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Kataria S, Juneja D, Singh O. Redefining haemostasis: Role of rotational thromboelastometry in critical care settings. World J Crit Care Med 2025; 14:102521. [DOI: 10.5492/wjccm.v14.i2.102521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2024] [Revised: 01/20/2025] [Accepted: 02/08/2025] [Indexed: 02/27/2025] Open
Abstract
Management of patients with acute hemorrhage requires addressing the source of bleeding, replenishing blood volume, and addressing any coagulopathy that may be present. Assessing coagulopathy and predicting blood requirements in real-time in patients experiencing ongoing bleeding can pose substantial challenges. In these patients, transfusion concepts based on ratios do not effectively address coagulopathy or reduce mortality. Moreover, ratio-based concepts do not stop bleeding; instead, they just give physicians more time to identify the bleeding source and plan management strategies. In clinical practice, standard laboratory coagulation tests (SLCT) are frequently used to assess various aspects of blood clotting. However, these tests may not always offer a comprehensive understanding of clinically significant coagulopathy and the severity of blood loss. Furthermore, the SLCT have a considerable turnaround time, which may not be ideal for making prompt clinical decisions. In recent years, there has been a growing interest in point-of-care viscoelastic assays like rotational thromboelastometry, which provide real-time, dynamic information about clot formation and dissolution.
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Affiliation(s)
- Sahil Kataria
- Department of Critical Care Medicine, Holy Family Hospital, New Delhi 110025, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
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Noufal Y, Brenneis M, Dargel J, Boettner F, Schmitz F, Rehbein P. Perioperative patient blood management in one-stage bilateral calcar-guided short stem hip arthroplasty. Arch Orthop Trauma Surg 2025; 145:292. [PMID: 40372514 DOI: 10.1007/s00402-025-05912-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2025] [Accepted: 04/29/2025] [Indexed: 05/16/2025]
Abstract
BACKGROUND Total hip arthroplasty is the standard treatment for end stage osteoarthritis of the hip joint. In Germany about 180.000 procedures are performed every year. While most surgeries are performed unilaterally there is an increasing number of single-stage bilateral (SSBL) hip arthroplasties performed. The goal of this study was to demonstrate the safety of SSBL-procedures in terms of blood loss and blood transfusion rates using specific perioperative protocols. METHODS Data were collected from 469 patients who underwent one-stage bilateral hip arthroplasty in a single institution, between 2020 and 2023. The current study included patients who were operated on using a minimal-invasive anterolateral approach with a cementless calcar-guided short stem hip prosthesis. The patient's age, sex, comorbidities, medication and preoperative laboratory parameters were gathered as well as the intraoperative blood loss, postoperative hemoglobin levels, blood transfusions and the perioperative administration of tranexamic acid. RESULTS Out of 469 patients who underwent SSBL hip arthroplasty, nine (1.9%) required blood transfusions after surgery. In total, 14 red blood cell concentrates (RBC) were transfused (0.029 RBCs per patient). The use of tranexamic acid significantly reduced the need for RBCs (p-value 0.018). Female sex, older age (> 76 years), low body mass index and body weight as well as lower preoperative hemoglobin levels were associated with an increased risk of RBC transfusion. DISCUSSION This study demonstrated that SSBL hip arthroplasty, when combined with a minimally invasive approach (anterolateral in supine position), cementless short stem implants, and optimized blood management (including the use of tranexamic acid), is a safe procedure in terms of blood loss and transfusion risk.
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Nwose EU, Bwititi PT. Correlation Between Blood Coagulation Profile and Viscosity: Clinical Laboratory Observational Study. Med Sci (Basel) 2025; 13:20. [PMID: 39982245 PMCID: PMC11843925 DOI: 10.3390/medsci13010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Revised: 01/31/2025] [Accepted: 02/13/2025] [Indexed: 02/22/2025] Open
Abstract
Whole blood viscosity is a test for blood stasis and is an ideal evidence-based pathology parameter that is largely undervalued and retrogressing in clinical utilization. Coagulation profiles as indices of haemostasis are available but limited to central or referral laboratories and often involve long turn-around time. It is therefore important to study the correlation between the index of stasis and indices of haemostasis. OBJECTIVE To investigate the correlation of index of stasis with indices of haemostasis. METHOD The clinical laboratory observational research method, using archived pathology data. Indices of haemostasis including activated partial thromboplastin time (APTT) and prothrombin time (PT), the international normalization ratio (INR), and plasma D-dimer were evaluated. On the other hand, the index of blood stasis used was the estimated whole blood viscosity (eWBV) and derived haematocrit and serum protein levels. All (N = 193) tests were collected within a calendar year from the same pathology service, and further, for the correlation, each set of variables from the same blood sample collection was used. RESULTS The haemostasis data are skewed (skewness > 2.0), while eWBV and platelet count are normal (skewness < 2.0). Haemostasis indices have an inverse association with eWBV (p < 0.001). The concordance and correlation of eWBV with platelet count is positive, weak, and significant (p < 0.001), but negative and negligible with PT and APTT. CONCLUSION There are limitations to the possible correlation between eWBV and haemostasis indices. However, haemostasis indices have inverse associations with eWBV, and the latter can aid in the evaluation of haemostasis hence could be utilized as an alternative or complementary test to haemostasis tests. Research may normalize skewed data to obtain better correlation; therefore, further study is required to advance discourse, giving cognizance to clinical practice.
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Affiliation(s)
- Ezekiel U. Nwose
- School of Health & Medical Sciences, University of Southern Queensland, Toowoomba, QLD 4350, Australia
| | - Phillip T. Bwititi
- School of Dentistry & Medical Sciences, Charles Sturt University, Wagga Wagga, NSW 2650, Australia;
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Fang T, Zhang R, Li Y. Examining the controversies in venous thromboembolism prophylaxis for vascular surgery patients: A critical review. Vascul Pharmacol 2024; 157:107436. [PMID: 39419294 DOI: 10.1016/j.vph.2024.107436] [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: 08/02/2024] [Revised: 10/12/2024] [Accepted: 10/12/2024] [Indexed: 10/19/2024]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a significant concern in vascular surgery due to its potentially severe consequences. Effective prophylactic measures are essential to minimize the risks associated with VTE. However, considerable controversy remains regarding the optimal strategies for VTE prevention in patients undergoing vascular procedures. METHODS This review critically analyzes key clinical research, guidelines, and expert opinions to explore the advantages and limitations of various VTE prophylaxis approaches. The pharmacological and mechanical methods are explored, with a focus on balancing the risk of VTE against the potential for bleeding complications, particularly in high-risk patients. RESULTS The review addresses controversial issues such as the choice of anticoagulants, dosage, timing, and duration of prophylaxis. The lack of consensus in existing guidelines and the variability in clinical practice regarding VTE prevention in vascular surgery patients is highlighted. The role of patient-specific risk factors, including the use of intraoperative anticoagulation and bleeding risks, is also examined. CONCLUSION This review provides a comprehensive evaluation of VTE prophylaxis strategies in vascular surgery, emphasizing the need for individualized, evidence-based approaches. Clarifying these controversies is crucial for optimizing patient outcomes and minimizing both thrombotic and hemorrhagic complications.
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Affiliation(s)
- Tao Fang
- Department of Vascular Surgery, Yantai Mountain Hospital, Yantai, Shandong Province 264001, China
| | - Ran Zhang
- Department of Vascular Surgery, Yantai Mountain Hospital, Yantai, Shandong Province 264001, China
| | - Yanmei Li
- Department of Vascular Surgery, Yantai Mountain Hospital, Yantai, Shandong Province 264001, China.
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Shi Y, Chen S, Liu G, Lian B, Chen Y, Zhang L. Different antithrombotic strategies after coronary artery bypass grafting to prevent adverse events: a retrospective analysis. J Cardiothorac Surg 2024; 19:422. [PMID: 38965617 PMCID: PMC11223268 DOI: 10.1186/s13019-024-02937-y] [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: 02/23/2024] [Accepted: 06/15/2024] [Indexed: 07/06/2024] Open
Abstract
OBJECTIVE Coronary artery bypass grafting (CABG) is associated with antithrombotic therapy in terms of postoperative adverse events; however, it is still unknown whether the early use of such drugs after CABG is safe and effective. In this study, we aim to evaluate the relationship between different postoperative antithrombotic strategies and in-hospital adverse events in patients undergoing isolated coronary artery bypass grafting surgery. METHODS This was a single-center, retrospective cohort analysis of patients undergoing isolated CABG due to coronary artery disease (CAD) between 2001 and 2012. Data were extracted from the Medical Information Mart for Intensive Care III database. The patients involved were divided into the ASA (aspirin 81 mg per day only) or DAPT (aspirin plus clopidogrel 75 mg per day) group according to the antiplatelet strategy. Patients were also stratified into subgroups based on the type of anticoagulation. The in-hospital risk of bleeding and adverse events was investigated and compared between groups. Propensity score matching (PSM) was performed to reduce the potential effects of a selection bias. RESULTS A total of 3274 patients were included in this study, with 2358 in the ASA group and 889 in the DAPT group. Following the PSM, no significant difference was seen in the risk of major bleeding between the two groups according to the PLATO, TIMI or GUSTO criteria. There was no difference in the postoperative mortality. In subgroup analysis, patients given anticoagulant therapy had an increased incidence of bleeding-related events. Multivariable analysis revealed that postoperative anticoagulant therapy and the early use of heparin, but not DAPT, were independent predictors of bleeding-related events. CONCLUSIONS Postoperative DAPT was not associated with an increased occurrence of bleeding-related events in patients undergoing isolated CABG and appears to be a safe antiplatelet therapy. The addition of anticoagulants to antiplatelet therapy increased the risk of bleeding and should be considered cautiously in clinical practice.
