CI: 72-85). Most respondents believed the evidence supporting an effect on renal injury of intraoperative target blood pressure during cardiac surgery was of high or moderate quality. Other factors, including a specific nonrenal rationale, surgeon preference, department- or institution-level decisions, tradition, or habit, also frequently were reported to affect decision making across queried strategies. Potential renoprotective strategies most frequently requested for inclusion in a subsequent detailed, evidence-based review were intraoperative target blood pressure and choice of vasopressor agent to achieve target pressure. CONCLUSIONS A large number of perioperative strategies are believed to variably affect renal injury in adult patients undergoing cardiac surgery, with wide variation in perceived quality of evidence for a renal effect of these strategies.
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Affiliation(s)
- David R McIlroy
- Vanderbilt University Medical Center, Nashville, TN; Monash University, Commercial Road, Melbourne, Victoria, Australia.
| | - Bennett Roman
- Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121
| | | | - Bruce A Bollen
- Missoula Anesthesiology and The International Heart Institute of Montana, 500 W Broadway St, Missoula, MT 59802
| | - Amanda Fox
- UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Tx, 75390
| | - Mariya Geube
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44122
| | - Hong Liu
- University of California Davis Health, 4150 V Street, Sacramento, CA, 95817
| | - Linda Shore-Lesserson
- Zucker School of Medicine at Hofstra Northwell, 300 Community Drive, Manhasset, NY, 11030
| | | | - Andrew D Shaw
- University of Alberta, 8440-112 Street NW, Edmonton, AB, T6G 2G3, Canada
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15
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Chieffo A, Dudek D, Hassager C, Combes A, Gramegna M, Halvorsen S, Huber K, Kunadian V, Maly J, Møller JE, Pappalardo F, Tarantini G, Tavazzi G, Thiele H, Vandenbriele C, van Mieghem N, Vranckx P, Werner N, Price S. Joint EAPCI/ACVC expert consensus document on percutaneous ventricular assist devices. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:570-583. [PMID: 34057173 DOI: 10.1093/ehjacc/zuab015] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/11/2021] [Indexed: 11/12/2022]
Abstract
There has been a significant increase in the use of short-term percutaneous ventricular assist devices (pVADs) as acute circulatory support in cardiogenic shock and to provide haemodynamic support during interventional procedures, including high-risk percutaneous coronary interventions. Although frequently considered together, pVADs differ in their haemodynamic effects, management, indications, insertion techniques, and monitoring requirements. This consensus document summarizes the views of an expert panel by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Association for Acute Cardiovascular Care (ACVC) and appraises the value of short-term pVAD. It reviews the pathophysiological context and possible indications for pVAD in different clinical settings and provides guidance regarding the management of pVAD based on existing evidence and best current practice.
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Affiliation(s)
- Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland and Maria Cecilia Hospital GVM, Cotignola, Ravenna, Italy
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, and Department of Medical Intensive Care Unit, Cardiology Institute, Pitieé Salpeêtrieère Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, F-75013 Paris, France
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål and University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna, and Sigmund Freud University, Medical School, Freudplatz 3, A-1020 Vienna, Austria
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - Jiri Maly
- Cardiac Center, IKEM Prague, Videnska 1958/9, 14021 Prague 4, Czech Republic
| | - Jacob Eifer Møller
- Department of Cardiology, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Via Ernesto Triconi 5, 94100 Palermo, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Unit of Anaesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Piazzale Golgi 19, 27100 Pavia, Italy
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Struempellstr 30, 04289 Leipzig, Germany
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.,Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
| | - Nicolas van Mieghem
- Department of Interventional Cardiology, Erasmus University Medical Centre, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium, and Faculty of Medicine and Life Sciences University of Hasselt Martelarenplein 42, 3500 Hasselt, Belgium
