RESUMEN
OBJECTIVE: The two most commonly used heparin-coated systems for cardiopulmonary bypass (CPB) are the Carmeda Bio-Active Surface (CBAS) (Medtronic, Minneapolis, MN, USA) and the Duraflo II coating (Baxter Healthcare, Irvine, CA, USA). The two surfaces are technically unequal and previous experimental studies have demonstrated disparities in effects on the immune system and blood cells. However, little is known concerning the influence of the two surfaces on markers for brain and myocardial dysfunction. METHODS: Forty patients undergoing elective, primary coronary bypass grafting with CPB were prospectively randomized to either the CBAS system or the Duraflo II circuit. During and after CPB, biological markers for brain dysfunction and myocardial injury were analysed. RESULTS: Both markers for brain dysfunction S-100B and neuron-specific enolase (NSE) increased significantly during CPB (p = 0.01). The elevation during bypass correlated significantly with the duration of CPB (r = 0.39 and r = 0.38, respectively, both p < 0.02). NSE was somewhat more elevated in the Duraflo II group at the end of CPB (p = 0.01) and 5 h after CPB (p = 0.02); for S-100B, there were no intergroup differences. Also, the markers related to myocardial injury, myoglobin and creatine kinase (CK-MB) mass increased during CPB (p = 0.01), while elevation of troponin-I occurred 5 h after CPB (p = 0.01). There were no statistically significant intergroup differences. No significant correlation was seen between the release of cardiac markers and the duration of CPB. The clinical course was similar in both groups. CONCLUSIONS: Except for a slightly higher elevation of NSE at the end of CPB and 5 h after CPB in the Duraflo II group, there were no significant differences between the CBAS group and the Duraflo II group concerning markers for brain and myocardial dysfunction.
Asunto(s)
Encefalopatías/prevención & control , Cardiomiopatías/prevención & control , Puente Cardiopulmonar/instrumentación , Materiales Biocompatibles Revestidos/farmacología , Heparina/farmacología , Anciano , Biomarcadores/sangre , Encefalopatías/sangre , Encefalopatías/etiología , Cardiomiopatías/sangre , Cardiomiopatías/etiología , Puente Cardiopulmonar/efectos adversos , Creatina Quinasa/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mioglobina/sangre , Factores de Crecimiento Nervioso , Fosfopiruvato Hidratasa/sangre , Subunidad beta de la Proteína de Unión al Calcio S100 , Proteínas S100/sangre , Troponina I/sangreRESUMEN
OBJECTIVES: The use of heparin-coated circuits for cardiopulmonary bypass attenuates the postperfusion inflammatory response. Postoperative bleeding and the need for allogeneic blood transfusions are reduced, particularly in combination with lowered systemic anticoagulation. The two most commonly used heparin-coated systems are the Carmeda BioActive Surface (Medtronic Inc, Minneapolis, Minn) and the Duraflo II coating (Baxter Healthcare Corp, Bentley Laboratories Division, Irvine, Calif). The 2 surfaces are technically unequal, and previous experimental studies have demonstrated disparities in effects on the immune system and the blood cells. However, no larger comparative studies of relevant clinical end points have thus far been reported. METHODS: Over a 24-month period, all patients undergoing coronary artery bypass were prospectively randomized to one of the two heparin-coated circuits. Altogether, 1336 consecutive patients were included. The heparin dose was reduced in all cases, with an activated coagulation time of more than 250 seconds. Clinical data were consecutively collected and stored on a computer for comparative analyses. RESULTS: There were no statistically significant differences in any demographic or operative parameters. The Duraflo II patients required less heparin to keep the target-activated clotting time, confirming the previous finding of some leakage of heparin from the surface to the circulation. Otherwise, there were no significant differences in time for ventilatory support (Duraflo II, 1.7 +/- 1.3 hours; Carmeda BioActive Surface, 1.6 +/- 1.0 hours; P =.37), amount of postoperative mediastinal drainage (Duraflo II, 665 +/- 257 mL; Carmeda BioActive Surface, 688 +/- 243 mL; P =.07), need for allogeneic blood-plasma transfusions (Duraflo II, 4.2% of the patients; Carmeda BioActive Surface, 4.4% of the patients; P =.93), or hemoglobin concentration at hospital discharge (Duraflo II, 120 +/- 13 g/L; Carmeda BioActive Surface, 119 +/- 13 g/L; P =.08). The effects on renal function and platelets were similar, as were the incidences of perioperative myocardial infarction (Duraflo II, 1.5%; Carmeda BioActive Surface, 1.5%; P =.96), stroke (Duraflo II, 1.3%; Carmeda BioActive Surface, 1.2%; P =.47), and hospital mortality (Duraflo II, 1 [0.14%] patient; Carmeda BioActive Surface, 3 [0.45%] patients; P =.31). CONCLUSIONS: Despite differences in technology, complexity, and effects on biologic markers, no clinical differences were observed between the Carmeda BioActive Surface system and the Duraflo II coating after coronary artery bypass operations. The overall clinical results were favorable in both groups, confirming the safety and feasibility of routine use of heparin-coated circuits in combination with reduced systemic anticoagulation.
