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Casselman FPA, Lance MD, Ahmed A, Ascari A, Blanco-Morillo J, Bolliger D, Eid M, Erdoes G, Haumann RG, Jeppsson A, van der Merwe HJ, Ortmann E, Petricevic M, Weltert LP, Milojevic M, EACTS/EACTAIC/EBCP Scientific Document Group
. 2024 EACTS/EACTAIC Guidelines on patient blood management in adult cardiac surgery in collaboration with EBCP. Eur J Cardiothorac Surg 2025; 67:ezae352. [PMID: 39385500 DOI: 10.1093/ejcts/ezae352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Collaborators] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 08/08/2024] [Accepted: 10/01/2024] [Indexed: 10/12/2024] Open
Affiliation(s)
- Filip P A Casselman
- Department of Cardiovascular Surgery, Heart Center OLV Clinic, Aalst, Belgium
| | - Marcus D Lance
- Aga Khan University Hospital Nairobi, Department of Anesthesiology, Nairobi, Kenya
| | - Aamer Ahmed
- Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Alice Ascari
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Juan Blanco-Morillo
- ECLS Care and Perfusion Unit, Cardiac Surgery Department, University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Maroua Eid
- University Hospital of Angers, Department of Cardiac Surgery, Angers, France
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Renard Gerhardus Haumann
- Department of Cardio-thoracic surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
- Department Of Biomechanical Engineering, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hendrik J van der Merwe
- Netcare Blaauwberg and Christiaan Barnard Memorial Hospital, The Keyhole Thorax Centre, Cape Town, South Africa
| | - Erik Ortmann
- Department of Anaesthesiology Schüchtermann-Klinik Heart Centre, Bad Rothenfelde, Germany
| | - Mate Petricevic
- Department of Cardiac Surgery, University Hospital Center Split, Split, Croatia
- University Department of Health Studies, University of Split, Split, Croatia
| | - Luca Paolo Weltert
- European Hospital, Cardiac Surgery Department, Rome, Italy
- Saint Camillus International University for Health Sciences, Heart Surgery Department, Rome, Italy
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
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Collaborators
J Rafael Sadaba, Marco Ranucci, Seema Agrawal, Adrian Bauer, Denis Berdajs, Stuart A McCluskey, Daniel Engelman, Tomas Gudbjartsson, Emma Hansson, Andreas Koster, Filip De Somer, Eric De Waal, Alexander Wahba, Fernando Yévenes,
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2
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Maxey-Jones C, Seelhammer TG, Arabia FA, Cho B, Cardonell B, Smith D, Leo V, Dias J, Shore-Lesserson L, Hartmann J. TEG® 6s-Guided Algorithm for Optimizing Patient Blood Management in Cardiovascular Surgery: Systematic Literature Review and Expert Opinion. J Cardiothorac Vasc Anesth 2025; 39:1162-1172. [PMID: 40016048 DOI: 10.1053/j.jvca.2025.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Revised: 01/24/2025] [Accepted: 02/06/2025] [Indexed: 03/01/2025]
Abstract
OBJECTIVES To propose a comprehensive TEG 6s-based intraoperative and/or immediately postoperative treatment algorithm for bleeding patients undergoing cardiac surgery. To achieve this, TEG-based treatment algorithms in cardiac surgery were evaluated through a literature review and structured expert opinion. DESIGN Systematic literature review. SETTING Cardiac surgery. PARTICIPANTS Adult patients undergoing cardiac surgery with intraoperative and/or immediately postoperative bleeding. INTERVENTIONS TEG-guided transfusion algorithm. MEASUREMENTS AND MAIN RESULTS A literature search was conducted for original studies reporting TEG-based treatment algorithms in cardiac surgery settings. Of 304 identified manuscripts, fourteen met all inclusion criteria, with two further articles identified through authors' suggestions. There is limited evidence describing the use of TEG 6s assays in cardiac surgery with only one study reporting a dedicated algorithm using the TEG 6s device at a non-US center. Two additional studies assessed TEG 6s assays. The remaining manuscripts reported algorithms based on the TEG 5000 device. Following the author's review of the available data, and feedback from expert opinion, a simple transfusion algorithm was proposed as an initial framework for developing a TEG 6s-based protocol with consideration for the 2021 Society of Thoracic Surgery/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology/Society for the Advancement of Patient Blood Management Patient Blood Management Guidelines. CONCLUSIONS A new algorithm for cardiac surgery based on TEG 6s assays has been proposed based on the available evidence and expert opinion for research alignment and clinical validation.