| | - Nikos Werner
- Heart Center Trier, Department of Internal Medicine III, Krankenhaus der Barmherzigen Brüder, Nordallee 1, 54292 Trier, Germany
| | - Susanna Price
- Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
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16
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Kimura Y, Okahara S, Abo K, Koyama Y, Kuriyama M, Ono K, Hidaka H. Infective Endocarditis Is a Risk Factor for Heparin Resistance in Adult Cardiovascular Surgical Procedures: A Retrospective Study. J Cardiothorac Vasc Anesth 2021; 35:3568-3573. [PMID: 34144872 DOI: 10.1053/j.jvca.2021.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/09/2021] [Accepted: 05/10/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Heparin resistance (HR), defined as a decrease in heparin responsiveness, can result in adverse events with prolonged duration of surgery. Although some clinical risk factors have been suggested, the relationship with the surgical diagnosis is unclear. The aim of present study was to elucidate the clinical predictors of HR including the surgical diagnosis. DESIGN This retrospective cohort study determined the incidence of HR (defined as activated clotting time [ACT] <400 seconds after 250-350 IU/kg of heparin administration) and heparin sensitivity index (HSI) was calculated from the rate of change in ACT per heparin dose. Preoperative demographic data, medication history, and laboratory data also were analyzed. SETTING Single institution, tertiary care hospital. PARTICIPANTS Adult patients who underwent cardiovascular surgery with cardiopulmonary bypass between January 2012 and September 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 287 patients, 88 (30.7%) were classified as HR. In univariate analysis, infective endocarditis (IE), platelet count, and serum fibrinogen and albumin levels were associated with HR. After adjustment for baseline ACT and initial heparin dose, IE (odds ratio 4.57, [95% CI: 1.10-19.1]; p = 0.037) and albumin ≤3.5 g/dL (3.17, [1.46-6.93]; p = 0.004) were associated independently with HR. Patients with IE had significantly lower HSI than those with other diseases. All HR patients were treated with additional heparin, and 17 of them received human antithrombin-III concentrate. CONCLUSIONS Infective endocarditis and preoperative hypoalbuminemia were associated independently with HR. The optimal anticoagulation strategy for patients with these risk factors requires further investigations based on the authors' findings.
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Affiliation(s)
- Yoshikazu Kimura
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan.
| | - Shuji Okahara
- Department of Intensive Care Medicine, Okayama University Hospital, Okayama, Japan
| | - Kanae Abo
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
| | - Yusuke Koyama
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
| | - Mitsuhito Kuriyama
- Department of Cardiovascular Surgery, Saiseikai Imabari Hospital, Ehime, Japan
| | - Kazumi Ono
- Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hidekuni Hidaka
- Department of Anesthesiology and Oncological Pain Medicine, Fukuyama City Hospital, Hiroshima, Japan
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17
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Antiphospholipid Syndrome and Cardiac Bypass: The Careful Balance between Clotting and Bleeding. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:46-49. [PMID: 33814605 DOI: 10.1182/ject-2000040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/29/2020] [Indexed: 11/20/2022]
Abstract
Antiphospholipid syndrome (APS) is an acquired autoimmune condition characterized by the presence of antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibody, and anti-β2 glycoprotein-I antibody) which leads to clinical thrombosis via a multifactorial mechanism of action. Despite the propensity to form clot in vivo, these antibodies interfere with the assembly of the prothrombinase complex on phospholipids in in vitro assays, leading to prolongation of activated clotting time and activated partial thromboplastin time. This disconnect between what occurs in vivo and in vitro makes monitoring anticoagulation during cardiac surgery particularly complex. We present a patient with APS undergoing coronary artery bypass grafting with cardiopulmonary bypass. We delineate our strategy for managing anticoagulation in the presence of this syndrome using the Hepcon Hemostasis Management System Plus (Medtronic, Inc. Minneapolis, MN) device by targeting whole blood heparin concentration to monitor anticoagulation.
