Anticoagulation management during pulmonary endarterectomy with cardiopulmonary bypass and deep hypothermic circulatory arrest.

Autor:	Veerhoek D; Department of Cardio-Thoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands., van Barneveld LJ; Department of Cardio-Thoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands., Haumann RG; Department of Cardio-Thoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands., Kamminga SK; Department of Anesthesiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands., Vonk AB; Department of Cardio-Thoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands., Boer C; Department of Anesthesiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands., Symersky P; Department of Cardio-Thoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands.
Jazyk:	angličtina
Zdroj:	Perfusion [Perfusion] 2021 Jan; Vol. 36 (1), pp. 87-96. Date of Electronic Publication: 2020 Jun 10.
DOI:	10.1177/0267659120928682
Abstrakt:	Introduction: Pulmonary endarterectomy requires cardiopulmonary bypass and deep hypothermic circulatory arrest, which may prolong the activated clotting time. We investigated whether activated clotting time-guided anticoagulation under these circumstances suppresses hemostatic activation. Methods: Individual heparin sensitivity was determined by the heparin dose-response test, and anticoagulation was monitored by the activated clotting time and heparin concentration. Perioperative hemostasis was evaluated by thromboelastometry, platelet aggregation, and several plasma coagulation markers. Results: Eighteen patients were included in this study. During cooling, tube-based activated clotting time increased from 719 (95% confidence interval = 566-872 seconds) to 1,273 (95% confidence interval = 1,136-1,410 seconds; p < 0.01) and the cartridge-based activated clotting time increased from 693 (95% confidence interval = 590-796 seconds) to 883 (95% confidence interval = 806-960 seconds; p < 0.01), while thrombin-antithrombin showed an eightfold increase. The heparin concentration showed a slightly declining trend during cardiopulmonary bypass. After protamine administration (protamine-to-heparin bolus ratio of 0.82 (0.71-0.90)), more than half of the patients showed an intrinsically activated coagulation test and intrinsically activated coagulation test without heparin effect clotting time >240 seconds. Platelet aggregation through activation of the P2Y12 (adenosine diphosphate test) and thrombin receptor (thrombin receptor activating peptide-6 test) decreased (both -33%) and PF4 levels almost doubled (from 48 (95% confidence interval = 42-53 ng/mL) to 77 (95% confidence interval = 71-82 ng/mL); p < 0.01) between weaning from cardiopulmonary bypass and 3 minutes after protamine administration. Conclusion: This study shows a wide variation in individual heparin sensitivity in patients undergoing pulmonary endarterectomy with deep hypothermic circulatory arrest. Although activated clotting time-guided anticoagulation management may underestimate the level of anticoagulation and consequently result in a less profound inhibition of hemostatic activation, this study lacked power to detect adverse outcomes.
Databáze:	MEDLINE
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