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Affiliation(s)
| | | | | | - Brian Cho
- Johns Hopkins University, Baltimore, MD
| | | | | | | | | | - Linda Shore-Lesserson
- Northwell, New Hyde Park, NY; and Anesthesiology, North Shore University Hospital, Manhasset, NY
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Velibey Y, Altay S, Bolca O. The management of antiplatelet therapy in patients with coronary artery disease and thrombocytopenia. Am J Med Sci 2025:S0002-9629(25)00986-3. [PMID: 40268271 DOI: 10.1016/j.amjms.2025.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Revised: 03/06/2025] [Accepted: 04/16/2025] [Indexed: 04/25/2025]
Abstract
Ischemic heart disease is the leading cause of death in the world. Patients who have acute coronary syndrome (ACS) or chronic coronary syndrome (CCS) with significant thrombocytopenia are at high risk for bleeding. In the literature, studies conducted on this patient group are very few. For this reason, although it is difficult for physicians to manage antiplatelet therapy in these patients, the risk of bleeding can be minimized with some current guideline recommendations. This review aims to explore in detail the management of antiplatelet therapy in patients who have moderate and severe thrombocytopenia with coronary artery disease (CAD).
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Affiliation(s)
- Yalçın Velibey
- Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Department of Cardiology, Istanbul, Türkiye.
| | - Servet Altay
- Faculty of Medicine Trakya University, Department of Cardiology, Edirne, Türkiye
| | - Osman Bolca
- Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Department of Cardiology, Istanbul, Türkiye
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Erdoes G, Birschmann I, Nagler M, Koster A. Personalizing Management of Antiplatelet Therapy in Cardiac Surgery: The Ongoing Need to Nourish "Dry Land". J Cardiothorac Vasc Anesth 2025; 39:873-876. [PMID: 39909766 DOI: 10.1053/j.jvca.2025.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2025] [Accepted: 01/17/2025] [Indexed: 02/07/2025]
Affiliation(s)
- Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Switzerland
| | - Andreas Koster
- Clinic for Anaesthesiology and Interdisciplinary Intensive Care Medicine, Sana Heart Center Cottbus, Germany and Ruhr-University Bochum, Germany
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So DYF, Wells GA, Lordkipanidzé M, Chong AY, Ruel M, Perrault LP, Le May MR, Sun L, Tran D, Labinaz M, Glover C, Russo J, Welman M, Chan V, Chen L, Bernick J, Rubens F, Tanguay JF. Early vs Delayed Bypass Surgery in Patients With Acute Coronary Syndrome Receiving Ticagrelor: The RAPID CABG Randomized Open-Label Noninferiority Trial. JAMA Surg 2025; 160:387-394. [PMID: 39969871 PMCID: PMC11840690 DOI: 10.1001/jamasurg.2024.7066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 12/05/2024] [Indexed: 02/20/2025]
Abstract
Importance Perioperative bleeding is a major concern in patients receiving ticagrelor for acute coronary syndromes (ACS) when coronary artery bypass graft (CABG) surgery is required. Objective To evaluate whether early CABG surgery at 2 to 3 days after ticagrelor cessation is noninferior to waiting 5 to 7 days. Design, Setting, and Participants RAPID CABG was a noninferiority, open-label randomized trial with 6 months of follow-up. Participants were patients with ACS who had received ticagrelor and required CABG. Patients were enrolled in tertiary centers in Canada between January 2016 and March 2021. Data were analyzed from March 2021 to December 2023. Intervention Early or delayed CABG. Main Outcomes and Measures The primary outcome was based on noninferiority comparison of class 3 or 4 universal definition of perioperative bleeding (UDPB). Noninferiority was prespecified as 8% between groups. Twelve-hour chest tube drainage was reported as a noninferiority comparison. Other bleeding, ischemic, and length-of-stay outcomes were assessed for superiority. Results Among 143 randomized patients, the median (IQR) age was 65 (58-72) years; there were 117 male patients (82%) and 26 female (18%). Of these, 123 patients (86.0%) underwent surgery in the allocated time frame (per protocol). The median (IQR) time to surgery was 3 (2-3) days in the early group and 6 (5-7) days in the delayed group (P < .001). In a per-protocol analysis, severe or massive UDPB occurred in 3 of 65 early-group patients (4.6%) and 3 of 58 patients (5.2%) in the delayed group (between-group difference, -0.6%; 95% CI, -8.3% to 7.1%; P = .03 for noninferiority). Median (IQR) chest tube drainage was 470 (330-650) mL vs 495 (380-610) mL (between-group difference -25 mL; 95% CI, -111.25 to 35; P = .01 for noninferiority). Median (IQR) hospital stay was 9 (7-13) days and 12 (10-15) days for the early and delayed groups (P < .001). Conclusion and Relevance This study found that an early surgical strategy, 2 to 3 days after ticagrelor cessation, was noninferior in incurring perioperative bleeding. The data support a reduction in the delay between ticagrelor cessation and CABG surgery and may decrease hospital length of stay. Trial Registration ClinicalTrials.gov Identifier: NCT02668562.