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Affiliation(s)
- Yi Shi
- Department of Cardiac Surgery, Peking University People's Hospital, Peking University Health and Science Center, Xizhimen St, Beijing, 100044, China
| | - Shenglong Chen
- Department of Cardiac Surgery, Peking University People's Hospital, Peking University Health and Science Center, Xizhimen St, Beijing, 100044, China
| | - Gang Liu
- Department of Cardiac Surgery, Peking University People's Hospital, Peking University Health and Science Center, Xizhimen St, Beijing, 100044, China
| | - Bo Lian
- Department of Cardiac Surgery, Peking University People's Hospital, Peking University Health and Science Center, Xizhimen St, Beijing, 100044, China
| | - Yu Chen
- Cardiac Center, Anhui Second People's Hospital, Hefei City, Anhui, China
| | - Lixue Zhang
- Department of Cardiac Surgery, Peking University People's Hospital, Peking University Health and Science Center, Xizhimen St, Beijing, 100044, China.
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Czerwińska-Jelonkiewicz K, Sanetra K, Buszman PP, Gryszko L, Wood A, Crescenzi O, Milewski K, Buszman PE. Hemostatic disorders in patients with infective endocarditis undergoing urgent surgical valve replacement - Rethinking current beliefs. Int J Cardiol 2023; 388:131112. [PMID: 37343789 DOI: 10.1016/j.ijcard.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/19/2023] [Accepted: 06/02/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Although infective endocarditis (IE) represents a unique model of thrombo-inflammatory disease, the most frequent early complications of surgical valve replacement (SVR) in IE population are coagulopathy and bleeding. The hemostatic capacity and procedure-related coagulation disorders of IE patients undergoing SVR are unknown. The aims of this study were to test periprocedural hemostasis in IE patients undergoing urgent SVR, and to assess the association between disorders of hemostasis and early bleeding as well as with thromboembolic events. METHODS A prospective, two-center, hypothesis generating, observational study was performed between Dec 2017 and Jan 2020. Periprocedural hemostasis of IE patients was assessed using Total Thrombus-formation Analysis System (T-TAS Plus) within 24 h before and 72 h post SVR. RESULTS Overall, 25 patients with active IE undergoing urgent SVR were tested. Hemostatic capacity of IE patients was significantly impaired pre-SVR as well as post-SVR compared to normal values, in most aspects of T-TAS assays under high and low shear forces, including prolonged activation of coagulation (T10), final clot formation (OT) and clot strength (AUC30). Post-SVR T-TAS results were significantly associated with early bleeding and with red blood cell, platelet, and fresh frozen plasma administration. No association with thrombo-embolic events was found. CONCLUSIONS Patients with active IE undergoing urgent SVR have significantly reduced hemostatic capacity before and after SVR. Hemostatic insufficiency post-SVR is related to bleeding and blood products transfusion. T-TAS may be helpful in assessment of periprocedural hemostasis in patients with IE undergoing SVR.
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Affiliation(s)
- Katarzyna Czerwińska-Jelonkiewicz
- Division of Cardiology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; Adults Intensive Care Unit, Royal Brompton and Harefiled Hospitals, NHS Foundation Trust, London, United Kingdom.
| | - Krzysztof Sanetra
- Division of Cardiology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; Department of Cardiac Surgery, American Heart of Poland Inc., Bielsko-Biała, Poland
| | - Piotr P Buszman
- Division of Cardiology, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland; Center for Cardiovascular Research and Development, American Heart of Poland Inc., Poland
| | - Leszek Gryszko
- Department of Cardiac Surgery, Military Institute of Medicine, Warsaw, Poland
| | - Alice Wood
- Cardiology Department, Glenfield Hospital, Leicester, United Kingdom
| | - Oliviero Crescenzi
- Department of Anaesthesia and Critical Care, Royal Brompton and Harefiled Hospitals, NHS Foundation Trust, London, United Kingdom
| | - Krzysztof Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland Inc., Poland
| | - Paweł E Buszman
- Medical University of Silesia, Epidemiology Department, Katowice, Poland
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Mihaljevic MZ, Petricevic M, Konosic S, Svetina L, Urlic M, Starcevic Z, Krzelj K, Milosevic M, Kalamar V, Gasparovic H, Biocina B. The Association between Glycosylated Hemoglobin Level and Platelets Reactivity in Patients with Diabetes Mellitus Undergoing Elective Coronary Artery Bypass Grafting. Thorac Cardiovasc Surg 2023; 71:469-482. [PMID: 35752164 DOI: 10.1055/s-0042-1748768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Diabetic patients tend to have increased platelet reactivity after coronary artery bypass grafting (CABG). The aim of this study was to determine the association between hemoglobin A1c (HbA1c) values and platelet reactivity and to evaluate the consequent impact on clinical outcomes in patients undergoing CABG. METHODS This prospective observational trial consecutively enrolled 225 diabetic patients undergoing CABG, between February 2014 and October 2018. HbA1c levels and platelet function (multiple electrode aggregometry [MEA]) were analyzed the day before surgery and on postoperative day 4 (POD 4). Patients were divided into two groups according to the HbA1c value: HBA1c < 7% and HbA1c ≥ 7%. RESULTS Significantly higher postoperative ASPI (platelet function test based on arachidonic acid) and ADP (platelet function test based on adenosine diphosphate) test values were observed at POD 4 compared with preoperative values (ASPI test: p < 0.001; ADP test: p < 0.001). The prevalence of preoperative aspirin resistance (AR) was 46.4% relative to 57.2% after surgery showing consistent increase in postoperative AR by approximately 10%. In addition, the prevalence of AR in the HbA1c < 7% group was higher by 10% compared with the HbA1c ≥ 7% group, both before and after surgery. We did not demonstrate differences in clinical outcomes between the HbA1c groups. CONCLUSION Perioperative assessment of platelet reactivity in diabetic patients detects those with AR who may be at increased risk of adverse ischemic events. A personalized approach guided by MEA and administration of early and more potent antiaggregation therapy after CABG can be beneficial in this group of patients.
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Affiliation(s)
- Martina Zrno Mihaljevic
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Mate Petricevic
- Department of Cardiac Surgery, University Department of Health Studies, University of Split, UHC Zagreb, Split, Croatia
| | - Sanja Konosic
- Department of Anesthesiology, University Clinical Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Lucija Svetina
- Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Marjan Urlic
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Zrinka Starcevic
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Kristina Krzelj
- Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Milan Milosevic
- Andrija Stampar Teaching Institute of Public Health, Zagreb, Croatia
| | - Viktor Kalamar
- Department of Thoracic Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery, University Clinical Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
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Truckenmueller P, Fritzsching J, Schulze D, Früh A, Jacobs S, Ahlborn R, Vajkoczy P, Prinz V, Hecht N. Outcome and management of decompressive hemicraniectomy in malignant hemispheric stroke following cardiothoracic surgery. Sci Rep 2023; 13:12994. [PMID: 37563196 PMCID: PMC10415332 DOI: 10.1038/s41598-023-40202-9] [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: 04/10/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023] Open
Abstract
Management of malignant hemispheric stroke (MHS) after cardiothoracic surgery (CTS) remains difficult as decision-making needs to consider severe cardiovascular comorbidities and complex coagulation management. The results of previous randomized controlled trials on decompressive surgery for MHS cannot be generally translated to this patient population and the expected outcome might be substantially worse. Here, we analyzed mortality and functional outcome in patients undergoing decompressive hemicraniectomy (DC) for MHS following CTS and assessed the impact of perioperative coagulation management on postoperative hemorrhagic and cardiovascular complications. All patients that underwent DC for MHS resulting as a complication of CTS between June 2012 and November 2021 were included in this observational cohort study. Outcome was determined according to the modified Rankin Scale (mRS) score at 1 and 3-6 months. Clinical and demographic data, anticoagulation management and postoperative hemorrhagic and thromboembolic complications were assessed. In order to evaluate a predictive association between clinical and radiological parameters and the outcome, we used a multivariate logistic regression analysis. Twenty-nine patients undergoing DC for MHS after CTS with a female-to-male ratio of 1:1.9 and a median age of 60 (IQR 49-64) years were identified out of 123 patients undergoing DC for MHS. Twenty-four patients (83%) received pre- or intraoperative substitution. At 30 days, the in-hospital mortality rate and neurological outcome corresponded to 31% and a median mRS of 5 (5-6), which remained stable at 3-6 months [Mortality: 42%, median mRS: 5 (4-6)]. Postoperatively, 15/29 patients (52%) experienced new hemorrhagic lesions and Bayesian logistic regression predicting mortality (mRS = 6) after imputing missing data demonstrated a significantly increased risk for mortality with longer aPPT (OR = 13.94, p = .038) and new or progressive hemorrhagic lesions after DC (OR = 3.03, p = .19). Notably, all but one hemorrhagic lesion occurred before discontinued anticoagulation and/or platelet inhibition was re-initiated. Despite perioperative discontinuation of anticoagulation and/or platelet inhibition, no coagulation-associated cardiovascular complications were noted. In conclusion, Cardiothoracic surgery patients suffering MHS will likely experience severe neurological disability after DC, which should remain a central aspect during counselling and decision-making. The complex coagulation situation after CTS, however, should not per se rule out the option of performing life-saving surgical decompression.