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18
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Yoshinaga K, Otsuka Y, Furukawa T, Amitani S, Kimura N, Sanui M. Correlation between activated clotting time monitoring and heparin concentration measurement in a patient with antiphospholipid syndrome during cardiac valve surgery: a case report. JA Clin Rep 2021; 7:24. [PMID: 33715057 PMCID: PMC7956925 DOI: 10.1186/s40981-021-00427-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/18/2021] [Accepted: 03/04/2021] [Indexed: 11/16/2022] Open
Abstract
Background Anticoagulation management of patients with antiphospholipid syndrome (APS) undergoing cardiac surgery is challenging due to the prolongation of activated clotting time (ACT). Currently, no study has compared the utility of ACT monitoring using the Hemochron Jr. Signature+ and that of heparin concentration management using the Hemostasis Management System (HMS) Plus in patients with APS. Case presentation A 71-year-old woman with APS was scheduled to undergo an aortic valve replacement for aortic regurgitation. The ACT was measured using the Hemochron Jr. Signature+, and the heparin concentration was measured concurrently using the HMS Plus. ACT over 480 s corresponded to an adequate heparin concentration during cardiopulmonary bypass. The clinical course was uneventful, and no thrombotic or hemorrhagic complications were observed. Conclusion In the present patient with APS, the Hemochron Jr. Signature+ was useful as an anticoagulation management during cardiac valve surgery.
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Affiliation(s)
- Koichi Yoshinaga
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, 1-847, Amanumacho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan
| | - Yuji Otsuka
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, 1-847, Amanumacho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan.
| | - Taku Furukawa
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, 1-847, Amanumacho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan
| | - Shizuka Amitani
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, 1-847, Amanumacho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care, Jichi Medical University Saitama Medical Center, 1-847, Amanumacho, Omiya-ku, Saitama-city, Saitama, 330-8503, Japan
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19
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Krause M, Morabito JE, Mackensen GB, Perry TE, Bartels K. Current Neurologic Assessment and Neuroprotective Strategies in Cardiac Anesthesia: A Survey to the Membership of the Society of Cardiovascular Anesthesiologists. Anesth Analg 2020; 131:518-526. [PMID: 31880633 DOI: 10.1213/ane.0000000000004601] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Neurologic injury and cognitive disorder after cardiac surgery are associated with morbidity and mortality. Variability in the application of neuroprotective strategies likely exists during cardiac surgery. The Society of Cardiovascular Anesthesiologists (SCA) conducted a survey among its members on common perioperative neuroprotective strategies: assessment of aortic atheromatous burden, management of intraoperative blood pressure, and use of cerebral oximetry. METHODS A 15-item survey was developed by 3 members of the SCA Continuous Practice Improvement - Cerebral Protection Working Group. The questionnaire was then circulated among all working group members, adapted, and tested for face validity. On March 26, 2018, the survey was sent to members of the SCA via e-mail using the Research Electronic Data Capture system. Responses were recorded until April 16, 2018. RESULTS Of the 3645 surveys e-mailed, 526 members responded (14.4%). Most responders worked in academic institutions (58.3%), followed by private practices (38.7%). Epiaortic ultrasound for the assessment of aortic atheromatous burden was most commonly utilized at the surgeon's request (46.5%). Cerebral oximetry was most commonly used in patients with increased perioperative risk of cerebral injury (41.4%). Epiaortic ultrasound (1.9%) and cerebral oximetry (5.2%) were rarely part of a standardized monitoring approach. A majority of respondents (52.0%) reported no standardized management strategies for neuroprotection during cardiac surgery at their institution. A total of 55.3% stated that no standardized institutional guidelines were in place for managing a patient's blood pressure intraoperatively or during cardiopulmonary bypass. When asked about patients at risk for postoperative cerebral injury, 41.3% targeted a blood pressure goal >65 mmHg during cardiopulmonary bypass. The majority of responders (60.4%) who had access to institutional rates of postoperative stroke/cerebral injury had standard neuroprotective strategies in place. CONCLUSIONS Our data indicate that approximately half of the respondents to this SCA survey do not use standardized guidelines/standard operating procedures for perioperative cerebral protection. The lack of standardized neuroprotective strategies during cardiac surgery may impact postoperative neurologic outcomes. Further investigations are warranted and should assess the association of standardized neuroprotective approaches and postoperative neurological outcomes.
