Hemostasis In Cardiac Surgery Research Articles

Post-Neutralisation Activated Clotting Time and Postoperative Transfusions in Cardiac Surgery Outcome.

To assess the impact of post-protamine neutralisation activated clotting time (ACT) values on postoperative outcomes including chest drain output, transfusion requirements, and CICU stay, in patients undergoing cardiac surgery. Observational comparative study. Place and Duration of the Study: Department of Anaesthesiology, The Aga Khan University Hospital, Karachi, Pakistan, from February to August 2023. Ethical approval was obtained to collect data from elective cardiac surgery patients' charts. A sequential sampling approach analysed the baseline and post-protamine neutralisation ACT values, categorising patients into two groups. Group A maintained ACT within 10% of baseline, while Group B deviated. The outcomes measured included transfusion needs, chest drain output, additional protamine, cardiac intensive care unit (CICU) stay, and postoperative reopening. Statistical analysis included mean, median, frequency, t-test / Mann-Whitney U test, and Chi-square test. The study comprised 101 patients (39 in Group A, 62 in Group B), with similar baseline health. No significant differences were found in tranexamic acid use, CICU stay, chest drain output, or transfusion rates between the groups (p >0.05). Maintaining ACT within 10% of baseline post-protamine neutralisation results in similar intraoperative and postoperative outcomes, suggesting potential benefits in avoiding the aggressive protamine therapy and ensuring haemostasis in cardiac surgery. Coronary Artery bypass grafting, Cardiopulmonary bypass, Activated clotting time (ACT), Heparin, Postoperative bleeding, Blood transfusions.

Post-Neutralisation Activated Clotting Time and Postoperative Transfusions in Cardiac Surgery Outcome.

To assess the impact of post-protamine neutralisation activated clotting time (ACT) values on postoperative outcomes including chest drain output, transfusion requirements, and CICU stay, in patients undergoing cardiac surgery. Observational comparative study. Place and Duration of the Study: Department of Anaesthesiology, The Aga Khan University Hospital, Karachi, Pakistan, from February to August 2023. Ethical approval was obtained to collect data from elective cardiac surgery patients' charts. A sequential sampling approach analysed the baseline and post-protamine neutralisation ACT values, categorising patients into two groups. Group A maintained ACT within 10% of baseline, while Group B deviated. The outcomes measured included transfusion needs, chest drain output, additional protamine, cardiac intensive care unit (CICU) stay, and postoperative reopening. Statistical analysis included mean, median, frequency, t-test / Mann-Whitney U test, and Chi-square test. The study comprised 101 patients (39 in Group A, 62 in Group B), with similar baseline health. No significant differences were found in tranexamic acid use, CICU stay, chest drain output, or transfusion rates between the groups (p >0.05). Maintaining ACT within 10% of baseline post-protamine neutralisation results in similar intraoperative and postoperative outcomes, suggesting potential benefits in avoiding the aggressive protamine therapy and ensuring haemostasis in cardiac surgery. Coronary Artery bypass grafting, Cardiopulmonary bypass, Activated clotting time (ACT), Heparin, Postoperative bleeding, Blood transfusions.

Thromboelastography: A Novel Approach to Hemostasis in Cardiac Surgery

Thromboelastography: A Novel Approach to Hemostasis in Cardiac Surgery

Blood Conservation and Hemostasis in Cardiac Surgery: A Survey of Practice Variation and Adoption of Evidence-Based Guidelines.