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Affiliation(s)
- Peter Truckenmueller
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Jonas Fritzsching
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Daniel Schulze
- Institute of Medical Biometrics and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anton Früh
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Robert Ahlborn
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Vincent Prinz
- Department of Neurosurgery, Goethe Universität Frankfurt, Frankfurt am Main, Germany
| | - Nils Hecht
- Department of Neurosurgery and Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
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Cartwright B, Mundell N. Anticoagulation for cardiopulmonary bypass: part one. BJA Educ 2023; 23:110-116. [PMID: 36844440 PMCID: PMC9947996 DOI: 10.1016/j.bjae.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 01/25/2023] Open
Affiliation(s)
- B. Cartwright
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- University of Sydney, Sydney, NSW, Australia
| | - N. Mundell
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Yao Y, Li X, Wang Z, Xu S, Lv Q. The impact of high on-treatment platelet reactivity and fibrinogen levels on ischemic events in patients with ST elevation myocardial infarction: a prospective observational study. Int J Clin Pharm 2023; 45:461-472. [PMID: 36639521 DOI: 10.1007/s11096-022-01525-1] [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: 08/16/2022] [Accepted: 11/28/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND After treatment, high residual platelet reactivity (HRPR) is considered as an essential risk factor for recurrent ischemic events. AIM To evaluate the impact of fibrinogen on HRPR after implantation of emergency drug-eluting stents (DES) in patients treated with aspirin and clopidogrel or ticagrelor due to ST-elevation myocardial infarction (STEMI) and to explore the predictive values of HRPR and fibrinogen for adverse ischemic events at 12 months. METHOD This single-center prospective observational study analyzed patients with STEMI who underwent primary percutaneous coronary intervention (PCI) with second-generation DES implantation from January 2017 to December 2018. Platelet reactivity was measured by thromboelastography (TEG) at 60-72 h after primary PCI. HRPR was defined as the adenosine diphosphate-induced maximum amplitude (MAADP) > 47 mm. RESULTS A total of 919 patients were analyzed, of which 512 (55.8%) received aspirin and clopidogrel and 406 (44.2%) received aspirin and ticagrelor. Elevated fibrinogen levels were associated with an increased prevalence of HRPR (P < 0.001). High fibrinogen (quartile IV, ≥ 410 mg/dL) was an independent risk factor for HRPR after multivariate regression (odds ratio 6.556, 95% confidence interval [CI]: 3.200-13.431, P < 0.001). When analyzed by Kaplan-Meier survival curves, the combination of high fibrinogen and HRPR was strongly predictive for ischemic major adverse cardiac events at 12 months compared to the group without HRPR and with low fibrinogen (hazard ratio 9.681, 95% CI: 4.467-20.98, log-rank P < 0.001). Similar results were confirmed in subgroups according to different dual antiplatelet therapies. CONCLUSION A combination of high fibrinogen and HRPR may identify recurrent adverse ischemic events over 12 months. Ticagrelor exhibited more potent platelet inhibition and a better prognosis than clopidogrel.
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Affiliation(s)
- Yao Yao
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zi Wang
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shikun Xu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China.
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11
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Paleczny S, Fatima R, Amador Y, El Diasty M. Should nasogastric tube be used routinely in patients undergoing cardiac surgery? A narrative review. J Card Surg 2022; 37:5300-5306. [PMID: 36251277 DOI: 10.1111/jocs.17040] [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: 05/27/2022] [Revised: 08/27/2022] [Accepted: 10/05/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIM Nasogastric tube (NGT) use has been common in the immediate postoperative period in surgical patients for decades. Potential advantages include the decompression of gastric contents and the early administration of time-sensitive medications. However, its routine use after cardiac surgery has not been established as a gold standard yet. The NGT use for prevention of postoperative nausea and vomiting has been a matter of debate in literature. Also, NGT use has also been associated with the incidence of some respiratory and gastrointestinal complications and it may be a source of significant pain and discomfort to patients. In this article, we review the current available literature regarding the use of NGT during and immediately after cardiac surgery, with particular emphasis on its potential role in enhanced postoperative recovery. METHODS We performed a database search in October 2021 using Embase, Cochrane Library, and Medline to identify studies that examined the use of NGT in patients that underwent cardiac surgery. Data and literature about NGT's impact on post-operative nausea and vomiting, early administration of medications, interference with imaging, post-operative complications, respiratory complications, gastrointestinal complications, pain and discomfort, and enhanced recovery after surgery were examined. RESULTS Three reports investigating the use of NGT to reduce post-operative nausea and vomiting were examined with sample sizes of 114, 104, and 202. The use of NGT did not significantly reduce the incidence of post-operative nausea and vomiting in 2/3 of the studies: a 2% nausea reduction with NGT (p < 0.05), a 7.7% nausea reduction with NGT (p = 0.6), and a 14% vomiting reduction with NGT (p = 0.007). The prevalence of pneumonia following NGT use has been shown to vary ranging from 4 to 95% with associated mortality rates of 17 to 62%. CONCLUSION Based on our findings, there is currently not sufficient evidence to support the routine use of NGT during cardiac surgery. Further research is needed to establish the role of NGT in this patient population.
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Affiliation(s)
- Sarah Paleczny
- Department of Surgery, Division of Cardiac Surgery, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Rubab Fatima
- Department of Surgery, Division of Cardiac Surgery, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Yannis Amador
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Mohammad El Diasty
- Department of Surgery, Division of Cardiac Surgery, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
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12
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Bartakke AA, Carmona-Garcia P, Fuster-Gonzalez M, Reparaz-Vives X. Manejo anestésico en la cirugía de reparación valvular mitral. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Kainuma A, Ning Y, Kurlansky PA, Wang AS, Latif F, Farr MA, Sayer GT, Uriel N, Takayama H, Naka Y, Takeda K. Deep vein thrombosis and pulmonary embolism after heart transplantation. Clin Transplant 2022; 36:e14705. [PMID: 35545895 DOI: 10.1111/ctr.14705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 04/22/2022] [Accepted: 05/03/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important and serious postoperative complication after heart transplantation. We sought to characterize in-hospital VTE after heart transplantation and its association with clinical outcomes. METHOD Adult (≧18 years) patients undergoing heart transplantation from 2015 to 2019 at our center were retrospectively reviewed. Post-transplant VTE was defined as newly diagnosed venous system thrombus by imaging studies. RESULTS There were 254 patients. The cohort's median age was 55 years. A total of 61 patients were diagnosed with VTE, including 1 with right atrial thrombus, 54 with upper extremity DVT in which one patient subsequently developed PE, 4 with lower extremity DVT, and 2 with upper and lower extremity DVT. The cumulative incidence of VTE was 42% at 60-days of post heart transplant. Patients with VTE had longer hospital stay (p<0.001), higher in-hospital mortality (p = 0.010), and worse 5-year survival (p = 0.009). On the multivariable Cox analysis, history of DVT/PE and intubation for more than 3 days were associated with an increased risk of in hospital VTE. CONCLUSION The incidence of VTE in heart transplant recipients is high. Post-transplant surveillance, and appropriate preventive measures and treatment strategies after diagnosis are warranted. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Atsushi Kainuma
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Yuming Ning
- Center for Innovation and Outcomes Research, Columbia University, New York, New York, USA
| | - Paul A Kurlansky
- Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA.,Center for Innovation and Outcomes Research, Columbia University, New York, New York, USA
| | - Amy S Wang
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Farhana Latif
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Maryjane A Farr
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Gabriel T Sayer
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Nir Uriel
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
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Nei SD, Wamsley KS, Mara KC, Stulak JM, Zieminski JJ. Safety Comparison of Monotherapy Aspirin to Dual Antiplatelet Therapy Following Coronary Artery Bypass Surgery. Clin Appl Thromb Hemost 2022; 28:10760296221124902. [PMID: 36112808 PMCID: PMC9478706 DOI: 10.1177/10760296221124902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/13/2022] [Accepted: 08/22/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is recommended over single antiplatelet therapy (SAPT) in patients following coronary artery bypass grafting (CABG). The compilation of evidence has focused on the efficacy of DAPT to limit risk of graft occlusion, however the safety, especially in the on-pump CABG population, is less well described. The aim of this study was to assess the safety of DAPT versus SAPT after on-pump CABG. METHODS This was a single-center, retrospective cohort analysis of adult patients following isolated on-pump CABG between January 2012 and December 2019 not on oral anticoagulation at discharge. The primary endpoint was occurrence of a composite bleeding event identified by pre-specified ICD codes. Secondary endpoints consisted of 30-day and 1-year mortalities along with individual bleeding components. RESULTS Of the 2341 patients included 1250 patients were in the SAPT arm and 1091 patients in the DAPT arm. The study populations differed by age, prior MI, PAD, and CHF status/stage. Bleeding events occurred in a total of 70 patients (3.0%), with 36 patients (2.9%) in the SAPT arm and 34 patients (3.1%) in the DAPT arm (P = .74). 30-day (SAPT 0.7% vs DAPT 0.4%) and 1-year (SAPT 3.3% vs DAPT 2.3%) mortality were not significantly different between groups. The most frequent bleed event was in the gastrointestinal tract. CONCLUSION In this study, DAPT was not associated with an increase in composite bleeding compared to SAPT. This study could reduce the barrier to prescribing of DAPT given previous efficacy data.
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Affiliation(s)
- Scott D. Nei
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | | | - Kristin C. Mara
- Department of Clinical Trials and Biostatistics, Mayo Clinic,
Rochester, MN, USA
| | - John M. Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Trevis J, Akowuah E. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6570807. [PMID: 35439299 PMCID: PMC9419678 DOI: 10.1093/icvts/ivac085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/17/2022] [Accepted: 04/05/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jason Trevis
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, TS4 3BW, UK
- Corresponding author. Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, TS4 3BW, UK. Tel: 01642 850850; e-mail: (J. Trevis)
| | - Enoch Akowuah
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, TS4 3BW, UK
- Newcastle University, Framlington Place, Newcastle-upon-Tyne, NE2 4HH, UK
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How to Handle Arterial Conduits in Liver Transplantation? Evidence From the First Multicenter Risk Analysis. Ann Surg 2021; 274:1032-1042. [PMID: 31972653 DOI: 10.1097/sla.0000000000003753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aims of the present study were to identify independent risk factors for conduit occlusion, compare outcomes of different AC placement sites, and investigate whether postoperative platelet antiaggregation is protective. BACKGROUND Arterial conduits (AC) in liver transplantation (LT) offer an effective rescue option when regular arterial graft revascularization is not feasible. However, the role of the conduit placement site and postoperative antiaggregation is insufficiently answered in the literature. STUDY DESIGN This is an international, multicenter cohort study of adult deceased donor LT requiring AC. The study included 14 LT centers and covered the period from January 2007 to December 2016. Primary endpoint was arterial occlusion/patency. Secondary endpoints included intra- and perioperative outcomes and graft and patient survival. RESULTS The cohort was composed of 565 LT. Infrarenal aortic placement was performed in 77% of ACs whereas supraceliac placement in 20%. Early occlusion (≤30 days) occurred in 8% of cases. Primary patency was equivalent for supraceliac, infrarenal, and iliac conduits. Multivariate analysis identified donor age >40 years, coronary artery bypass, and no aspirin after LT as independent risk factors for early occlusion. Postoperative antiaggregation regimen differed among centers and was given in 49% of cases. Graft survival was significantly superior for patients receiving aggregation inhibitors after LT. CONCLUSION When AC is required for rescue graft revascularization, the conduit placement site seems to be negligible and should follow the surgeon's preference. In this high-risk group, the study supports the concept of postoperative antiaggregation in LT requiring AC.