Asunto(s)
Anticoagulantes , Puente Cardiopulmonar/instrumentación , Materiales Biocompatibles Revestidos , Fibrinolíticos , Heparina , Anticoagulantes/administración & dosificación , Coagulación Sanguínea , Femenino , Fibrinolíticos/administración & dosificación , Heparina/administración & dosificación , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Factores de TiempoRESUMEN
BACKGROUND: Coronary artery bypass grafting was performed in 5,658 consecutive patients during the period 1989-1998. Due to changes over time, both in patients' risk profile and surgical strategies, a review was undertaken to study trends and results after coronary artery bypass surgery. MATERIAL AND METHODS: Our database includes more than 160 variables per patient, covering preoperative risk factors, catheterization data, operative and postoperative results. These data form the basis for analysis over time. RESULTS: Median age increased for both genders, from 58 years to 64 years for males and 62.5 years to 69 years for females. The female proportion increased from 12.8% to 19.8%. A high operative risk profile was registered in 23.7% in 1989 compared to 61.8% in 1998. Heparin-coated extracorporeal equipment and blood cardioplegia were gradually introduced in routine practice. Despite higher age and operative risk profile the morbidity and hospital mortality (0.41% overall) remained nearly unchanged. INTERPRETATION: Due to continuous improvement of technical equipment and treatment strategies, coronary artery bypass surgery represents a safe option for both high and low risk patients.
Asunto(s)
Puente de Arteria Coronaria , Adulto , Anciano , Transfusión de Sangre Autóloga , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/normas , Puente de Arteria Coronaria/estadística & datos numéricos , Bases de Datos como Asunto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Noruega , Complicaciones Posoperatorias/diagnóstico , Cuidados Preoperatorios , Sistema de Registros , Factores de RiesgoRESUMEN
BACKGROUND: Increasing hospital costs, restricted resources, and new surgical strategies have stimulated effectiveness of all routines in cardiac surgery. Over a 10-year period, 5,658 consecutive patients undergoing coronary artery bypass grafting followed a protocol aiming at short postoperative intubation times and rapid physical rehabilitation. METHODS: The patients were prepared for rapid recovery, emphasizing (1) preoperative education and respiratory training, (2) low-dose fentanyl anesthesia, (3) limited ischemic times and pump times, (4) mild hypothermia and rewarming to a rectal temperature of 36 degrees C, (5) restricted use of extended monitoring, (6) autologous blood salvage to avoid allogeneic blood transfusions, and (7) active physical training from postoperative day 1. All in-hospital data relevant to these steps were prospectively stored in a database. RESULTS: The median extubation time after arrival in the intensive care unit was 1.5 hours (0 to 320 hours). More than 99% of the patients were extubated within 5 hours. Sixty-two patients (1.1%) were reintubated and ventilated for a median of 24 hours (1 to 430 hours), mostly due to resternotomy for bleeding or cardiopulmonary decompensation. In total, 5,594 patients (98.9%) were able to sit in a chair the first postoperative day. Within the fourth postoperative day, 82.5% were able to move freely in the hospital area and were in fact physically fit for hospital discharge. Allogeneic blood products were given to 3.9% of the patients. Twenty-three patients (0.41%) died in-hospital. CONCLUSIONS: With the application of a protocol for rapid physical recovery in patients undergoing "on-pump" coronary artery bypass grafting, extubation within 1 to 2 hours was safe and feasible in most patients. After 5 hours, 99.3% of the patients were extubated, with a reintubation rate of 1.1%. More than 80% of the patients were fully physically mobile within 4 days after the operation.
Asunto(s)
Puente Cardiopulmonar/rehabilitación , Puente de Arteria Coronaria/rehabilitación , Complicaciones Posoperatorias/rehabilitación , Adulto , Anciano , Anciano de 80 o más Años , Puente Cardiopulmonar/mortalidad , Puente de Arteria Coronaria/mortalidad , Ambulación Precoz , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Estudios Prospectivos , Análisis de SupervivenciaRESUMEN
OBJECTIVE: Autotransfusion during and after cardiac surgery is widely performed, but its effects on coagulation, fibrinolysis, and inflammatory response have not been known in detail. METHODS: Hemostatic and inflammatory markers were extensively studied in 40 coronary artery bypass patients undergoing a consistent intraoperative and postoperative autotransfusion protocol. An identical autotransfusion protocol was applied to 4916 consecutive coronary patients and the overall clinical results were evaluated in this large patient population. RESULTS: The autologous blood pooled before bypass remained nearly inactivated after storage. A slight elevation of thrombin-antithrombin complex and prothrombin fragment 1.2, as well as plasmin/alpha(2)-antiplasmin complex was found in the content of the extracorporeal circuit after surgery, indicating thrombin formation and fibrinolytic activity. Also some increase of beta-thromboglobulin was present. In the mediastinal shed blood, complete coagulation, as evidenced by the absence of fibrinogen, had taken place and all parameters described above were extremely elevated. However, no thrombin activity was detected. As for the inflammatory response, moderately increased levels of complement activation products, terminal complement complex, and interleukin-6 traced in the extracorporeal circuit reached very high levels in mediastinal shed blood. Autotransfusion of the residual extracorporeal circuit blood and the mediastinal drainage was followed by elevation of most of these markers in circulating plasma. On the other hand, no correlating harmful effects were recorded in the study patients or in the consecutive 4916 patients. Coagulation disturbances were rare and allogeneic transfusions were required in fewer than 4% of all patients. CONCLUSIONS: The hemostatic and immunologic systems were moderately activated in the autologous blood remaining in the extracorporeal circuit, whereas the mediastinal shed blood was highly activated in all aspects. However, autotransfusion had no correlating clinical side-effects and the subsequent exposure to allogeneic blood products was minimal.