Blood conservation and hemostasis are integral parts of reducing avoidable blood transfusions and the associated morbidity and mortality. Despite the publication of blood conservation guidelines for cardiac surgery, evidence suggests persistent variability in practice patterns. Members of the Society of Cardiovascular Anesthesiologists (SCA) created a survey to audit conformance to existing guidelines and use the results to help narrow the evidence-to-practice gap. Members of the SCA and its Continuous Practice Improvement (CPI)- Blood Conservation Work Group developed a 48-item Blood Conservation and Hemostasis in Cardiac Surgery (BCHCS) survey. The questionnaire included the components of the Anesthesia Quality Institute's (AQI) composite measure AQI49. The survey was distributed to the entire SCA membership by e-mail via the Research Electronic Data Capture (REDCap) Consortium between the fall of 2017 and early 2018. Of 3152 SCA members, 536 returned surveys for a response rate of 17%. Most responders worked at academic institutions. The median transfusion trigger after cardiopulmonary bypass was hemoglobin (Hgb) 7.0 to 8.0 g/dL. There are 4 components to AQI49, and the composite conformance to all of them was low due to 1 specific component: the use of transfusion algorithms supplemented with point-of-care (POC) testing. There was good conformance to the other 3 components of AQI49: use of antifibrinolytics, minimization of hemodilution and use of red cell salvage. Overall, practices with a multidisciplinary patient blood management (PBM) team were the most successful in meeting all 4 AQI49 criteria. The survey demonstrated widespread adoption of several best practices, including the tolerance of lower hemoglobin transfusion triggers, use of antifibrinolytics, minimization of hemodilution, and use of red cell salvage. The survey also confirms that gaps remain in preoperative anemia management and the use of transfusion algorithms supplemented with POC hemostasis testing. Serial use of this survey can be used to identify barriers to implementation and audit the effectiveness of interventions described in this article. This instrument could also help harmonize local, regional, and national efforts and become an essential component of an implementation strategy for PBM in cardiac surgery.

Heparin Dose and Point-of-Care Measurements of Hemostasis in Cardiac Surgery—Results of a Randomized Controlled Trial

High heparin doses during cardiopulmonary bypass (CPB) have been suggested to reduce thrombin activation and consumption coagulopathy and consequently bleeding complications. The authors investigated the effect of a high heparin dose during CPB on point-of-care measurements of coagulation. The authors hypothesized that during CPB a high heparin dose compared with a lower heparin dose would reduce thrombin generation and platelet activation and tested whether this would be reflected in the results of rotational thromboelastometry (TEM) and platelet aggregation, measured with multiple electrode aggregometry (MEA). Prospective, randomized, controlled, open single-center study. University teaching hospital. Sixty-three consecutive patients undergoing elective coronary artery bypass grafting with CPB were enrolled. Patients were randomly assigned to receive either a high (600 IU/kg, n = 32) or a low (300 IU/kg, n = 31) initial dose of heparin. Target levels of activated clotting time during CPB were >600 seconds in the high heparin dose group and >400 seconds in the low heparin dose group. Blood samples were collected (1) preoperatively after induction of anesthesia, (2) 10 minutes after aortic declamping, (3) 30 minutes after protamine administration, and (4) 3 hours after protamine administration. TEM and MEA were then measured. There was no difference in blood loss up to 18 hours postoperatively (median 735 mL for high dose v 610 mL for low dose; p < 0.056) or transfusions between the groups. Total median heparin dose (54,300 IU v 27,000 IU; p = 0.001) and median antifactor Xa levels during CPB (9.38 U/mL v 5.04 U/mL; p = 0.001) were greater in the high than in the low heparin dose group. However, neither TEM nor MEA results differed significantly between the groups. Compared with a lower dose of heparin during CPB, a high dose of heparin had little effect on the point-of-care measurements of hemostasis, TEM, and MEA. Based on the similarity of platelet and coagulation activity assessments, the higher heparin dose does not appear to offer benefit during CPB.

Feasibility of a novel, synthetic, self-assembling peptide for suture-line haemostasis in cardiac surgery