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Nair D, Sreejith N, Bhambra A, Bruce J, Mellor S, Brown LJ, Harky A. Cardiac Surgery in Patients With Blood Disorders. Heart Lung Circ 2021; 31:167-176. [PMID: 34686413 DOI: 10.1016/j.hlc.2021.09.013] [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: 06/27/2021] [Revised: 08/18/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
Blood disorders that can contribute to abnormal bleeding can have a detrimental effect during cardiac surgery. Patients who are known to have such pathologies should be investigated thoroughly and cautious measures would need to be taken when cardiac surgery is needed in this cohort. The majority of current literature for cardiac surgery in patients with von Willebrand Disease and haemophilia are case reports. Nevertheless, evidence shows that optimising factor levels pre, intra and postoperatively offers outcomes similar to that of patients without these disorders. Preoperative screening followed by appropriate iron therapy reduces mortality for patients with anaemia. In this group, haemoglobin levels can be improved postoperatively through iron supplementation. The management strategy of cardiac surgery for people with blood disorders requires a multidisciplinary approach that is highly individualised for each patient. It is essential to adequately adjust preoperative, perioperative and postoperative care to the patient's blood disorder in order to achieve outcomes similar to that of patients without blood disorders.
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Affiliation(s)
- Devika Nair
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Amman Bhambra
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jonathan Bruce
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sophie Mellor
- Sandwell & West Birmingham NHS Trust, Sandwell General Hospital, West Bromwich, UK
| | - Louise J Brown
- North Cumbria Integrated Care NHS Foundation Trust, Cumberland Infirmary, Carlisle, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK; Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, UK.
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Tajchman DH, Nabi H, Aslam M, Butt JH, Grove EL, Engstrøm T, Holmvang L, Fosbøl EL, Køber L, Sørensen R. Initiation of and persistence with P2Y12 inhibitors in patients with myocardial infarction according to revascularization strategy: a nationwide study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:774-786. [PMID: 34570197 DOI: 10.1093/ehjacc/zuab043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/24/2021] [Accepted: 05/26/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND We aimed to analyse initiation of and persistence with P2Y12 inhibitors after first-time myocardial infarction (MI). METHODS AND RESULTS Using Danish nationwide registries, we identified patients ≥30 years with first-time MI during 1 January 2005-30 June 2016 and subsequent prescriptions of P2Y12 inhibitors. Independent factors related to initiation of and persistence with P2Y12 inhibitors were analysed by multivariable logistic regression and a Cox proportional hazards model. Patients were stratified by revascularization strategy: percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or medical therapy alone (MTA). Overall, 79 597 MI patients were included with 39 172 undergoing PCI, 2619 CABG, and 16 640 MTA, showing initiation of P2Y12 inhibitors of 93.4%, 49.0%, and 51.5%, respectively. Congestive heart failure, cerebrovascular disease, cardiac dysrhythmias, renal failure, previous bleeding, and oral anticoagulants were associated with less initiation of P2Y12 inhibitors. Female sex was associated with less initiation of P2Y12 inhibitors following MTA. MTA, coronary angiography, cerebrovascular disease, diabetes with complications, previous bleeding, antidiabetics, and ticagrelor as P2Y12 inhibitor were associated with non-persistence, whereas female sex, advanced age, and concomitant pharmacotherapy with angiotensin-converting enzyme inhibitors, beta-blockers, statins, oral anticoagulants, and aspirin were associated with high persistence. CONCLUSION Initiation of P2Y12 inhibitors in PCI-treated MI patients was high in contrast to those treated with CABG or MTA and patients with certain comorbidities. Further studies on the benefit-risk ratio of P2Y12 inhibitors in CABG-treated or MTA-treated patients and patients with comorbidities after first-time MI are warranted, as is focus on persistence among patients receiving MTA, patients with comorbidities, and users of ticagrelor.
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Affiliation(s)
- Daniel H Tajchman
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Hafsah Nabi
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Mohsin Aslam
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lene Holmvang
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Johnson SM, Tsang D, Dansby M, Allen C. New and Off-Label Uses of Tranexamic Acid. AACN Adv Crit Care 2021; 32:237-242. [PMID: 34490442 DOI: 10.4037/aacnacc2021193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Stephanie M Johnson
- Stephanie M. Johnson is Postgraduate Year 2 Emergency Medicine Pharmacy Resident, Department of Pharmacy Services, Tampa General Hospital, PO Box 1289, Tampa, FL 33601
| | - Dawn Tsang
- Dawn Tsang is Emergency Medicine Clinical Pharmacist, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida
| | - Mary Dansby
- Mary Dansby is Emergency Medicine Clinical Pharmacist, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida
| | - Christopher Allen
- Christopher Allen is Trauma/Surgical Intensive Care Unit Clinical Pharmacist, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida
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20
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Mach M, Watzal V, Cuhaj C, Hasan W, Poschner T, Szalkiewicz P, Strouhal A, Adlbrecht C, Delle-Karth G, Grabenwöger M, Winkler B. The impact of antiplatelet and antithrombotic regimen after TAVI: Data from the VIenna CardioThOracic Aortic Valve RegistrY (VICTORY). Eur J Clin Invest 2021; 51:e13589. [PMID: 34120335 DOI: 10.1111/eci.13589] [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: 10/28/2020] [Revised: 02/17/2021] [Accepted: 04/11/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND We compared the outcomes and adverse events of TAVI patients based on the discharge and long-term antiplatelet or anticoagulant treatment regimens (single antiplatelet [SAPT] vs. dual antiplatelet [DAPT] vs. anticoagulation [OAC] vs. no treatment [NT]). METHODS The outcome of 532 consecutive patients treated with TAVI was evaluated. As the main study endpoint, the 1-year all-cause mortality was chosen to compare the different discharge treatment regimens and the 3-year all-cause mortality to compare the different long-term treatment regimens. The secondary endpoints were adverse events as defined by the Valve Academic Research Consortium-II. RESULTS One-year survival after TAVI was highest amongst patients treated with DAPT compared to SAPT (P < .001) and OAC (P = .003), and patients under OAC demonstrated improved 1-year survival over patients treated with SAPT (P = .006). Furthermore, there was a strong trend towards improved 3-year survival for patients in the OAC cohort treated with non-vitamin K antagonists compared to vitamin K antagonists (N-VKAs vs. VKA; log-rank P = .056). CONCLUSION The lower all-cause mortality for DAPT within the first year and N-VKAs over VKA within the first 3 years warrant considerable attention in further recommendations of antithrombotic and anticoagulation regimens after TAVI.
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Affiliation(s)
- Markus Mach
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.,Heart Team Vienna, Department of Cardio-Vascular Surgery Clinic Floridsdorf, Karl Landsteiner Institute for Cardio-Vascular Research, Vienna, Austria
| | - Victoria Watzal
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Carina Cuhaj
- Heart Team Vienna, Department of Cardio-Vascular Surgery Clinic Floridsdorf, Karl Landsteiner Institute for Cardio-Vascular Research, Vienna, Austria
| | - Waseem Hasan
- Heart Team Vienna, Department of Cardio-Vascular Surgery Clinic Floridsdorf, Karl Landsteiner Institute for Cardio-Vascular Research, Vienna, Austria.,Imperial College London, London, UK
| | - Thomas Poschner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Philipp Szalkiewicz
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Strouhal
- Department of Cardiology, Clinic Floridsdorf, Karl Landsteiner Institute for Cardiovascular & Intensive Care Research Vienna, Vienna, Austria
| | - Christopher Adlbrecht
- Department of Cardiology, Clinic Floridsdorf, Karl Landsteiner Institute for Cardiovascular & Intensive Care Research Vienna, Vienna, Austria
| | - Georg Delle-Karth
- Department of Cardiology, Clinic Floridsdorf, Karl Landsteiner Institute for Cardiovascular & Intensive Care Research Vienna, Vienna, Austria
| | - Martin Grabenwöger
- Heart Team Vienna, Department of Cardio-Vascular Surgery Clinic Floridsdorf, Karl Landsteiner Institute for Cardio-Vascular Research, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Bernhard Winkler
- Heart Team Vienna, Department of Cardio-Vascular Surgery Clinic Floridsdorf, Karl Landsteiner Institute for Cardio-Vascular Research, Vienna, Austria
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21
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Ozment CP, Scott BL, Bembea MM, Spinella PC. Anticoagulation and Transfusion Management During Neonatal and Pediatric Extracorporeal Membrane Oxygenation: A Survey of Medical Directors in the United States. Pediatr Crit Care Med 2021; 22:530-541. [PMID: 33750092 DOI: 10.1097/pcc.0000000000002696] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare current practices within the United States of anticoagulation management and blood transfusion in neonatal and pediatric extracorporeal membrane oxygenation patients with a 2013 international report. DESIGN Cross-sectional survey distributed between August and December 2019. SETTING Extracorporeal Life Support Organization-registered neonatal and pediatric extracorporeal membrane oxygenation centers in the United States. PARTICIPANTS Extracorporeal membrane oxygenation medical directors. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty-three medical directors at 108 centers responded. After removing four duplicate responses, 79 surveys were analyzed. Seventy-nine percent (n = 62) report a written extracorporeal membrane oxygenation protocol for both anticoagulation and blood product management. Ninety-four percent (n = 74) report unfractionated heparin as their primary anticoagulant; the remaining use the direct thrombin inhibitor, bivalirudin. Ninety percent (n = 71) report measuring antifactor Xa levels. Most centers report using a combination of assays to monitor heparin therapy, either antifactor Xa and activated partial thromboplastin time (54%) or more commonly antifactor Xa and activated clotting time (68%). Forty-one percent use viscoelastic tests to aid management. Goal monitoring levels and interventions generated by out of range values are variable. Fifty-one percent will replace antithrombin. Platelet transfusion thresholds vary by age and center with ranges from 50,000 to 100,000 cells/µL. Eighty-two percent of respondents are willing to participate in a randomized controlled trial comparing anticoagulation strategies for patients receiving extracorporeal membrane oxygenation. CONCLUSIONS Compared with the 2013 pediatric population, extracorporeal membrane oxygenation center anticoagulation and blood transfusion approaches continue to vary widely. Most report continued use of heparin as their primary anticoagulant and follow a combination of monitoring assays with the majority using the antifactor Xa assay in their practices, a significant shift from prior results. Antithrombin activity levels and viscoelastic tests are followed by a growing number of centers. Platelet transfusion thresholds continue to vary widely. Future research is needed to establish optimal anticoagulation and blood transfusion management.