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Affiliation(s)
- Derek Y. F. So
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - George A. Wells
- Cardiovascular Research Methods Centre, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marie Lordkipanidzé
- Montreal Heart Institute Research Centre, Montreal, Quebec, Canada
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | - Aun Yeong Chong
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Louis P. Perrault
- Division of Cardiac Surgery, Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Michel R. Le May
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Louise Sun
- Division of Cardiac Anesthesia, Department of Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Diem Tran
- Division of Cardiac Anesthesia, Department of Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marino Labinaz
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Christopher Glover
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Juan Russo
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mélanie Welman
- Montreal Heart Institute Research Centre, Montreal, Quebec, Canada
| | - Vincent Chan
- Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Lily Chen
- Cardiovascular Research Methods Centre, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jordan Bernick
- Cardiovascular Research Methods Centre, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Fraser Rubens
- Division of Cardiac Surgery, Department of Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jean-Francois Tanguay
- Department of Medicine, Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
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Ong BJA, See Tow HX, Fong ATW, Ling RR, Shekar K, Teoh K, Ti LK, MacLaren G, Fan BE, Ramanathan K. Monitoring Hemostatic Function during Cardiac Surgery with Point-of-Care Viscoelastic Assays: A Narrative Review. Semin Thromb Hemost 2025. [PMID: 39938563 DOI: 10.1055/s-0045-1802573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2025]
Abstract
Bleeding is a well-known and severe complication of cardiac surgery. Cardiopulmonary bypass, along with heparinization and hemodilution, is thought to affect all pathways of the hemostatic process, leading to excessive bleeding and worsened morbidity and mortality. The traditionally used standard laboratory tests (SLTs) were not designed for the surgical setting, have long turnaround times, and are poor predictors of bleeding. This review aims to give an overview of viscoelastic assays (VEAs), compare VEAs to conventional testing methods, and summarize the evidence for VEAs in cardiac surgery. A search of Medline via Pubmed, Scopus, and Embase yielded 2,868 papers, which we reviewed and summarized the key findings. VEAs such as rotational thromboelastometry and thromboelastography provide a quick turnaround, graphical, global impression of hemostasis in whole blood. VEAs allow for the analysis of specific contributors to the coagulation process and may facilitate cause-oriented hemostatic treatment and the development of treatment algorithms. VEAs have been found to have a high specificity and high negative predictive value for coagulopathic bleeding. Patients treated with VEA-based algorithms have been shown to have lower rates of bleeding, transfusion requirements, and exposure to allogeneic blood products. However, VEA-based algorithms have not demonstrated a mortality benefit and evidence for outcomes such as surgical re-exploration and hospital length of stay remains equivocal. In conclusion, VEAs have been shown to be comparable if not superior to SLTs in cardiac surgery. Further large-scale studies are needed to better evaluate the impact of VEAs on clinical outcomes.