BackgroudTo assess the feasibility and efficacy of PuraStat®, a novel haemostatic agent, in achieving suture line haemostasis in a wide range of cardiac surgical procedures and surgery of the thoracic aorta.MethodsA prospective, non-randomised study was conducted at our institution. Operative data on fifty consecutive patients undergoing cardiac surgery where PuraStat® was utilised in cases of intraoperative suture line bleeding was prospectively collected. Questionnaires encompassing multiple aspects of the ease of use and efficacy of PuraStat® were completed by ten surgeons (five consultants and five senior registrars) and analysed to gauge the performance of the product.ResultsNo major adverse cardiac events were reported in this cohort. Complications such as atrial fibrillation, pacemaker requirement and pleural effusions were comparable to the national average. Mean blood product use of packed red cells, platelets, fresh-frozen plasma (FFP) and cryoprecipitate was below the national average. There was one incidence of re-exploration, however this was due to pericardial constriction rather than bleeding. Analysis of questionnaire responses revealed that surgeons consistently rated PuraStat® highly (between a score of 7 and 10 in the various subcategories). The transparent nature or PuraStat® allowed unobscured visualisation of suture sites and possessed excellent qualities in terms of adherence to site of application. The application of PuraStat® did not interfere with the use of other haemostatic agents or manipulation of the suture site by the surgeon.ConclusionPuraStat® is an easy-to-use and effective haemostatic agent in a wide range of cardiac and aortic surgical procedures.

Blockage of a Mechanical Aortic Valve Leaflet with BioGlue: A Case Report

Mechanical aortic valve dysfunction is a very rare event and is usually due to thrombosis, pannus overgrowth, or both. BioGlue as a cause for such a complication has been reported only occasionally. We describe a case of a 63-year-old woman who underwent operation for symptomatic tight aortic stenosis. After implantation of an aortic valve (AGN-751, size 19; St. Jude Medical, St. Paul, MN, USA) because of a transverse tear of the aortic wall above the annulus occurring during the suturing of the aortotomy, a triangular Vascutek Dacron patch (Vascutek/Terumo, Inchinnan, Scotland, UK) was included. To secure hemostasis, BioGlue (CryoLife, Kennesaw, GA, USA) was applied. A transthoracic echocardiography (TTE) examination performed after signs of ischemia appeared in the electrocardiogram on postoperative day 5 revealed an aortic transvalvular gradient of 74/38 mm Hg and a functional valve area of 1.0 cm2. No coronary lesions were revealed in a coronarography evaluation, but cinefluoroscopy (CF) examination revealed immobility of 1 valve leaflet. The reoperation revealed a thick, rough layer of the glue on the inner side of the patch. This glue had run down to the valve, blocking a mechanical leaflet. Cleaning the valve was not possible, and the valve had to be changed. The subsequent postoperative course was uneventful. The transvalvular gradient was 39/20 mm Hg, and the functional valve area was 1.2 cm2. We believe that the use of BioGlue and other surgical sealants is justified to secure complex suture lines and for maintaining hemostasis in cardiac surgery, but some precautionary rules must be respected. Authors have indicated that the glue enters through the needle holes in such cases, but our findings suggest it can also pass to the Dacron patch itself. CF is superior to TTE and transesophageal echocardiography for analyzing movement of the mechanical valve leaflet, and cardiac catheterization is rarely needed.

Topical use of autologous fibrin glue in high-risk CABG patients

BACKGROUND: Surgical site wound complications following cardiothoracic surgery are associated with increased costs, morbidity, and mortality. Several factors have been shown to be associated with an increase in deep and superficial wound healing problems. Recent publications have suggested protective effects of topical autologous blood components with regard to wound healing disturbances after various surgical procedures. The aim of this retrospective analysis was to assess the impact of autologous fibrin glue on surgical site complications in high-risk coronary artery bypass graft patients. METHODS: 1394 consecutive patients who underwent CABG surgery from a single centre were included in the study. Autologous fibrin glue was used in 122 patients (8.8%) with elevated risk for wound complications according to institutional guidelines. The demography of both groups was compared and the following outcome variables were analyzed: deep sternal wound infection, sternal re-wiring, bleeding, re- exploration rate, and the use of a vacuum assisted closure system. RESULTS: No treatment-related adverse events were noted. The group of patients who received autologous fibrin sealant had significantly higher BMI levels, included more diabetics and repeat cardiac procedures and they underwent percutaneous coronary intervention more often. Furthermore, they were more likely to receive bilateral mammary artery grafts. Despite the high-risk profile of the Fibrin glue group rates of revision, deep sternal wound healing problems tended to be lower than in the control group. CONCLUSIONS: In our experience autologous fibrin glue does not invoke any adverse events and serves as a useful adjunct to haemostasis in cardiac surgery. However, the incidence of wound disturbances was similar in both arms of the study. In light of the ever-increasing clinical use a prospective randomized controlled trial examining the impact of autologous fibrin glue is warranted.

