Accelerated activation of the coagulation pathway during cardiopulmonary bypass in aortic replacement surgery: a prospective observational study.

Hideo Sato,Yoshinori Nakata,Koji Yamamoto,Akihito Kakinuma,Shigehito Sawamura

doi:10.1186/s13019-015-0295-9

Hideo Sato, Yoshinori Nakata + Show 3 more

Open Access

https://doi.org/10.1186/s13019-015-0295-9

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Abstract

BackgroundAny form of surgery or tissue damage causes release of tissue factor into the circulation. This may lead to the accelerated consumption of coagulation factors, resulting in severe consumptive coagulopathy. In this study, we compared the molecular markers involved in coagulation activation during cardiopulmonary bypass (CPB) between patients who underwent aortic replacement surgery and those who underwent valve surgery.MethodsThis prospective observational study was performed in each 14 patients who underwent aortic replacement surgery or valve surgery. We evaluated the differences in the levels of fibrinogen, activated factor VII (FVIIa), thrombin–antithrombin complex (TAT), and soluble fibrin monomer complex (SFMC) during surgery between these two groups.ResultsThe change in fibrinogen levels showed no difference between the groups. The magnitude of increase in TAT was much larger in patients who underwent aortic replacement surgery than in those who underwent valve surgery (173.6 vs. 49.4 ng/mL; p = 0.0001). More importantly, the elevation of FVIIa was significantly higher in patients who underwent aortic replacement (28.5 vs. 19.0 mU/mL; p = 0.0122). The magnitude of increase in SFMC was also larger in the aortic replacement surgery.ConclusionsThe activation of coagulation during CPB was dramatically higher in the aortic replacement surgery compared with the valve surgery, probably owing to the activation of the extrinsic coagulation pathway in the former. This could potentially exacerbate consumptive coagulopathy after CPB termination in patients who underwent aortic replacement, possibly resulting in massive hemorrhage due to impaired hemostasis.

Highlights

Any form of surgery or tissue damage causes release of tissue factor into the circulation
The patient characteristics and preoperative laboratory data showed no significant differences between the groups, except that the thrombin-antithrombin complex (TAT) and soluble fibrin monomer complex (SFMC) levels were significantly higher in the aortic replacement surgery group (Table 1)
No significant differences were observed between the groups except the duration of cardiopulmonary bypass (CPB) time, time required for hemostasis, bleeding and transfusion volumes during surgery (Table 2)

Summary

Introduction

Any form of surgery or tissue damage causes release of tissue factor into the circulation. Sato et al Journal of Cardiothoracic Surgery (2015) 10:84 activates factor VII (FVII) and forms the TF/activated factor VII (FVIIa) complex This complex may generate thrombin massively during CPB despite full heparinization because of the limited thrombin-inhibiting effect and the subsequent soluble fibrin formation of heparin with antithrombin on the extrinsic coagulation pathway. Higher levels of TAT and FVIIa during CPB were observed in patients who underwent aortic replacement surgery compared with those who underwent valve surgery This observation suggests the accelerated activation of coagulation and consumptive coagulopathy, through the activation of the extrinsic coagulation pathway in patients who underwent aortic replacement, possibly resulting in the impaired hemostasis frequently observed in aortic replacement surgery

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