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Affiliation(s)
- Caroline P Ozment
- Department of Anesthesiology and Critical Care, Johns Hopkins University, Baltimore, MD
| | - Briana L Scott
- Department of Anesthesiology and Critical Care, Johns Hopkins University, Baltimore, MD
| | - Melania M Bembea
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Philip C Spinella
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 3071] [Impact Index Per Article: 767.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Dimitriadis S, Qian E, Irvine A, Harky A. Secondary Prevention Medications Post Coronary Artery Bypass Grafting Surgery-A Literature Review. J Cardiovasc Pharmacol Ther 2021; 26:310-320. [PMID: 33514291 DOI: 10.1177/1074248420987445] [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] [Indexed: 02/03/2023]
Abstract
Secondary prevention after coronary artery bypass graft (CABG) surgery is imperative in slowing the progression of atherosclerosis in both native and grafted vessels. Aspirin and statins remain the key medications for all patients without significant contraindications. The evidence for dual antiplatelet therapy with clopidogrel is less convincing, but there is hope for newer antiplatelet agents, such as ticagrelor. Meanwhile, β-blockers and angiotensin converting enzyme inhibitors might only offer benefits to specific sub-groups. Post-CABG patients appear to have different medication needs to the general cardiovascular patient and respond differently. In this review, we cover the drug regimens proposed by recent guidelines and the evidence behind their use. Assessing the evidence behind these recommendations, we find that there is an unmet need in some areas for robust population-specific evidence. We hope that future research will address this gap.
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Affiliation(s)
- Stavros Dimitriadis
- 12205Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Evelyn Qian
- 12205Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Amy Irvine
- 12205Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, 8959Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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Papadimas E, Tan YK, Choong AMTL, Kofidis T, Teoh KLK. Anticoagulation After Isolated Mitral Valve Repair: A Systematic Review and Meta-Analysis of Clinical Outcomes. Heart Lung Circ 2020; 30:247-253. [PMID: 33082110 DOI: 10.1016/j.hlc.2020.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/29/2020] [Accepted: 09/06/2020] [Indexed: 11/27/2022]
Abstract
Recommendations from international guidelines on optimal thromboprophylaxis after mitral repair are controversial and based on underpowered observational studies. This study aimed to evaluate the prophylactic use of warfarin after isolated mitral valve repair (MVr). A PubMed, EMBASE and Scopus search for studies in English on postoperative thromboprophylaxis for isolated MVr published to February 2020 was performed. The analysis excluded all studies with combined operations, mitral valve replacement and preoperative or postoperative atrial fibrillation. Clinical endpoints that were studied were thromboembolic events, bleeding complications and mortality. Random effects meta-analyses of the effect of postoperative warfarin use as compared with no warfarin use across all clinical endpoints was conducted. Warfarin use did not confer benefit in terms of thromboembolic prophylaxis after isolated MVr in patients without atrial fibrillation (OR, 0.97; 95% CI, 0.72-1.31). At the same time, it did not increase the risk of bleeding complications (OR, 1.10; 95% CI, 0.53-2.30) or affect overall survival during the follow-up period of the included studies (OR, 1.06; 95% CI, 0.28-4.05). To conclude, warfarin use is not necessary for patients after isolated MVr who remain in sinus rhythm. Recommendations from international guidelines may need to be revisited for this group of patients.
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Affiliation(s)
- Evangelos Papadimas
- Department of Cardiac Thoracic & Vascular Surgery, National University Heart Centre, Singapore.
| | | | - Andrew M T L Choong
- Department of Cardiac Thoracic & Vascular Surgery, National University Heart Centre, Singapore; Cardiovascular Research Institute, National University of Singapore, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Theo Kofidis
- Department of Cardiac Thoracic & Vascular Surgery, National University Heart Centre, Singapore; Yong Loo Lin School of Medicine, Singapore; Cardiovascular Research Institute, National University of Singapore, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kristine L K Teoh
- Department of Cardiac Thoracic & Vascular Surgery, National University Heart Centre, Singapore
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Carretta A, Lapenna E. Venous thromboembolism prophylaxis after minimally-invasive cardiac surgery: harm or benefit? J Thorac Dis 2020; 12:3469-3472. [PMID: 32802423 PMCID: PMC7399420 DOI: 10.21037/jtd.2020.03.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- Angelo Carretta
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.,Department of Thoracic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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29
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Shirozu K, Karashima Y, Yamaura K. Effect of antithrombin in fresh frozen plasma on hemostasis after cardiopulmonary bypass surgery. Perfusion 2020; 36:395-400. [PMID: 32781884 DOI: 10.1177/0267659120948435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Supplementation of fresh frozen plasma immediately after cardiopulmonary bypass is an effective method to enhance clotting ability as coagulation factors are consumed in the extracorporeal circuit during cardiopulmonary bypass. On the other hand, the anticoagulation factors in fresh frozen plasma can also deter the clotting ability. This study investigated the effect of fresh frozen plasma administration on the comprehensive clotting ability following cardiopulmonary bypass. METHODS This prospective observational study included 22 patients scheduled for cardiac surgery. Clotting times and maximum clot firmness were evaluated using the types of rotational thromboelastometry, intrinsic rotational thromboelastometry, and heparinase thromboelastography preoperatively, immediately after cardiopulmonary bypass, and 1 hour after cardiopulmonary bypass. Activated clotting time, antithrombin activity, and heparin concentration were also measured at these time-points. RESULTS Antithrombin activity (62.9 ± 7.2% vs. 51.1 ± 7.4%, p < 0.0001) and activated clotting time (132.6 ± 9.6% vs. 120.0 ± 9.0%, p < 0.001) were significantly higher 1 hour after cardiopulmonary bypass compared to measurements taken immediately after cardiopulmonary bypass. Heparin concentration 1 hour after cardiopulmonary bypass was significantly decreased compared to that immediately after cardiopulmonary bypass. On the other hand, maximum clot firmness determined via intrinsic rotational thromboelastometry was significantly greater 1 hour after cardiopulmonary bypass (53.8 ± 4.8 mm) than that immediately after cardiopulmonary bypass (49.5 ± 4.8 mm). Clotting time determined via intrinsic rotational thromboelastometry and heparinase thromboelastography was also significantly shorter 1 hour after cardiopulmonary bypass than that immediately after cardiopulmonary bypass. CONCLUSION Fresh frozen plasma administration increased antithrombin activity and caused activated clotting time prolongation, but then increased clotting ability. Thus, testing by rotational thromboelastometry after cardiopulmonary bypass could be valuable in the detection of comprehensive clotting ability.
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Affiliation(s)
- Kazuhiro Shirozu
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Yuji Karashima
- Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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30
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Gencpinar T, Bayrak S, Bilen C, Kemahli B, Akokay P, Baris M, Erdal C. Effect of bivalirudin on neointimal hyperplasia and endothelial proliferation in rabbit. Gen Thorac Cardiovasc Surg 2020; 69:425-433. [PMID: 32748197 DOI: 10.1007/s11748-020-01454-8] [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: 06/16/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to investigate the effects of bivalirudin on endothelial cell proliferation and neointimal hyperplasia in a rabbit carotid artery model. METHODS "New Zealand rabbits (n = 12)" weighing 2-3 kg were randomly divided into two groups. Arteriotomy was performed to the rabbit carotid artery and closed with continuous suture technique. Group B (n = 6) as a control group received 150 U/kg heparin sodium; however, group A (n = 6) was given 0.75 mg/kg bivalirudin i.v. bolus and infusion 1.75 mg/kg/hour (B01AE06-Bivalirudin 250 mg) during perioperation period. At the end of the 28th day, the carotid artery segment was excised and evaluated histologically. RESULTS All histological and immune staining analyzes were performed by two blind researchers in the treatment of rabbits. In the control group rabbit carotid artery sections, tunica intima was observed to thicken. In the bivalirudin group, intimal hyperplasia was less observed compared to the control group. No significant difference was observed between groups in tunica media thickness. Lumen diameter and lumen area were found to be wider in the experimental group. P value was found to be less than 0.05. CONCLUSION Our study demonstrates that bivalirudin significantly affects and prevents neointimal hyperplasia and endothelial cell proliferation.