Asunto(s)
Antifibrinolíticos , Transfusión de Sangre Autóloga , Puente de Arteria Coronaria , Anciano , Antitrombina III/análisis , Biomarcadores/sangre , Coagulación Sanguínea/fisiología , Puente Cardiopulmonar , Activación de Complemento , Complejo de Ataque a Membrana del Sistema Complemento/análisis , Drenaje , Femenino , Fibrinógeno/análisis , Fibrinolisina/análisis , Fibrinólisis/fisiología , Hemostasis/fisiología , Humanos , Interleucina-6/sangre , Cuidados Intraoperatorios , Modelos Lineales , Masculino , Mediastino , Persona de Mediana Edad , Fragmentos de Péptidos/análisis , Péptido Hidrolasas/análisis , Cuidados Posoperatorios , Protrombina/análisis , Síndrome de Respuesta Inflamatoria Sistémica/etiología , Trombina/biosíntesis , alfa 2-Antiplasmina/análisis , beta-Tromboglobulina/análisisRESUMEN
Postoperative organ dysfunction after cardiac operations has been related to the damaging effects of cardiopulmonary bypass (CPB). These complications are considered to be mediated partly by complement activation and subsequent activation of leucocytes due to the contact between blood and the large nonendothelial surfaces in the bypass circuit. Removal of leucocytes by filtration during the reperfusion period may potentially reduce the postoperative morbidity after CPB. Forty patients undergoing elective, primary coronary artery bypass grafting were randomized to initial identical bypass circuits until the aortic crossclamp was released. Then, the ordinary arterial line filter was closed and either a leucocyte depletion filter (n = 20), or a control filter (n = 20) was incorporated in the circuits during the reperfusion period of CPB. Blood samples were drawn at fixed intervals and analysed for white blood cell and platelet counts, plasma concentration of myeloperoxidase, C3-complement activation products, the terminal complement complex, and interleukins (IL)-6 and -8. The numbers of circulating white blood cells in the leucocyte-depleted group decreased during the reperfusion period from 5.5 (4.8-6.8) to 5.3 (4.4-6.2) x 10(9)/l, and increased in the control group from 6.5 (5.1-8.0) to 7.4 (5.7-9.0) x 10(9)/l. Two hours postoperatively the total white blood cell count in the leucocyte-depleted group was 14.7 (12.1-17.2) x 10(9)/l, and in the control group 17.6 (14.5-20.7) x 10(9)/l. The differences between the groups were statistical significant (p = 0.05). There were no statistically significant differences between the groups with regard to other test parameters or clinical data. We conclude that the use of leucocyte filters during the reperfusion period in elective coronary artery bypass surgery significantly reduced the number of circulating leucocytes, whereas no effects were seen for granulocyte activation measured as myeloperoxidase release, platelet counts, complement activation, or IL-6 and -8 release. The clinical benefit of leucocyte filters in routine or high risk patients remains to be demonstrated and is suggested to be dependent on both the efficacy and the biocompatibility of the filters.
Asunto(s)
Puente de Arteria Coronaria , Leucaféresis , Reperfusión Miocárdica , Circulación Pulmonar , Reperfusión , Anciano , Complemento C3b/análisis , Complejo de Ataque a Membrana del Sistema Complemento/análisis , Femenino , Humanos , Interleucina-6/sangre , Interleucina-8/sangre , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Peroxidasa/sangre , Recuento de Plaquetas , Estudios Prospectivos , Circulación Pulmonar/fisiologíaRESUMEN
BACKGROUND: The activated clotting time is a bedside method routinely used to monitor heparin anticoagulation during operations requiring cardiopulmonary bypass. The thrombolytic assessment system heparin management test is a new bedside method for monitoring heparin effect. We compared these methods with respect to their ability to reflect the actual heparin concentration in plasma determined by an anti-FXa method. METHODS: Two studies were done, an ex vivo study on ten patients who had coronary artery bypass using non-heparin-coated cardiopulmonary bypass circuits and full systemic heparinization and an in vitro study on single donor plasma spiked with heparin 0 to 10 IU/mL. RESULTS: Ex vivo study correlation coefficients of activated clotting time and the thrombolytic assessment system heparin management test clotting times versus anti-FXa-based heparin assay were low (r = 0.53, p = 0.002/r = 0.64, p<0.001) in contrast with the corresponding correlation coefficients for the in vitro study (r = 0.98, p<0.001/r = 0.99, p<0.001). A substantial variability in duplicate activated clotting time determinations was noted, which was less pronounced with the thrombolytic assessment system heparin management test. CONCLUSIONS: The thrombolytic assessment system method does not correlate better to the actual amount of heparin during cardiopulmonary bypass procedures than the activated clotting time method, which should be performed in duplicate.
