Gruenwald and colleagues [1Gruenwald C.E. Manlhiot C. Abadilla A. et al.Heparin brand is associated with postsurgical outcomes in children undergoing cardiac surgery.Ann Thorac Surg. 2012; 93: 878-883Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] have described a provocative association between the heparin brand used during pediatric cardiac operations, bleeding, and thromboembolism. Unfractionated heparin (UFH) is a heterogenous mixture of mucopolysaccharides of various molecular weights. About one-third of these molecules bind to antithrombin, vastly augmenting antithrombin-dependent inactivation of factors IIa (thrombin), IXa, Xa, XIa, and XIIa. Excess dosing or inadequate reversal may cause bleeding. Paradoxically, heparin can promote self-limiting platelet aggregation, but the rare, immunologic heparin-induced thrombocytopenia can be catastrophic. Heparin use, therefore, has been associated with adverse clinical outcomes, both hemorrhagic and thrombotic. This retrospective study compares a period when the authors exclusively used PPC heparin (Pharmaceutical Partners of Canada Inc, Richmond Hill, ON, Canada) with an earlier period using only Hepalean (Organon Teknika Corp, Durham, NC). Manufacturing problems affecting brand quality can alter clinical outcome [2Kishimoto T.K. Viswanathan K. Ganguly T. et al.Contaminated heparin associated with adverse clinical events and activation of the contact system.N Engl J Med. 2008; 358: 2457-2467Crossref PubMed Scopus (538) Google Scholar], but although PPC announced in January 2007 that latex had been removed from their heparin product [3Pharmaceutical Partners of Canada IncHeparin line now complete.http://ppcdrugs.com/en/news-june1b-07.phpGoogle Scholar], this is likely unrelated because study findings are not typical manifestations of latex allergy. Differences in activity profile or immunogenicity between the PPC and Hepalean (both porcine [4Francis J.L. Palmer 3rd, G.J. Moroose R. Drexler A. Comparison of bovine and porcine heparin in heparin antibody formation after cardiac surgery.Ann Thorac Surg. 2003; 75: 17-22Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar]) would be a more likely mechanism. An in vitro or in vivo evaluation of drug potency and adequacy of reversal [5Gruenwald C.E. Manlhiot C. Chan A.K. et al.Randomized, controlled trial of individualized heparin and protamine management in infants undergoing cardiac surgery with cardiopulmonary bypass.J Am Coll Cardiol. 2010; 56: 1794-1802Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar] or the development of heparin-induced thrombocytopenia antibodies may have helped explain the findings of increased bleeding and thromboembolism associated with the PPC heparin brand. Readers should always consider the limitations of a retrospective analysis, which determines association, not causation, as confounding factors are only partially addressed by model adjustment. In this study, there are too few binary outcome events (bleeding, thromboembolism, and reoperation) to support logistic regression analysis with 12 covariates, according to the general “rule-of-thumb” of 10 outcomes per covariate [6Peduzzi P. Concato J. Kemper E. Holford T.R. Feinstein A.R. A simulation study of the number of events per variable in logistic regression analysis.J Clin Epidemiol. 1996; 49: 1373-1379Abstract Full Text PDF PubMed Scopus (5038) Google Scholar], and details of the multivariate models are not provided. We encourage authors to carefully explain crucial model development steps, especially in retrospective analyses. However, this study was used to generate a hypothesis now being evaluated prospectively, a laudable example of an appropriate application of retrospective data. McMaster University is listed as sponsoring a prospective, randomized study [7ClinicalTrials.govComparison of heparin types; efficacy and safety.http://clinicaltrials.gov/ct2/show/NCT01343381Google Scholar] testing the anticoagulant effect and reversal of the two brands of heparin discussed here. We eagerly await the results. Heparin Brand Is Associated With Postsurgical Outcomes in Children Undergoing Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 93Issue 3PreviewWe sought to determine whether the use of specific unfractionated heparin brands during cardiopulmonary bypass for pediatric cardiac surgery was associated with differences in postoperative outcomes, especially regarding the incidence of bleeding and thromboembolic complications. Full-Text PDF