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Affiliation(s)
- Tugra Gencpinar
- Department of Cardiovascular Surgery, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey.
| | - Serdar Bayrak
- Department of Cardiovascular Surgery, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Cagatay Bilen
- Department of Cardiovascular Surgery, Behcet Uz Children's Training and Research Hospital, İzmir, Turkey
| | - Baris Kemahli
- Department of Cardiovascular Surgery, Bozyaka Training and Research Hospital, İzmir, Turkey
| | - Pinar Akokay
- Medical Laboratory Technigues Programme, Izmir Kavram Vocational School, İzmir, Turkey
| | - Mustafa Baris
- Department of Radiology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
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Yoon S, Lim J, Park CM, Lee DS, Park JB, Choi K, Yoo K, Gil E, Yoon KW. Thromboelastographic Evaluation in Patients with Severe Sepsis or Septic Shock: A Preliminary Analysis. JOURNAL OF ACUTE CARE SURGERY 2020. [DOI: 10.17479/jacs.2020.10.2.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Li W, Wang P, Le S, Xi W, Wang J, Yin L, Wang Q, Zhang Y, Wang Z. Benefits may not outweigh risks of low molecular weight heparin (LMWH) in early postoperative thromboprophylaxis following minimally invasive cardiac surgery: a propensity score-matched analysis. J Thorac Dis 2020; 11:5266-5273. [PMID: 32030244 DOI: 10.21037/jtd.2019.11.56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Whether the benefits of early prophylactic anticoagulation by low molecular weight heparin (LMWH) would outweigh its possible harms in patients after minimally invasive cardiac surgery (MICS) remains contentious. The aims of this study were to define the incidence of venous thromboembolism (VTE) and to assess whether early prophylactic anticoagulation by LMWH postoperatively was indeed effective in reducing VTE without increasing risk of complications after MICS. Methods This investigation was a single-center, retrospective, propensity score-matched analysis study. A total of 473 patients underwent MICS, of whom 257 received prophylactic anticoagulation with LMWH (LMWH group) in the early postoperative period and 216 were not treated with LMWH (Control group). The main outcome measurements included the incidence of embolism events and major bleeding events, the volume of erythrocyte transfusion, the volume of drainage and the duration of drainage after MICS. In addition, the incidence of poor wound healing, the mechanical ventilation time, ICU stay time and postoperative hospitalization time were also documented. Results There were fewer embolic events (P=1.000) and a higher rate of major bleeding events (P=0.008) in the LMWH group than the Control group, and their magnitude and significance were maintained in the propensity matched analysis. In the matched cohorts, there was no significant difference in the total volume of red blood cell transfusion (P=0.552), assisted mechanical ventilation time (P=0.542), and the ICU stay time (P=0.166) between the two groups; while the volume of drainage (P<0.001) and the duration of drainage (P<0.001) in the LMWH group were significantly more than the Control group, and the incidence of poor wound healing (P=0.009) and the postoperative hospitalization time (P<0.001) were significantly increased in the LMWH group. Conclusions Early prophylactic anticoagulation with LMWH could not reduce the incidence of embolism events after MICS. Instead, it might increase postoperative major bleeding events and prolong drainage tube indwelling time and the length of hospital stay.
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Affiliation(s)
- Wei Li
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.,Department of Cardiothoracic Surgery, General Hospital of Central Theater Command, Wuhan 430012, China
| | - Pei Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Shiguan Le
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China.,Department of Surgery, 69220 Hospital of Chinese People's Liberation Army, Kuqa County 842000, China
| | - Wang Xi
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Jing Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Liang Yin
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Qing Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Yufeng Zhang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Zhinong Wang
- Department of Cardiothoracic Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
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Törnudd M, Ramström S, Kvitting JPE, Alfredsson J, Pihl R, Berg S. Protamine stimulates platelet aggregation in vitro with activation of the fibrinogen receptor and alpha-granule release, but impairs secondary activation via ADP and thrombin receptors. Platelets 2020; 32:90-96. [PMID: 31992110 DOI: 10.1080/09537104.2020.1719992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Heparin and protamine are fundamental in the management of anticoagulation during cardiac surgery. Excess protamine has been associated with increased bleeding. Interaction between protamine and platelet function has been demonstrated but the mechanism remains unclear. We examined the effect of protamine on platelet function in vitro using impedance aggregometry, flow cytometry, and thrombin generation. Platelets were exposed to protamine at final concentrations of 0, 20, 40, and 80 µg/mL, alone or together with adenosine diphosphate (ADP) or thrombin PAR1 receptor-activating peptide (TRAP). We found that in the absence of other activators, protamine (80 µg/mL) increased the proportion of platelets with active fibrinogen receptor (binding of PAC-1) from 3.6% to 97.0% (p < .001) measured with flow cytometry. Impedance aggregometry also increased slightly after exposure to protamine alone. When activated with ADP or TRAP protamine at 80 µg/mL reduced aggregation, from 73.8 ± 29.4 U to 46.9 ± 21.1 U (p < .001) with ADP and from 126.4 ± 16.1 U to 94.9 ± 23.7 U (p < .01) with TRAP. P-selectin exposure (a marker of alpha-granule release) measured by median fluorescence intensity (MFI) increased dose dependently with protamine alone, from 0.76 ± 0.20 (0 µg/mL) to 10.2 ± 3.1 (80 µg/mL), p < .001. Protamine 80 µg/mL by itself resulted in higher MFI (10.16 ± 3.09) than activation with ADP (2.2 ± 0.7, p < .001) or TRAP (5.7 ± 2.6, p < .01) without protamine. When protamine was combined with ADP or TRAP, there was a concentration-dependent increase in the alpha-granule release. In conclusion, protamine interacts with platelets in vitro having both a direct activating effect and impairment of secondary activation of aggregation by other agonists.
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Affiliation(s)
- Mattias Törnudd
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
| | - Sofia Ramström
- Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University , Linköping, Sweden.,Cardiovascular Research Centre, School of Medical Sciences, Örebro University , Örebro, Sweden
| | | | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
| | - Richard Pihl
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden.,Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University , Linköping, Sweden
| | - Sören Berg
- Department of Cardiothoracic and Vascular Surgery and Department of Medical and Health Sciences, Linköping University , Linköping, Sweden
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Chlebowski MM, Baltagi S, Carlson M, Levy JH, Spinella PC. Clinical controversies in anticoagulation monitoring and antithrombin supplementation for ECMO. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:19. [PMID: 31959232 PMCID: PMC6971875 DOI: 10.1186/s13054-020-2726-9] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/01/2020] [Indexed: 12/15/2022]
Abstract
During extracorporeal membrane oxygenation (ECMO), a delicate balance is required to titrate systemic anticoagulation to prevent thrombotic complications within the circuit and prevent bleeding in the patient. Despite focused efforts to achieve this balance, the frequency of both thrombotic and bleeding events remains high. Anticoagulation is complicated to manage in this population due to the complexities of the hemostatic system that are compounded by age-related developmental hemostatic changes, variable effects of the etiology of critical illness on hemostasis, and blood-circuit interaction. Lack of high-quality data to guide anticoagulation management in ECMO patients results in marked practice variability among centers. One aspect of anticoagulation therapy that is particularly challenging is the use of antithrombin (AT) supplementation for heparin resistance. This is especially controversial in the neonatal and pediatric population due to the baseline higher risk of bleeding in this cohort. The indication for AT supplementation is further compounded by the potential inaccuracy of the diagnosis of heparin resistance based on the standard laboratory parameters used to assess heparin effect. With concerns regarding the adverse impact of bleeding and thrombosis, clinicians and institutions are faced with making difficult, real-time decisions aimed at optimizing anticoagulation in this setting. In this clinically focused review, the authors discuss the complexities of anticoagulation monitoring and therapeutic intervention for patients on ECMO and examine the challenges surrounding AT supplementation given both the historical and current perspectives summarized in the literature on these topics.
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Affiliation(s)
- Meghan M Chlebowski
- Department of Pediatrics, Division of Pediatric Cardiology, Cardiovascular Intensive Care Unit, Cincinnati Children's Hospital/University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Sirine Baltagi
- Department of Pediatrics, Division of Critical Care Medicine, St. Joseph's Children's Hospital/University of Pittsburg School of Medicine, Tampa, FL, USA
| | | | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Philip C Spinella
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Havers-Borgersen E, Butt JH, Vinding NE, Torp-Pedersen C, Gislason G, Køber L, Fosbøl EL. Time in therapeutic range and risk of thromboembolism and bleeding in patients with a mechanical heart valve prosthesis. J Thorac Cardiovasc Surg 2020; 159:74-83.e4. [PMID: 30961980 DOI: 10.1016/j.jtcvs.2019.02.061] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 01/24/2019] [Accepted: 02/12/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Oral anticoagulation with vitamin K antagonists is recommended after mechanical heart valve replacement. However, data regarding the association between the quality of vitamin K antagonist treatment and the risk of complications are sparse. METHODS Patients undergoing mechanical heart valve replacement (1997-2012) with available data on international normalized ratio values were identified in Danish registries. The quality of vitamin K antagonist treatment between discharge after valve replacement and 6 months postdischarge (ie, index) was assessed as time in therapeutic range (TTR) ≥70% or <70% reflecting the percentage of time in therapeutic international normalized ratio interval. Patients were followed from index until occurrence of an outcome of interest (ie, thromboembolism and bleeding), death, or end of study (December 31, 2012), whichever came first. The risk of outcomes according to quality of vitamin K antagonist treatment was estimated with multivariable Cox regression. RESULTS In total, 659 patients undergoing mechanical heart valve replacement were included in the study. Median number of international normalized ratio measurements in the 6-month period after surgery was 13 (interquartile range, 8-19). Median TTR was 54.9% (interquartile range, 39.0%-72.9%) and 29.1% of patients had a TTR ≥70%. Median follow-up was 6.1 years. The risk of thromboembolism was significantly lower in the group with TTR ≥70% compared with TTR <70% (hazard ratio, 0.44; 95% confidence interval, 0.22-0.85), whereas no significant difference concerning risk of bleeding among groups was found (hazard ratio, 0.63; 95% confidence interval 0.36-1.08). CONCLUSIONS In patients undergoing mechanical heart valve replacement, TTR <70% in the 6-month period after surgery was associated with an increased risk of thromboembolic events but not bleeding compared with TTR ≥70%.