Asunto(s)
Anticoagulantes/administración & dosificación , Pruebas de Coagulación Sanguínea/métodos , Puente de Arteria Coronaria , Heparina/administración & dosificación , Anticoagulantes/sangre , Puente Cardiopulmonar , Heparina/sangre , HumanosRESUMEN
The main purpose of this study was to estimate the costs and savings related to a consistent autotransfusion programme. More than 8,000,000 ml of autologous blood or blood-containing fluid were collected from 3,637 consecutive patients undergoing coronary artery bypass and returned to the patients during and after the operation. Economic analyses revealed a price of NOK 13 million (approximately 2 million USD) for this amount of autologous blood, or NOK 3,500 (600 USD) per patient. In the present series the need for bank blood or blood products was modest, since 69 patients (1.9%) received packed red cells, with or without plasma, 76 patients (2.1%) were given plasma transfusions only, and 11 patients (0.3%) received platelets. Thus, 95.7% of the patients were not exposed to any homologous blood products during the stay in hospital. Absence of morbidity related to the low homologous blood transfusion rate was assumed to save costs substantially, although this saving was difficult to calculate in terms of currency. Post-operative complications were few, and the total in-hospital mortality rate was 0.4%.
Asunto(s)
Transfusión de Sangre Autóloga/economía , Puente de Arteria Coronaria/economía , Ahorro de Costo , Adulto , Anciano , Recolección de Muestras de Sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Noruega , Complicaciones Posoperatorias/diagnósticoRESUMEN
BACKGROUND: The concepts of minimally invasive coronary artery bypass grafting have gained increasing attention and interest from cardiac surgeons. Operations through small incisions are mostly applied to patients with less extensive coronary disease, mostly single-vessel disease. The aim of this study was to identify a baseline level of conventional coronary bypass grafting for this group of patients, particularly with regard to surgical complications and immediate results. METHODS: Of 3,637 consecutive patients undergoing coronary artery bypass grafting during the period 1989 to 1995, 99 patients (2.7%) were identified to have single-vessel disease. The preoperative and hospital data of this subset of patients were analyzed. RESULTS: The left internal mammary artery was grafted in 96% of the patients, either as single graft to the left anterior descending artery or sequentially to the left anterior descending artery and a diagonal branch. Additional vein grafts were placed in 36 patients, and the mean number of distal anastomoses was 1.6 +/- 0.6. Mean ischemic time and cardiopulmonary bypass time were 15.3 +/- 9.6 minutes and 29.0 +/- 12.5 minutes, respectively. The patients were weaned from the ventilator 1.5 +/- 0.8 hours postoperatively, and all patients were out of bed the morning after the operation. No patients required homologous blood or plasma transfusions. The morbidity rate was low, and all patients survived. CONCLUSIONS: For this highly selected group of patients, coronary artery bypass grafting based on median sternotomy, cardiopulmonary bypass, and cardioplegic arrest carries a very high rate of immediate success. Such data may be useful as a baseline when considering the costs and benefits of new surgical procedures.
Asunto(s)
Puente de Arteria Coronaria , Enfermedad Coronaria/cirugía , Puente Cardiopulmonar , Puente de Arteria Coronaria/métodos , Femenino , Paro Cardíaco Inducido , Humanos , Anastomosis Interna Mamario-Coronaria , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos , Valores de Referencia , Vena Safena/trasplante , Esternón/cirugíaRESUMEN
BACKGROUND: The use of completely heparin coated cardiopulmonary bypass circuits in combination with a reduced systemic heparin dose has previously been shown to reduce postoperative bleeding after cardiac operations. However, it has remained unknown whether this effect was related to the improved biocompatibility of the heparin-treated surfaces per se or to the reduced exposure to circulating heparin. Therefore we investigated patients undergoing heparin-coated extracorporeal circulation and full systemic heparinization. METHODS: Two hundred seventeen patients having first-time myocardial revascularization were prospectively randomized either to a group in which a completely ("tip-to-tip") heparin-coated circuit (Duraflo II) was used for perfusion (n = 107) or to a control group (n = 110) in which an uncoated, but otherwise identical, circuit was used. Full systemic heparinization was induced in both groups (activated clotting time, > 480 seconds). The postoperative blood loss, requirements for homologous blood transfusions, clinical performance, and complications were recorded. RESULTS: The amount of postoperative mediastinal drainage was nearly identical in the two groups. The mean 18-hour drainage was 694 +/- 313 mL in the heparin-coated group and 679 +/- 269 mL in the control group (p = not significant). Three patients in the heparin-coated group and 6 patients in the control group received homologous red blood cell transfusions (p = not significant). The incidence of postoperative atrial fibrillation was significantly lower in the heparin-coated group (21.8%) than in the control group (43.1%) (p = 0.002). Otherwise, there were no significant differences in the extubation times, the incidence of perioperative myocardial infarction, the creatinine concentration, the incidence of neurologic dysfunction, the progress in physical rehabilitation, or the hemoglobin concentration at discharge. CONCLUSIONS: The use of completely heparin coated cardiopulmonary bypass circuits and full systemic heparinization in patients undergoing coronary artery bypass procedures did not reduce postoperative bleeding or change clinical performance, except for a significant decrease in the incidence of postoperative atrial fibrillation.