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Affiliation(s)
- Martin Krause
- From the Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado
| | - Joseph E Morabito
- From the Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado
| | - G Burkhard Mackensen
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Tjörvi E Perry
- Department of Anesthesiology, University of Minnesota, Medical School, Minneapolis, Minnesota
| | - Karsten Bartels
- From the Department of Anesthesiology, University of Colorado, School of Medicine, Aurora, Colorado
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20
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Houston E, Moran P, Mayhew D. Massive atrial myxoma requiring emergency cardiopulmonary bypass in a patient with heparin resistance. Anaesth Rep 2020; 8:103-106. [PMID: 32789291 DOI: 10.1002/anr3.12063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2020] [Indexed: 11/06/2022] Open
Abstract
Heparin exhibits complex pharmacology with a wide variation in individual response. Despite this, heparin is the most commonly used anticoagulant during cardiopulmonary bypass. Heparin resistance in the context of a patient with severe cardiovascular compromise presents a potentially life-threatening challenge. A 31-year-old woman was listed for emergency excision of a massive left atrial myxoma. On induction of anaesthesia, she developed marked cardiovascular instability secondary to mitral inflow obstruction. An initial heparin dose of 600 units.kg-1 produced an activated clotting time of 360 s; however, immediate cardiopulmonary bypass was required. Heparin resistance remained problematic throughout the procedure, with an inadequate response to antithrombin three supplementation. Despite a total dose of 120,000 units of heparin, anticoagulation was fully reversed with 500 mg protamine and there was no subsequent re-heparinisation. Heparin resistance, when coinciding with profound cardiovascular instability, requires a pragmatic response to expedite establishment of cardiopulmonary bypass whilst minimising potential harm. In this case, successful cardiopulmonary bypass was achieved with additional heparin boluses from an alternative batch administered both intravenously and via the bypass circuit. We therefore advocate consideration of this approach as one possible solution to achieving safe entry onto cardiopulmonary bypass in a crisis scenario.
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Affiliation(s)
- E Houston
- North West (Mersey) Deanery Liverpool UK
| | - P Moran
- North West (Mersey) Deanery Liverpool UK
| | - D Mayhew
- Cardiothoracic Anaesthesia and Intensive Care Medicine Liverpool Heart and Chest Hospital Liverpool UK.,University of Liverpool UK
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21
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Bolliger D, Maurer M, Tanaka KA. Toward Optimal Anticoagulation Monitoring During Cardiopulmonary Bypass: It Is Still A Tough "ACT". J Cardiothorac Vasc Anesth 2020; 34:2928-2930. [PMID: 32741612 DOI: 10.1053/j.jvca.2020.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Markus Maurer
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland Medical Center, Baltimore, Maryland
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22
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Mazzeffi MA, Patel PA, Bolliger D, Erdoes G, Tanaka K. The Year in Coagulation: Selected Highlights From 2019. J Cardiothorac Vasc Anesth 2020; 34:1745-1754. [DOI: 10.1053/j.jvca.2020.01.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 01/27/2020] [Indexed: 12/26/2022]
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23
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Raphael J, Mazer CD, Shore-Lesserson L, Bollen B, Levy JH, Schwann N, Subramani S, Schroeder A, Abdalla M, Ferreira R, Roman PE, Patel N, Welsby I, Greilich PE, Harvey R, Ranucci M, Heller LB, Boer C, Wilkey A, Hill SE, Nuttall GA, Palvadi RR, Patel PA, Wilkey B, Gaitan B, Hill SS, Kwa J, Klick J, Abernathy J, Lau WT. In Response. Anesth Analg 2020; 130:e154-e156. [PMID: 32102015 DOI: 10.1213/ane.0000000000004709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jacob Raphael
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, Department of Anesthesiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, Northshore University Hospital, Manhasset, New York Missoula Anesthesiology, Affiliate with International Heart Institute of Montana at Providence St Patrick Hospital, Missoula, Montana Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina Department of Anesthesiology, Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, Tampa, Florida, AAA Anesthesia Associates, PhyMed Healthcare Group, Allentown, Pennsylvania
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