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Affiliation(s)
- Brandon Jin An Ong
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Hui Xin See Tow
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Alyssa Tze Wei Fong
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Australia and New Zealand Intensive Care Research Centre, School of Preventive Medicine and Public Health, Monash University, Melbourne, Victoria, Australia
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore
| | - Kiran Shekar
- Intensive Care Unit, Caboolture Hospital, Brisbane, Queensland, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Queensland, Australia
- Faculty of Health, Queensland University of Technology, University of Queensland, Brisbane, Queensland, Australia
| | - Kristine Teoh
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Division of Adult Cardiac Surgery, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Lian Kah Ti
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Bingwen Eugene Fan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Hematology, Tan Tock Seng Hospital, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
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Paciullo F, Gresele P. Antiplatelet Therapy in Low-Platelet-Count Patients After Percutaneous Coronary Intervention for Acute Coronary Syndromes. J Clin Med 2025; 14:838. [PMID: 39941509 PMCID: PMC11818633 DOI: 10.3390/jcm14030838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2024] [Revised: 01/13/2025] [Accepted: 01/21/2025] [Indexed: 02/16/2025] Open
Abstract
The risk of cardiovascular events increases considerably after an acute coronary syndrome (ACS), particularly in the first few months. Dual antiplatelet therapy represents the mainstay of secondary prevention during this period, but is associated with a not-negligible risk of bleeding which, among other factors, is influenced by the platelet count. Thrombocytopenic patients may experience an ACS, and several patients with ACSs develop thrombocytopenia during hospitalization: the management of antithrombotic therapy in this setting represents a challenge. Here, we review the available evidence on the use of antithrombotic therapy in patients with low platelet counts after an ACS.
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Affiliation(s)
- Francesco Paciullo
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
| | - Paolo Gresele
- Department of Medicine and Surgery, University of Perugia, Strada Vicinale Via Delle Corse, 06132 Perugia, Italy;
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Mazzeffi M, Tanaka KA, Gurbel PA, Tantry US, Levy JH. Platelet P2Y12 Receptor Inhibition and Perioperative Patient Management. Anesthesiology 2025; 142:202-216. [PMID: 39392789 DOI: 10.1097/aln.0000000000005148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2024]
Affiliation(s)
- Michael Mazzeffi
- University of Virginia School of Medicine, Department of Anesthesiology, Charlottesville, Virgina
| | - Kenichi A Tanaka
- Oklahoma University School of Medicine, Department of Anesthesiology, Oklahoma City, Oklahoma
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Jerrold H Levy
- Duke University School of Medicine, Department of Anesthesiology, Durham, North Carolina
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Dai J, Su L. Perioperative Application of Point-of-care Test for Blood Viscoelasticity: A Good Choice for Coagulation Management. J Perianesth Nurs 2024:S1089-9472(24)00396-4. [PMID: 39520424 DOI: 10.1016/j.jopan.2024.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 08/08/2024] [Accepted: 08/08/2024] [Indexed: 11/16/2024]
Abstract
Point-of-care test (POCT) of blood viscoelasticity can reflect the coagulation status of patients accurately and timely. POCT can be used to monitor the effect of preoperative antithrombotic drugs on coagulation function, which will inform the selection of appropriate surgical timing. It can also be applied to analyze the reasons of intraoperative bleeding and guide the transfusion of blood products. Also, it is useful to assess the risk of postoperative thromboembolism and hint the need for prophylactic anticoagulation. This article mainly introduces the principles and clinical application of several frequently used POCTs for blood viscoelasticity, with a focus on their role in special types of diseases in which coagulation function changes significantly, such as cardiac disease, trauma, pathological obstetrics, and liver disease. Furthermore, we describe the role of microparticle in coagulation, which is a novel potential biomarker for diagnosing thrombotic disorders and possesses potential to be applied in POCTs of blood viscoelasticity.
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Affiliation(s)
- Jiazhen Dai
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Lin Su
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, China.
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10
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Petricevic M, Goerlinger K, Milojevic M, Petricevic M. Methodological Considerations for Studies Evaluating Bleeding Prediction Using Hemostatic Point-of-Care Tests in Cardiac Surgery. J Clin Med 2024; 13:6737. [PMID: 39597881 PMCID: PMC11595064 DOI: 10.3390/jcm13226737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 10/28/2024] [Accepted: 11/04/2024] [Indexed: 11/29/2024] Open
Abstract
A certain proportion of patients undergoing cardiac surgery may experience bleeding complications that worsen outcomes. Numerous studies have investigated bleeding in cardiac surgery and some evaluate the role of hemostatic point-of-care tests in cardiac surgery patients. The prevalence of excessive bleeding varies in the literature, and such variability stems from the lack of a standardized definition of excessive bleeding. Herein, we report numerous definitions of excessive bleeding and methodological considerations for studies evaluating bleeding using hemostatic point-of-care tests in cardiac surgery patients. We evaluated the role of hemostatic point-of-care devices in contemporary research on bleeding complications and hemostatic management in cardiac surgery. The type of studies (prospective vs. retrospective, interventional vs. observational), patient selection (less complex vs. complex cases), as well as data analysis with comprehensive statistical considerations have also been provided. This article provides a comprehensive insight into the research field of bleeding complications in cardiac surgery and may help readers to better understand methodological flaws and how they influence current evidence.