Asunto(s)
Puente Cardiopulmonar , Heparina/administración & dosificación , Arritmias Cardíacas/etiología , Transfusión Sanguínea , Puente de Arteria Coronaria , Drenaje , Femenino , Humanos , Masculino , Mediastino , Persona de Mediana Edad , Cuidados Posoperatorios , Complicaciones Posoperatorias , Hemorragia Posoperatoria/prevención & control , Estudios ProspectivosRESUMEN
The possible activation of monocytes to express tissue factor procoagulant activity (TF-PCA) during CPB (cardiopulmonary bypass) was investigated. 22 patients undergoing myocardial revascularization were randomly assigned to two groups. In group C, heparin-coated circuits (Duraflo II) and reduced systemic heparinization (ACT > 250s) were used. In group NC, non-coated circuits and standard heparin administration (ACT > 480s) were used. Adherent monocytes retrieved from the oxygenators immediately after bypass arrest showed a 2-3-fold increase in TF-PCA when compared to circulating cells pre-CPB (P < 0.01). When cell PCA was expressed as percent change from pre-CPB (baseline) values, circulating monocytes in group NC at CPB-arrest showed a 2-fold increase in PCA compared to group C (P < 0.05). Moreover, the percent increase in PCA of oxygenator-retrieved monocytes was 7-fold in group NC and 2-fold in group C (P < 0.008 and P < 0.004, respectively). Thus, heparin-coating of the extracorporeal circuit reduced induction of adherent cell TF-PCA by 70% (P < 0.05). Thus, monocyte TF-PCA may cause activation of the extrinsic coagulation pathway during CPB surgery. It is apparent that heparin-coating enhanced biocompatibility of extracorporeal circuits. Reduced systemic heparinization in group C proved to be safe. However, further reduction of heparin administration may not be advisable, since monocytes were still activated in the coated oxygenator.
Asunto(s)
Factores de Coagulación Sanguínea/metabolismo , Puente de Arteria Coronaria , Circulación Extracorporea , Heparina/uso terapéutico , Tromboplastina/metabolismo , Coagulación Sanguínea , Femenino , Humanos , Lipopolisacáridos/metabolismo , Masculino , Microscopía Electrónica de Rastreo , Persona de Mediana Edad , Revascularización MiocárdicaRESUMEN
OBJECTIVE: Heparin-coated extracorporeal circuits allow reduced amounts of systemic heparin and protamine. However, the effects on the coagulation and fibrinolytic systems when reducing systemic anticoagulation, have partly remained unknown. METHODS: Thirty-three patients undergoing elective first time myocardial revascularization were prospectively randomized either to have a cardiopulmonary bypass (CPB) circuit completely coated with covalently bound heparin, in combination with reduced systemic heparinization (activated clotting time (ACT) > 250 s (n = 17), or to a control group perfused with identical but uncoated circuits and full heparin dose (ACT > 480 s) (n = 16). Tests indicative of thrombin generation, platelet activation, and fibrinolytic activity were performed intraoperatively and postoperatively. RESULTS: During CPB, the plasma level of prothrombin fragment 1.2 (PF 1.2) increased from median 1.5 (1.1-1.9) nmol/l to 5.4 (3.3-6.6) nmol/l in the heparin-coated group, and was significantly higher (P = 0.01) than the increase from 1.4 (1.2-1.9) nmol/l to 3.2 (2.2-4.3) nmol/l seen in the control group. However, the increase on CPB was modest compared to the major elevation observed after completed surgery and reversal of the anticoagulation. The concentrations reached median 9.7 (6.8-19.5) nmol/l in the heparin-coated group and 13.2 (4.2-18.4) nmol/l in the control group (no significant intergroup difference). A similar pattern was observed for the thrombin-antithrombin (TAT) complex. Regression analysis revealed significant correlation between the levels of the thrombin markers and duration of CPB in both groups (P < 0.05). There was no correlation between ACT or plasma heparin levels on bypass and the PF 1.2 and TAT complex. The platelet release of beta-thromboglobulin increased in both groups during CPB and significantly more in the control group at the end of bypass (P < 0.01), indicating less platelet activation in the heparin-coated group. There were no significant intergroup differences with regard to fibrinolytic activity. Plasma fibrinogen as well as platelet counts were unchanged after the operation, compared to baseline. Except for one patient in the control group sustaining perioperative myocardial infarction, the postoperative course was uneventful in all cases. CONCLUSIONS: Completely heparin-coated CPB can safely be performed in combination with reduced systemic heparinization. The heparin and protamine amounts could be lowered to 35% of normal doses. Indications of more thrombin generation on CPB compared to the uncoated controls were seen, but the levels remained within low ranges in both groups. There was no evidence of thromboembolic episodes or clot formation in the extracorporeal circuits.
