Transcatheter aortic valve implantation combined with conventional heart surgery: Hybrid approach for complex cardiac pathologic features

Abstract

DISCUSSION Nafamostat mesilate has been used as an anticoagulant in substitution for heparin in the situations of CPB, left ventricular assist devices, and hemodialysis. The main advantages of nafamostat mesilate are its short half-life and its functioning to inactivate coagulation, fibrinolysis, and platelet aggregation.Muraseandcolleagues 8 demonstratedthatnafamostat mesilate inhibits fibrinolysis, preserves platelet function during CPB, and reduces bloodloss. Ota and associates 9 demonstrated successfulCPB managementwithmesilatefor 3 patients with recent intracranial hemorrhage. Both groups emphasized that inhibition of fibrinolysis activation was the mostimportant supplementary effectofnafamostatmesilate, because as excessive fibrinolysis can cause intracranial bleeding during and after CPB. 8,9 On the other hand, heparin enhances fibrinolytic activity during CPB, leading to dissolution of clots and recurrence of bleeding. In this study we demonstrated successful CPB management with a continuous infusion of nafamostat mesilate in open heart surgical procedures for patients after acute stroke. Some authors have maintained that low-dose heparin can achieve adequate anticoagulation during CPB, but Ovrum and coworkers 2 reported that clot formation in the cardiotomy reservoir occurred during CPB with lowdose heparin. In our opinion, low-dose heparinization during CPB should not be routinely used because of the risk of clot formation; however, it provides an advantage for patients with the risk of bleeding. We believe that the combination of low-dose heparin and nafamostat