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Affiliation(s)
- Eva Havers-Borgersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Naja E Vinding
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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36
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Panhwar MS, Ginwalla M, Kalra A, Gupta T, Kolte D, Khera S, Bhatt DL, Sabik JF. Association of Acute Venous Thromboembolism With In-Hospital Outcomes of Coronary Artery Bypass Graft Surgery. J Am Heart Assoc 2019; 8:e013246. [PMID: 31533551 PMCID: PMC6806036 DOI: 10.1161/jaha.119.013246] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background While venous thromboembolism (VTE) prophylaxis is a strong recommendation after most surgeries, it is controversial in cardiac surgeries such as coronary artery bypass grafting (CABG), because of perceived low VTE incidence and increased bleeding risk. Prior studies may not have been adequately powered to study outcomes of VTE in this population. We sought to investigate the postoperative incidence and outcomes of CABG patients using a large national inpatient database. Methods and Results We utilized the 2013 to 2014 National Inpatient Sample to identify all patients >18 years of age who underwent CABG (without concomitant valvular procedures), and had VTE during the hospital stay. We then compared clinically relevant outcomes in patients with and without VTE. We identified 331 950 CABG procedures. Of these, 1.3% (n=4205) had VTE. Patients with VTE were more likely to be older (mean 67.2±10.4 years versus 65.2±10.4 years, P<0.001). VTE was associated with higher incidence of inpatient mortality (6.8% versus 1.7%; adjusted odds ratio 1.92 [95% CI 1.40–2.65]; P<0.001) and complications. VTE was also associated with higher cost (mean±SE $81 995±$923 versus $48 909±$55) and longer length of stay (mean±SE 17.06±0.16 days versus 8.52±0.01 days). Conclusions Our analysis of >330 000 CABG procedures suggests that while postoperative VTE after CABG is rare, it is associated with increased morbidity and mortality. Randomized controlled trials are needed to identify optimal strategies for VTE prophylaxis in these patients.
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Affiliation(s)
- Muhammad S Panhwar
- Tulane University Heart and Vascular Institute Tulane University School of Medicine New Orleans LA
| | - Mahazarin Ginwalla
- Division of Cardiovascular Medicine Harrington Heart & Vascular Institute University Hospitals Cleveland Medical Center Case Western Reserve University School of Medicine Cleveland OH
| | - Ankur Kalra
- Department of Cardiovascular Medicine Cleveland Clinic Cleveland Clinic Lerner College of Medicine of Case Western Reserve University Cleveland OH
| | - Tanush Gupta
- Montefiore Medical Center Albert Einstein College of Medicine New York NY
| | - Dhaval Kolte
- Massachusetts General Hospital Harvard Medical School Boston MA
| | - Sahil Khera
- Division of Cardiology Icahn School of Medicine at Mount Sinai New York New York
| | - Deepak L Bhatt
- Brigham & Women's Hospital Heart & Vascular Center Harvard Medical School Boston MA
| | - Joseph F Sabik
- Department of Surgery Harrington Heart & Vascular Institute University Hospitals Cleveland Medical Center Case Western Reserve University School of Medicine Cleveland OH
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Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM. Guidelines for Perioperative Care in Cardiac Surgery. JAMA Surg 2019; 154:755-766. [DOI: 10.1001/jamasurg.2019.1153] [Citation(s) in RCA: 347] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel T. Engelman
- Heart and Vascular Program, Baystate Medical Center, Springfield, Massachusetts
| | | | | | | | - V. Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rakesh C. Arora
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
- Now with Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Ali Khoynezhad
- MemorialCare Heart and Vascular Institute, Los Angeles, California
| | - Marc Gerdisch
- Franciscan Health Heart Center, Indianapolis, Indiana
| | | | - Kevin Lobdell
- Atrium Health, Department of Cardiovascular and Thoracic Surgery, North Carolina
| | - Nick Fletcher
- St Georges University of London, London, United Kingdom
| | - Matthias Kirsch
- Centre Hospitalier Universitaire Vaudois Cardiac Surgery Centre, Lausanne, Switzerland
| | | | | | | | - Edward M. Boyle
- Department of Cardiac Surgery, St Charles Medical Center, Bend, Oregon
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van Valen R, van Gameren M, Mokhles MM, Takkenberg JJM, Ter Horst M, Hofland J, Bogers AJJC. Effectiveness of adherence to a preoperative antiplatelet and anticoagulation cessation protocol in cardiac surgery. Interact Cardiovasc Thorac Surg 2019; 26:820-825. [PMID: 29309597 DOI: 10.1093/icvts/ivx401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/19/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Reduction of blood loss after cardiac surgery remains challenging. The effectiveness of adherence to a protocol on cessation of anticoagulants and platelet-inhibiting medications was investigated together with the influence of protocol violations on blood loss after surgery, use of blood products, surgical re-explorations and 30-day mortality. METHODS Between 2009 and 2013, data were collected prospectively for all elective cardiac surgery procedures in adult patients (n = 1637). Two groups were distinguished: Group 1 adhered to the protocol for cessation or continuation of medication (n = 1287, 79%) and Group 2 violated the protocol (n = 350, 21%). RESULTS Median blood loss was 300 ml (interquartile range 175-500 ml). Eighty patients underwent re-exploration due to blood loss (5%). Thirty-day mortality was 2% (n = 27). Protocol violation was associated with increased blood loss [median 275 ml (175-475 ml) vs 350 ml (250-612); P ≤ 0.001] and with increased average use of fresh frozen plasma (226 ml vs 139 ml; P << 0.00001), red blood cell transfusion (115 ml vs 87 ml; P = 0.081) and thrombocyte transfusions (52 ml vs 37 ml; P = 0.0082). The number of re-explorations (4% vs 6%; P = 0.39) and mortality risk (1% vs 2%; P = 0.72) did not differ. CONCLUSIONS Balancing the benefit of continuing platelet inhibitors or anticoagulants versus cessation before surgery remains challenging. Adherence to the protocol will lead to lower blood loss and in a lower consumption of blood products although the decision to go for re-exploration and 30-day mortality does not differ compared with the protocol violation. Stopping medication does not lead to thromboembolic events.
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Affiliation(s)
- Richard van Valen
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | | | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Jan Hofland
- Department of Anesthesiology, Radboud UMC, Nijmegen, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
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Sotiri I, Robichaud M, Lee D, Braune S, Gorbet M, Ratner BD, Brash JL, Latour RA, Reviakine I. BloodSurf 2017: News from the blood-biomaterial frontier. Acta Biomater 2019; 87:55-60. [PMID: 30660001 DOI: 10.1016/j.actbio.2019.01.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 01/09/2019] [Accepted: 01/14/2019] [Indexed: 12/26/2022]
Abstract
From stents and large-diameter vascular grafts, to mechanical heart valves and blood pumps, blood-contacting devices are enjoying significant clinical success owing to the application of systemic antiplatelet and anticoagulation therapies. On the contrary, research into material and device hemocompatibility aimed at alleviating the need for systemic therapies has suffered a decline. This research area is undergoing a renaissance fueled by recent fundamental insights into coagulation and inflammation that are offering new avenues of investigation, the growing recognition of the limitations facing existing therapeutic approaches, and the severity of the cardiovascular disorders epidemic. This Opinion article discusses clinical needs for hemocompatible materials and the emerging research directions for fulfilling those needs. Based on the 2017 BloodSurf conference that brought together clinicians, scientists, and engineers from academia, industry, and regulatory bodies, its purpose is to draw the attention of the wider clinical and scientific community to stimulate further growth. STATEMENT OF SIGNIFICANCE: The article highlights recent fundamental insights into coagulation, inflammation, and blood-biomaterial interactions that are fueling a renaissance in the field of material hemocompatibility. It will be useful for clinicians, scientists, engineers, representatives of industry and regulatory bodies working on the problem of developing hemocompatible materials and devices for treating cardiovascular disorders.
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Milojevic M, Pisano A, Sousa-Uva M, Landoni G. Perioperative Medication Management in Adult Cardiac Surgery: The 2017 European Association for Cardio-Thoracic Surgery Guidelines. J Cardiothorac Vasc Anesth 2019; 33:304-306. [PMID: 30385193 DOI: 10.1053/j.jvca.2018.09.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Indexed: 12/15/2022]
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Valchanov K, Falter F, George S, Burt C, Roscoe A, Ng C, Besser M, Nasser S. Three Cases of Anaphylaxis to Protamine: Management of Anticoagulation Reversal. J Cardiothorac Vasc Anesth 2019; 33:482-486. [DOI: 10.1053/j.jvca.2018.03.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Indexed: 01/12/2023]
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Czerwińska-Jelonkiewicz K, Cisowski M, Bochenek A, Buszman P, Milewski K, Kunik P, Mularska M, Kocot K, Politowski P, Brączkowski J, Trznadel A, Aboodi MS, Buszman P. Low molecular weight heparin in surgical valve procedures: When and how much for an optimal prophylaxis? Cardiol J 2018; 27:548-557. [PMID: 30484265 DOI: 10.5603/cj.a2018.0146] [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: 09/20/2018] [Revised: 10/26/2018] [Accepted: 11/20/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Periprocedural antithrombotic prophylaxis in patients undergoing surgical valve procedures (SVP) is insufficiently investigated. Low molecular weight heparin (LMWH) has been considered as an alternative to unfractionated heparin (UFH). However, safety and efficacy of this prophylaxis strategy is unknown. This study aimed to investigate safety and efficacy of periprocedural LMWH prophylaxis and determine optimal dosage and timing for periprocedural cessation and initiation. METHODS The present study is a retrospective, single-center observational analysis of 388 patients who underwent SVP (valve replacement or valvuloplasty) between 2015 and 2016. In-hospital endpoints were bleeding, transfusions, reoperation due to bleeding, and thromboembolic events. RESULTS Giving the first dose of LMWH on the day of SVP was a risk factor for bleeding (OR 1.07; 95% CI 1.04-1.10; p < 0.001), transfusions (OR 1.04; 95% CI 1.01-1.07; p = 0.008) and reoperation due to bleeding (OR 1.20; 95% CI 1.12-1.28; p < 0.001), with > 40 mg/day as a predictor. A higher dosage of LMWH premedication was an independent risk factor for bleeding (OR 1.02; 95% CI 1.00-1.04; p = 0.03) and transfusion (OR 1.03; 95% CI 1.01-1.05; p = 0.01), with > 60 mg/day as a predictor for these events. LMWH dosed within 24 h prior to SVP increased the risk of transfusion (AUC 0.636; 95% CI 0.496-0.762; p = 0.04). CONCLUSIONS Bleeding is an important early concern after surgical valve procedures. Safety and efficacy of periprocedural prophylaxis with LMWH depends on dosage and the timing of its administration. The most optimal periprocedural prophylaxis in the SVP population appears to be LMWH in dosage of 40-60 mg/day, which is recommended for deep vein thrombosis prophylaxis, ceased at least one day before SVP.