Asunto(s)
Coagulación Sanguínea/efectos de los fármacos , Puente Cardiopulmonar/instrumentación , Fibrinólisis/efectos de los fármacos , Heparina , Revascularización Miocárdica , Adulto , Anciano , Coagulación Sanguínea/fisiología , Diseño de Equipo , Femenino , Fibrinólisis/fisiología , Heparina/administración & dosificación , Humanos , Masculino , Persona de Mediana Edad , Activación Plaquetaria/efectos de los fármacos , Activación Plaquetaria/fisiología , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/tratamiento farmacológico , Propiedades de Superficie , Trombina/metabolismo , Tiempo de Coagulación de la Sangre TotalRESUMEN
Complete heparin-coated extracorporeal circuits, including cardiotomy reservoir, have recently become available for routine cardiac surgery. The effects on complement and granulocyte activation using a heparin-coated circuit in combination with reduced systemic heparinization (activated clotting time (ACT) > 250 s) were studied in 33 patients undergoing elective first time myocardial revascularization. The patients were prospectively randomized either to a heparin-coated group (Group H, n = 17), or to a control group (Group C, n = 16) treated with an identical uncoated circuit and full heparin dose (ACT > 480 s). During cardiopulmonary bypass (CPB) the C3 activation products C3b, iC3b, and C3c (C3bc) and the terminal SC5b-9 complement complex (TCC) increased markedly in both groups compared to baseline, but to a much lesser extent in the heparin-coated group. The maximal increase of C3bc during the operation was a median of 28 arbitrary units (AU)/ml in the heparin-coated group, compared to 45 AU/ml in the control group (P = 0.01). Similarly, in Group H the maximal increase of TCC was significantly lower (median 0.8 AU/ml) than the levels recognized in Group C (median 1.9 AU/ml) (P < 0.0001). The release of the granulocyte activation enzymes lactoferrin and myeloperoxidase also increased during CPB in both groups compared to baseline level. The maximal increase of lactoferrin concentration was a median of 229 micrograms/l in Group H and significantly lower than 647 micrograms/l in the control group (P = 0.0002). As for myeloperoxidase, there were no significant intergroup differences. In conclusion, a complete heparin-coated circuit and low systemic heparinization for CPB in coronary artery surgery were associated with reduced activation of the complement system and less release of lactoferrin. The results indicate improved biocompatibility of this option for extracorporeal circulation.
Asunto(s)
Puente Cardiopulmonar/métodos , Activación de Complemento , Puente de Arteria Coronaria , Granulocitos/fisiología , Heparina/uso terapéutico , Adulto , Anciano , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Lactoferrina/metabolismo , Masculino , Persona de Mediana Edad , Peroxidasa/metabolismo , Estudios ProspectivosRESUMEN
BACKGROUND: Cardiopulmonary bypass with heparin-coated circuits allows reduced amounts of systemic heparin. Heparin inhibits activation of the complement cascade experimentally, but the effects of different levels of systemic heparin on activation of complement and granulocytes in patients have remained unknown. METHODS: Fifty-two patients undergoing coronary artery bypass procedures were studied. Cardiopulmonary bypass circuits completely coated with surface-bound heparin were used for one group given low-dose heparin (n = 17) (activated clotting time > 250 seconds), and was compared with a second group having normal high-dose heparin (activated clotting time > 480 seconds) (n = 18). A third control group was perfused with ordinary uncoated circuits and a full heparin dose (n = 17). RESULTS: During cardiopulmonary bypass, the C3 activation products C3b, iC3b, and C3c increased markedly in all three groups compared with baseline, but significantly less in the two heparin-coated groups (high dose, median maximal increase 58 arbitrary units (AU)/mL; low dose, 48 AU/mL) compared with the uncoated control group (74 AU/mL) (p < 0.01). The difference between the two coated groups was not significant. Similarly, the maximal increase in terminal SC5b-9 complement complex was considerably lower in the heparin-coated groups (high dose, 2.5 AU/mL; low dose, 2.6 AU/mL) compared with the level observed in the uncoated control group (5.3 AU/mL) (p < 0.01). The release of the granulocyte activation enzymes myeloperoxidase and lactoferrin increased from the beginning of the operation, with peak levels at the end of cardiopulmonary bypass (p < 0.01). The concentration of lactoferrin was significantly (p < 0.01) reduced in the low heparin dose group compared with the two other groups receiving normal high heparin doses, indicating that circulating heparin is an important granulocyte agonist, acting independently of the presence or absence of heparin-coated surfaces. Also for myeloperoxidase a higher level was observed in the high heparin dose group. CONCLUSIONS: Complement activation was significantly reduced in both heparin-coated groups and was independent of the level of systemic heparinization, whereas granulocyte activation was reduced only in patients who received low doses of systemically administered heparin. The results indicate that a moderate reduction of the systemic heparin dose may be an advantage with regard to improved biocompatibility when using heparin-coated cardiopulmonary bypass circuits.