Effect of cardio-pulmonary bypass on procoagulant components of haemostasis in cardiac surgery

Effect of cardio-pulmonary bypass on procoagulant components of haemostasis in cardiac surgery

A review of transfusion risks and optimal management of perioperative bleeding with cardiac surgery

TransfusionVolume 48, Issue s1 p. 2S-30S A review of transfusion risks and optimal management of perioperative bleeding with cardiac surgery George Despotis, George Despotis From the Departments of Pathology and Immunology and Anesthesiology, Washington University School of Medicine, St Louis, Missouri.Search for more papers by this authorCharles Eby, Charles Eby From the Departments of Pathology and Immunology and Anesthesiology, Washington University School of Medicine, St Louis, Missouri.Search for more papers by this authorDouglas M. Lublin, Douglas M. Lublin From the Departments of Pathology and Immunology and Anesthesiology, Washington University School of Medicine, St Louis, Missouri.Search for more papers by this author George Despotis, George Despotis From the Departments of Pathology and Immunology and Anesthesiology, Washington University School of Medicine, St Louis, Missouri.Search for more papers by this authorCharles Eby, Charles Eby From the Departments of Pathology and Immunology and Anesthesiology, Washington University School of Medicine, St Louis, Missouri.Search for more papers by this authorDouglas M. Lublin, Douglas M. Lublin From the Departments of Pathology and Immunology and Anesthesiology, Washington University School of Medicine, St Louis, Missouri.Search for more papers by this author First published: 21 February 2008 https://doi.org/10.1111/j.1537-2995.2007.01573.xCitations: 88 George Despotis, MD, Department of Pathology and Immunology, Box 8118, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110; e-mail: gdespotis@path.wustl.edu. Disclosure of potential conflicts of interest: Dr Despotis has received speaking honoraria and has served as a consultant for Bayer Pharmaceuticals, Dyax, Ferring, and Talecris. Dr Eby has received speaking honoraria from Beckman and Medicine Shop. Dr Lublin has nothing to disclose. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume48, Issues1Special Issue: Transfusion and Hemostasis in Cardiac Surgery–An UpdateMarch 2008Pages 2S-30S RelatedInformation

Transfusion and hemostasis in cardiac surgery

Transfusion and hemostasis in cardiac surgery

N-acetylcysteine and hemostasis in cardiac surgery

N-acetylcysteine and hemostasis in cardiac surgery

The use of Minimized Extracorporeal Circulation System has a Beneficial Effect on Hemostasis--A Randomized Clinical Study

Conventional cardiopulmonary bypass (CPB) is associated with increased coagulation and fibrinolytic activity. A closed miniaturized bypass circuit (CorX) features a significantly reduced tubing set, an integrated pump, and an air removal system without a cardiotomy reservoir. In a prospective randomized trial, the effects on hemostasis were investigated while comparing CorX with conventional CPB in patients undergoing coronary artery bypass grafting. Over a period of 1 year, 81 patients were randomly assigned either to the CorX system (n = 39, group A) or standard CPB system (n = 42, group B). Primary endpoints were platelet count, plasmin-antiplasmin complex (PAP), prothrombin fragments 1+2 (F1+F2), D-dimers, and fibrinogen. Secondary end-points were hematocrit, blood loss in the first 12 hours postoperatively, transfused packed red blood cells, and fresh frozen plasma in the first 24 hours postoperatively. In addition, we analyzed partial thromboplastin time, prothrombin time, and antithrombin III. After aortic declamping, PAP complex and prothrombin F1+F2 were significantly lower in group A than in group B. The difference in D-dimers between groups reached significance at 1 hour post-CPB. Hematocrit values at the end of CPB measured 26 +/- 6% in group A versus 22 +/- 4% in group B (P = .01). The rest of the observed parameters did not significantly differ between groups. Postoperative blood loss was not reduced in the present study. However, the use of the CorX system leads to a significant suppression of activation of coagulation and fibrinolytic cascades compared to conventional CPB, suggesting that miniaturized extracorporeal circuits are a step forward toward reduced imbalance of hemostasis in cardiac surgery.