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Affiliation(s)
| | - Marek Cisowski
- Ist Department of Cardiac Surgery, American Heart of Poland Inc, Armii Krajowej 101, 43-316 Bielsko-Biała, Poland
| | - Andrzej Bochenek
- Ist Department of Cardiac Surgery, American Heart of Poland Inc, Armii Krajowej 101, 43-316 Bielsko-Biała, Poland.,Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland
| | - Piotr Buszman
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland, Poland
| | - Krzysztof Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland, Poland
| | - Piotr Kunik
- Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland
| | | | - Krzysztof Kocot
- Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland
| | - Piotr Politowski
- Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland
| | | | - Agata Trznadel
- Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland
| | - Michael S Aboodi
- Department of Medicine, Montefiore Medical Center, New York, United States
| | - Paweł Buszman
- Medical University of Silesia, Medyków 18, 40-752 Katowice,, Poland.,Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland, Poland
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Redondo Palacios A, Muñoz Pérez R, López Menéndez J, Varela Barca L, Miguelena Hycka J, Martín García M, Fajardo Rodríguez E, Rodríguez-Roda Stuart J, Centella Hernández T. Manejo del tratamiento antitrombótico en cirugía cardiovascular: puntualización sobre el Documento de Consenso acerca del manejo perioperatorio y periprocedimiento del tratamiento antitrombótico. CIRUGIA CARDIOVASCULAR 2018. [DOI: 10.1016/j.circv.2018.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Dimberg A, Alström U, Ståhle E, Christersson C. Higher Preoperative Plasma Thrombin Potential in Patients Undergoing Surgery for Aortic Stenosis Compared to Surgery for Stable Coronary Artery Disease. Clin Appl Thromb Hemost 2018; 24:1282-1290. [PMID: 29768939 PMCID: PMC6714769 DOI: 10.1177/1076029618776374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aortic stenosis (AS) and coronary artery disease (CAD) influence the coagulation system, potentially affecting hemostasis during cardiac surgery. Our aim was to evaluate 2 preoperative global hemostasis assays, plasma thrombin potential and thromboelastometry, in patients with severe aortic valve stenosis compared to patients with CAD. A secondary aim was to test whether the assays were associated with postoperative bleeding. Calibrated automated thrombogram (CAT) in platelet-poor plasma and rotational thromboelastometry (ROTEM) in whole blood were analyzed in patients scheduled for elective surgery due to severe AS (n = 103) and stable CAD (n = 68). Patients with AS displayed higher plasma thrombin potential, both thrombin peak with median 252 nmol/L (interquartile range 187-319) and endogenous thrombin potential (ETP) with median 1552 nmol/L/min (interquartile range 1340-1838), when compared to patients with CAD where thrombin peak was median 174 nmol/L (interquartile range 147-229) and ETP median 1247 nmol/L/min (interquartile range 1034-1448; both P < .001). Differences persisted after adjustment for age, gender, comorbidity, and antithrombotic treatment. Differences observed in thromboelastometry between the groups did not persist after adjustment for baseline characteristics. Bleeding amount showed no relationship with plasma thrombin potential but weakly to thromboelastometry (R2 = .064, P = .001). Patients with AS exhibited preoperatively increased plasma thrombin potential compared to patients with CAD. Plasma thrombin potential was not predictive for postoperative bleeding in patients scheduled for elective surgery.
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Affiliation(s)
- Axel Dimberg
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ulrica Alström
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Elisabeth Ståhle
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Saadeh YS, Savastano LE, Gendreau JL, Pandey AS. Infected symptomatic carotid artery atheroma concurrent with bacterial endocarditis. BMJ Case Rep 2018; 2018:bcr-2017-223604. [PMID: 29545437 DOI: 10.1136/bcr-2017-223604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Optimal management of patients with stroke due to symptomatic carotid artery disease coexistent with bacterial endocarditis is still not well established. We report the case of a patient who presented with multifocal left middle cerebral artery stroke in the setting of Enterococcus faecalis endocarditis and was found to have near-occlusive ipsilateral carotid artery stenosis in stroke workup. Carotid artery endarterectomy was performed, and atheroma material demonstrated complicated plaque with cultures positive for E. faecalis This report demonstrates that patients with cardioembolic disorders such as bacterial endocarditis with vegetations who present with stroke may benefit from evaluation for extracranial vessel stenosis. Also, additional consideration should be given to the possibility of infected atheroma in patients with symptomatic carotid stenosis with recent or active endocarditis or bacteraemia.
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Affiliation(s)
- Yamaan S Saadeh
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Luis E Savastano
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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Meesters MI, Veerhoek D, de Lange F, de Vries JW, de Jong JR, Romijn JWA, Kelchtermans H, Huskens D, van der Steeg R, Thomas PWA, Burtman DTM, van Barneveld LJM, Vonk ABA, Boer C. Effect of high or low protamine dosing on postoperative bleeding following heparin anticoagulation in cardiac surgery. Thromb Haemost 2018; 116:251-61. [DOI: 10.1160/th16-02-0117] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/06/2016] [Indexed: 11/05/2022]
Abstract
SummaryWhile experimental data state that protamine exerts intrinsic anticoagulation effects, protamine is still frequently overdosed for heparin neutralisation during cardiac surgery with cardiopulmonary bypass (CPB). Since comparative studies are lacking, we assessed the influence of two protamine-to-heparin dosing ratios on perioperative haemostasis and bleeding, and hypothesised that protamine overdosing impairs the coagulation status following cardiac surgery. In this open-label, multicentre, single-blinded, randomised controlled trial, patients undergoing on-pump coronary artery bypass graft surgery were assigned to a low (0.8; n=49) or high (1.3; n=47) protamine-to-heparin dosing group. The primary outcome was 24-hour blood loss. Patient haemostasis was monitored using rotational thromboelastometry and a thrombin generation assay. The low protamine-to-heparin dosing ratio group received less protamine (329 ± 95 vs 539 ± 117 mg; p<0.001), while post-protamine activated clotting times were similar among groups. The high dosing group revealed increased intrinsic clotting times (236 ± 74 vs 196 ± 64 s; p=0.006) and the maximum post-protamine thrombin generation was less suppressed in the low dosing group (38 ± 40% vs 6 ± 9%; p=0.001). Postoperative blood loss was increased in the high dosing ratio group (615 ml; 95% CI 500–830 ml vs 470 ml; 95% CI 420–530 ml; p=0.021) when compared to the low dosing group, respectively. More patients in the high dosing group received fresh frozen plasma (11% vs 0%; p=0.02) and platelet concentrate (21% vs 6%; p=0.04) compared to the low dosing group. Our study confirms in vitro data that abundant protamine dosing is associated with increased postoperative blood loss and higher transfusion rates in cardiac surgery.
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Polito MV, Asparago S, Galasso G, Farina R, Panza A, Iesu S, Piscione F. Early myocardial surgical revascularization after ST-segment elevation myocardial infarction in multivessel coronary disease: bridge therapy is the solution? J Cardiovasc Med (Hagerstown) 2018; 19:120-125. [PMID: 29389817 DOI: 10.2459/jcm.0000000000000621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Many ST-segment elevation myocardial infarction (STEMI) patients have a multivessel disease that initially require percutaneous coronary intervention (PCI) of the culprit vessel but subsequently may require coronary artery bypass graft (CABG) of nonculprit vessels. Evidence supports staged revascularization, but the identification of optimal strategies (percutaneous or surgical), the timing and the management of antiplatelet therapy after recent PCI with stenting are matters of great controversies. METHODS In our retrospective registry, we have enrolled 21 patients presenting with STEMI and multivessel disease, who underwent PCI of the culprit vessel only and then CABG of nonculprit vessels. Demographic, clinical, echocardiographic, angiographic findings, preoperative score, surgical data and postoperative complications were collected. At 21.6 ± 15.6 months follow-up death, reinfarction and/or cardiovascular and noncardiovascular events were recorded. RESULTS Patients were 62 ± 9 years old and had in the most cases a good ejection fraction. At angiography, the culprit lesion was right coronary artery in 16 patients (76%). Angiographic characteristics excluded a staged PCI (SYNTAX score = 31.6 ± 7.4) and European System for Cardiac Operative Risk Evaluation II resulted low (1.46 ± 1.01). Following the indication to cardiac surgery after Heart Team discussion, the withdrawal of oral P2Y12 inhibitor was planned and tirofiban intravenous was started. Off-pump CABG was performed after 7.2 ± 3.2 days. No death, reinfarction and/or cardiovascular and noncardiovascular events occurred at follow-up. CONCLUSION We can conclude that a careful preoperative selection is mandatory for a good postoperative course and long-term survival and that early-staged CABG can, however, be performed using bridge therapy, also after STEMI.
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Affiliation(s)
- Maria V Polito
- Department of Medicine and Surgery, University of Salerno
| | | | | | | | - Antonio Panza
- Cardiac Surgery, Heart Department, A.O.U. 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Severino Iesu
- Cardiac Surgery, Heart Department, A.O.U. 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
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The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines ∗ —Anticoagulation During Cardiopulmonary Bypass. Ann Thorac Surg 2018; 105:650-662. [DOI: 10.1016/j.athoracsur.2017.09.061] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/09/2017] [Indexed: 01/01/2023]
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