Children undergoing cardiac surgery for complex cardiac defects show imbalance between pro- and anti-thrombotic activity

Ruth Heying,Ralph G Grabitz,Katharina Schumacher,Marie-Christine Seghaye,Bruno J Messmer,Wim Van Oeveren,Stefanie Wilhelm

doi:10.1186/cc5108

Abstract

IntroductionCardiac surgery with cardiopulmonary bypass (CPB) is associated with the activation of inflammatory mediators that possess prothrombotic activity and could cause postoperative haemostatic disorders. This study was conducted to investigate the effect of cardiac surgery on prothrombotic activity in children undergoing cardiac surgery for complex cardiac defects.MethodsEighteen children (ages 3 to 163 months) undergoing univentricular palliation with total cavopulmonary connection (TCPC) (n = 10) or a biventricular repair (n = 8) for complex cardiac defects were studied. Prothrombotic activity was evaluated by measuring plasma levels of prothrombin fragment 1+2 (F1+2), thromboxane B2 (TxB2), and monocyte chemoattractant protein-1 (MCP-1). Anti-thrombotic activity was evaluated by measuring levels of tissue factor pathway inhibitor (TFPI) before, during, and after cardiac surgery.ResultsIn all patients, cardiac surgery was associated with a significant but transient increase of F1+2, TxB2, TFPI, and MCP-1. Maximal values of F1+2, TxB2, and MCP-1 were found at the end of CPB. In contrast, maximal levels of TFPI were observed at the beginning of CPB. Concentrations of F1+2 at the end of CPB correlated negatively with the minimal oesophageal temperature during CPB. Markers of prothrombotic activity returned to preoperative values from the first postoperative day on. Early postoperative TFPI levels were significantly lower and TxB2 levels significantly higher in patients with TCPC than in those with biventricular repair. Thromboembolic events were not observed.ConclusionOur data suggest that children with complex cardiac defects undergoing cardiac surgery show profound but transient imbalance between pro- and anti-thrombotic activity, which could lead to thromboembolic complications. These alterations are more important after TCPC than after biventricular repair but seem to be determined mainly by low antithrombin III.

Highlights

Cardiac surgery with cardiopulmonary bypass (CPB) is associated with the activation of inflammatory mediators that possess prothrombotic activity and could cause postoperative haemostatic disorders
Maximal values of fragment 1+2 (F1+2), thromboxane B2 (TxB2), and monocyte chemoattractant protein-1 (MCP-1) were found at the end of CPB
Our data suggest that children with complex cardiac defects undergoing cardiac surgery show profound but transient imbalance between pro- and anti-thrombotic activity, which could lead to thromboembolic complications

Summary

Introduction

Cardiac surgery with cardiopulmonary bypass (CPB) is associated with the activation of inflammatory mediators that possess prothrombotic activity and could cause postoperative haemostatic disorders. This study was conducted to investigate the effect of cardiac surgery on prothrombotic activity in children undergoing cardiac surgery for complex cardiac defects. Cardiac surgery with cardiopulmonary bypass (CPB) is associated with inflammatory and haemostatic alterations that may lead to severe bleeding and/or thromboembolic events [1,2,3]. Abnormalities of the thrombin pathway play a main role in coagulation and fibrinolysis disorders observed in patients undergoing CPB [2,3]. Thrombin is a major activator of platelets. Its activity is associated with early mortality after coronary artery bypass grafting operations [5]. Platelet activation goes along with the activation of the arachidonic acid pathway in platelets and results in the release of the potent platelet-aggregating agent thromboxane A2, which is rapidly converted into the inactive product thromboxane B2 (TxB2) [6]

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