Asunto(s)
Anticoagulantes/administración & dosificación , Puente Cardiopulmonar , Activación de Complemento/efectos de los fármacos , Granulocitos/fisiología , Heparina/administración & dosificación , Adulto , Anciano , Anticoagulantes/farmacología , Complemento C3/metabolismo , Complejo de Ataque a Membrana del Sistema Complemento/análisis , Proteínas del Sistema Complemento/análisis , Puente de Arteria Coronaria , Femenino , Glicoproteínas/análisis , Heparina/farmacología , Humanos , Lactoferrina/sangre , Masculino , Persona de Mediana Edad , Peroxidasa/sangreRESUMEN
Complement and granulocyte activation were studied in cardiopulmonary bypass circuits completely coated with either end-attached covalent-bonded heparin, the Carmeda BioActive Surface, or with the Duraflo II bonded heparin, in combination with reduced systemic heparinization (activated clotting time > 250 seconds). The control groups were perfused with uncoated circuits and full heparin dose (activated clotting time > 480 seconds). Altogether 67 patients undergoing elective first-time myocardial revascularization were investigated, having extracorporeal perfusion with a Duraflo II coated circuit (n = 17), an identical but uncoated circuit (n = 17), a Carmeda coated circuit (n = 17), or an equivalent uncoated circuit (n = 16). During cardiopulmonary bypass, the C3 activation products C3b, iC3b, and C3c (C3bc) and the terminal SC5b-9 complemented complex increased markedly in all four groups compared with baseline, but significantly less in the two coated groups than in their control groups. Additionally, a significantly lower concentration of C3bc was observed in the Carmeda coated group, with maximal increase of median 28 AU/ml compared with 50 AU/ml in the Duraflo II coated group (p = 0.003). Similarly, in the Carmeda coated group, the maximal increase of terminal complement complex was considerably lower (0.8 AU/ml) than the levels recognized in the Duraflo II coated group (2.4 AU/ml) (p < 0.001). The release of the granulocyte activation myeloperoxidase and lactoferrin increased from the beginning of the operation, with peak levels at the end of bypass. A significant reduction of lactoferrin release was recognized when comparing the coated groups with the control groups. The difference between the two coated groups (Carmeda 228 micrograms/L; Duraflo II 332 micrograms/L; p = 0.05) was marginally significant. For myeloperoxidase, no significant differences were observed between the coated and uncoated groups. In conclusion, both types of heparin-coated circuits reduced complement activation and release of lactoferrin, but the Carmeda circuit proved to be more effective than the Duraflo II equipment.
Asunto(s)
Puente Cardiopulmonar/instrumentación , Activación de Complemento , Puente de Arteria Coronaria , Granulocitos/inmunología , Heparina , Anciano , Puente Cardiopulmonar/efectos adversos , Complemento C3/análisis , Complejo de Ataque a Membrana del Sistema Complemento/análisis , Procedimientos Quirúrgicos Electivos , Femenino , Heparina/administración & dosificación , Humanos , Lactoferrina/sangre , Masculino , Persona de Mediana Edad , Peroxidasa/sangre , Propiedades de SuperficieRESUMEN
BACKGROUND: Extracorporeal circulation with circuits coated with surface-bound heparin has allowed reduced levels of systemic heparinization. Clinical benefits have included reduced postoperative bleeding and less homologous blood usage. However, the effects on the hemostatic and fibrinolytic systems have remained in part unknown. METHODS AND RESULTS: Indications of thrombin generation, platelet activation, and fibrinolytic activity were investigated in patients undergoing coronary artery bypass surgery. Two groups were perfused with cardiopulmonary bypass (CPB) circuits completely coated with surface-bound heparin: one group with low systemic heparin dose (activated clotting time [ACT] > 250 seconds; n = 17) and a second group having a full heparin dose (ACT > 480 seconds; n = 18). A third control group was perfused with ordinary uncoated circuits and full heparin dose (n = 17). The plasma level of thrombin-antithrombin complex and prothrombin fragment 1.2 increased in all groups during bypass, and somewhat more in both the heparin-coated groups toward the end of CPB, compared with the control group (P < .01). However, the increase during CPB was minimal compared with the major elevation observed 2 hours after surgery in all groups. Platelet release of beta-thromboglobulin increased in all groups (P < .01) during CPB and significantly more in the high-dose group compared with the other two groups (P = .03). Fibrinolytic activities were similar in all groups, and there were no indications of major consumption of coagulation factors. CONCLUSIONS: Reduced systemic heparinization (ACT > 250 seconds) in patients having extracorporeal circulation with completely heparin-coated circuits did not lead to increased thrombogenicity. Thrombin formation remained within low ranges during CPB compared with patients receiving a full heparin dose and with the major elevations observed after surgery.
