Abstract
Protein S deficiency patient is characterized by recurrent thrombosis, and its risk is higher intraoperatively, especially in cardiac surgery involving cardiopulmonary bypass. Two heparin cessation periods are defined in cardiac surgery. One is the period between the cessation of heparin 4 to 5 h before surgery and the heparinization prior to cardiopulmonary bypass. The other is the period between protamine administration and resumption of heparin postoperatively. Because the risk of thromboembolism is high during the period of heparin cessation, other anticoagulants are necessary. Although fresh frozen plasma, rich in protein S, is often used in cardiac surgery for protein S deficiency patients, the most appropriate times and volume of its administration to prevent thromboembolism remain poorly understood. We herein report a case of on-pump coronary artery bypass grafting in a patient with protein S deficiency who received fresh frozen plasma targeting the two heparin cessation periods. Some qualitative measurements to identify the effect of fresh frozen plasma on the protein S level are desirable to evaluate whether our present administration strategy has any beneficial effects on protein S deficiency patients.
Highlights
Protein S (PS) serves as a cofactor for protein C (PC), an inhibitor of activated coagulation factors V and VIII, resulting in anticoagulation [1]
PS deficiency is characterized by recurrent thrombosis, anticoagulants such as heparin or warfarin are strongly recommended perioperatively [2]
Screening for a Sugimoto et al JA Clinical Reports (2018) 4:17 thrombophilic diathesis was performed at that time and showed a reduced PS activity level of 33.7%, while the PC activity level was normal at 123%
Summary
Protein S (PS) serves as a cofactor for protein C (PC), an inhibitor of activated coagulation factors V and VIII, resulting in anticoagulation [1]. The patient responded to medical therapy; elective on-pump coronary artery bypass grafting (CABG) was scheduled. He had a history of deep vein thrombosis and multiple cerebral infarctions at 46 years of age. An echocardiogram showed an ejection fraction of 50% and abnormal wall motion with mild aortic and mitral valve regurgitation His hemoglobin concentration was 11.3 g/dL, platelet count was 170,000/mm, prothrombin time-international normalized ratio (PT-INR) was 2.54, and activated partial thromboplastin time (aPTT) was 43.6 s (control, 30 s). Warfarin was stopped 7 days before surgery, and the patient was started on intravenous unfractionated heparin to maintain an aPTT of 45 to 75 s (1.5–2.5 times control). The postoperative period was uneventful, and the patient was discharged without any complications
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