Desmopressin for Haemostasis in Cardiac Surgery : When to Use?

Bleeding after cardiac surgery increases morbidity and exposes patients to the risks associated with blood transfusion. Desmopressin acetate, a synthetic vasopressin analogue, has been used in patients undergoing cardiac operations to reduce postoperative blood loss and transfusion requirements, although a benefit has not been demonstrated in large randomized controlled trials. Therefore, the routine use of desmopressin in uncomplicated cardiac operations is not recommended. This review article discusses the pharmacology of desmopressin as a haemostatic agent and evaluates available clinical evidence to determine current indications for desmopressin as a haemostatic agent in cardiac surgery.

A Double-Blind, Placebo-Controlled Trial of Epsilon-Aminocaproic Acid for Reducing Blood Loss in Coronary Artery Bypass Grafting Surgery

Epsilon-aminocaproic acid is a plasmin inhibitor that potentially reduces perioperative bleeding when administered prophylactically to cardiac surgery patients. To evaluate the efficacy of epsilon-aminocaproic acid, a prospective placebo-controlled trial was conducted in patients undergoing primary coronary artery bypass grafting surgery. One hundred patients were randomly assigned to receive either epsilon-aminocaproic acid (100 mg/kg before skin incision followed by 1 g/hour continuous infusion until chest closure, 10 g in cardiopulmonary bypass circuit) or placebo, and the efficacy of epsilon-aminocaproic acid was evaluated by the reduction in postoperative thoracic-drainage volume and in donor-blood transfusion up to postoperative day 12. Postoperative thoracic-drainage volume was significantly lower in the epsilon-aminocaproic acid group compared with the placebo group (epsilon-aminocaproic acid, 649 +/- 261 mL; versus placebo, 940 +/- 626 mL; p=0.003). There were no significant differences between the epsilon-aminocaproic acid and placebo groups in the percentage of patients requiring donor red blood cell transfusions (epsilon-aminocaproic acid, 24%; versus placebo, 18%; p=0.62) or in the number of units of donor red blood cells transfused (epsilon-aminocaproic acid, 2.2 +/- 0.8 U; versus placebo, 1.9 +/- 0.8 U; p=0.29). Epsilon-aminocaproic acid did not reduce the risk of donor red blood cell transfusions compared with placebo (odds ratio: 1.2, 95% confidence interval; 0.4 to 3.2, p=0.63). Prophylactic administration of epsilon-aminocaproic acid reduces postoperative thoracic-drainage volume by 30%, but it may not be potent enough to reduce the requirement and the risk for donor blood transfusion in cardiac surgery patients. This information is useful for deciding on a therapy for hemostasis in cardiac surgery.

Point-of-Care Testing of Hemostasis in Cardiac Surgery

An excessive perioperative blood loss, that requires transfusion of blood products, sometimes occurs in patients undergoing cardiopulmonary bypass for cardiac surgery. Blood loss and transfusion requirements in these patients may be reduced with a better control of heparin treatment and its reversal. Blood component administration in patients with excessive post-cardiopulmonary bypass bleeding has been empiric for a long time due to turnaround times of laboratory coagulation tests. Devices are now available for rapid, point-of-care assessment of hemostasis alterations to allow an appropriate, targeted therapy. In particular, a quick evaluation of platelet and coagulation defects with new point-of-care devices can optimize the administration of pharmacological and transfusion-based therapy in patients with excessive bleeding after cardiopulmonary bypass.

Book Review: Attar S (Ed), "Hemostasis in Cardiac Surgery"

Book Review: Attar S (Ed), "Hemostasis in Cardiac Surgery"

Hemostasis in Cardiac Surgery.

Hemostasis in Cardiac Surgery.