Asunto(s)
Puente Cardiopulmonar , Heparina/administración & dosificación , Trombosis/prevención & control , Adulto , Anciano , Coagulación Sanguínea/efectos de los fármacos , Puente Cardiopulmonar/efectos adversos , Femenino , Fibrinólisis/efectos de los fármacos , Humanos , Masculino , Persona de Mediana Edad , Activación Plaquetaria/efectos de los fármacos , Trombina/análisis , Trombosis/fisiopatologíaRESUMEN
BACKGROUND: When heparinized circuits are used for cardiopulmonary bypass, the amounts of heparin and protamine administered systemically can be reduced. However, it is not entirely known what effects this reduction in systemic anticoagulation has on clinical performance and on the coagulation and fibrinolytic systems. METHODS: Two hundred three patients undergoing first-time elective myocardial revascularization were prospectively randomized either to a group in which a completely heparin-coated circuit was used for perfusion (group H; n = 101 patients) and in which a reduced heparin dose was given (activated clotting time, > 250 seconds) or to a control group (group C; n = 102 patients) in which an uncoated, but otherwise identical, circuit was used and in which full systemic heparinization was induced (activated clotting time, > 480 seconds). Indicators of thrombin generation, platelet activation, and fibrinolytic activity were studied in a subset of 34 patients. RESULTS: The total amount of postoperative mediastinal drainage was significantly reduced in group H (median, 575 mL) compared with that in group C (median, 635 mL; p = 0.002). Two patients in group C but none in group H received homologous red blood cell transfusions (p = not significant). The loss of hemoglobin in group H was a median of 21 g/L, and this was significantly lower than the 25 g/L noted in the control group (p = 0.006). During cardiopulmonary bypass, the plasma levels of thrombin-antithrombin complex and prothrombin fragment 1.2 increased in both groups. At the end of cardiopulmonary bypass the plasma levels of these markers of thrombin formation were significantly higher in group H, although the increase was modest compared with the major increase observed 2 hours after operation in both groups. There were no significant intergroup differences in the platelet counts, the concentration of beta-thromboglobulin, or the plasma levels of fibrinogen and D-dimer. No differences in perioperative morbidity, the postoperative kidney function, or the intubation time were observed, and there were no hospital deaths. CONCLUSIONS: The combination of complete heparin-coated cardiopulmonary bypass circuits and low systemic heparinization is safe for patients undergoing elective coronary artery bypass procedures and reduces the perioperative blood loss. There was no evidence of increased thrombogenicity, fibrinolytic activity, or consumption of coagulation factors. No clinical or technical side effects were observed.
Asunto(s)
Puente Cardiopulmonar/métodos , Hemostasis Quirúrgica/métodos , Heparina/administración & dosificación , Adulto , Anciano , Antitrombina III/análisis , Pérdida de Sangre Quirúrgica/prevención & control , Puente Cardiopulmonar/instrumentación , Procedimientos Quirúrgicos Electivos , Femenino , Fibrinólisis , Hemostasis , Humanos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica , Péptido Hidrolasas/análisis , Estudios Prospectivos , Protaminas/administración & dosificaciónRESUMEN
BACKGROUND: Ventricular fibrillation after declamping of the aorta after cardioplegic arrest is commonly managed by direct-current countershock. However, in coronary artery bypass grafting, placement of the electrodes can cause mechanical damage to the grafts and anastomoses, and the surgical procedure must be interrupted. As an alternative, intraaortic infusion of potassium chloride through the arterial line from the heart-lung machine was investigated. METHODS: In a series of 100 patients with postischemic ventricular fibrillation (group P), 20 mmol of potassium chloride (plus 10 mmol later if necessary) was added to the oxygenator reservoir and perfused through the arterial line into the proximal aorta. The results were compared with those in a matched control group of 100 patients primarily treated with direct-current countershock (group DC). RESULTS: In group P, the ventricular fibrillation was effectively converted to a supraventricular rhythm in 82% of the patients. The remaining 18 patients required significantly (p < 0.005) fewer electric shocks than the patients in group DC. Serum K+ levels were slightly elevated for a short period after the potassium chloride infusion. Otherwise there were no significant differences in regard to incidence of heart block, temporary epicardial pacing, myocardial infarction, or atrial fibrillation between the two groups. CONCLUSIONS: Conversion of postischemic ventricular fibrillation with potassium chloride administered through the arterial line from the heart-lung machine is an effective, gentle, and convenient method. No side effects were noted.