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Affiliation(s)
- Mirna Petricevic
- University Department of Health Studies, University of Split, 21000 Split, Croatia;
| | - Klaus Goerlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45127 Essen, Germany;
- Medical Department, Tem Innovations, 80331 Munich, Germany
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, 101801 Belgrade, Serbia;
| | - Mate Petricevic
- University Department of Health Studies, University of Split, 21000 Split, Croatia;
- School of Medicine, University Hospital of Split, University of Split, 21000 Split, Croatia
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Dambruoso P, Raimondo P, Massaro F, D'Aniello M, Di pinto G. Thromboelastography with Platelet Mapping to Optimize Surgical Timing in Coronary Artery Bypass Grafting Patients on P2Y12 Receptor Blockers Therapy. Braz J Cardiovasc Surg 2024; e20230292:e20230292. [PMID: 39471263 PMCID: PMC11495379 DOI: 10.21470/1678-9741-2023-0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 12/11/2023] [Indexed: 11/01/2024] Open
Abstract
INTRODUCTION An increasing number of patients attending coronary artery bypass grafting (CABG) receive preoperative antiplatelet drugs (acetylsalicylic acid, clopidogrel, prasugrel, ticagrelor). The optimal assessment of preoperative platelet function is the aim of this study for a shorter surgical timing in patients undergoing elective coronary artery bypass grafting. METHODS This study was performed on patients presenting for first-time isolated CABG on therapy with an P2Y12 receptor blockers loading dose (clopidogrel [300 mg] or prasugrel [60 mg] or ticagrelor [180 mg]) or P2Y12 receptor blockers maintenance therapy at least for five days (clopidogrel [75 mg once daily], prasugrel [10 mg once daily], ticagrelor [90 mg twice daily]). All patients received simultaneously acetylsalicylate acid (100 mg daily). Exclusion criterion was emergency CABG regardless of preoperative antiplatelet and anticoagulant therapy. All patients' data were recorded in an Excel® file and analyzed using RStudio® software. RESULTS Forty-eight consecutive adult patients presenting for CABG were enrolled. Preoperative thromboelastography-platelet mapping showed platelet resistance to P2Y12 blockers receptor - 25% for clopidogrel (6/24), 33% for ticagrelor (6/18), 33% for prasugrel (2/6), and this data was useful to obtain a shorter CABG waiting time in comparison with current guidelines (2.7 vs. five days for clopidogrel, 2.5 vs. five days for ticagrelor, 3.3 vs. seven days for prasugrel). CONCLUSION Preoperative thromboelastography-platelet mapping is helpful to detect harmful P2Y12 receptor blockers resistance and to minimize CABG waiting time avoiding unnecessary and life-threatening delays.
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Affiliation(s)
| | - Pasquale Raimondo
- Anesthesia and Intensive Care Unit II, Azienda
Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Puglia, Italy
| | - Fabrizia Massaro
- Anesthesia and Intensive Care Unit, Ospedale Generale Regionale F.
Miulli, Acquaviva delle Fonti, Puglia, Italy
| | - Margherita D'Aniello
- Anesthesia and Intensive Care Unit II, Azienda
Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Puglia, Italy
| | - Giuseppe Di pinto
- Anesthesia and Intensive Care Unit II, Azienda
Ospedaliero-Universitaria Consorziale Policlinico di Bari, Bari, Puglia, Italy
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Mehta C, Osorio B, Sodha NR, Gibson HC, Clancy A, Poppas A, Hyder ON, Saad M, Kataria R, Abbott JD, Vallabhajosyula S. Anticoagulation Medications, Monitoring, and Outcomes in Patients with Cardiogenic Shock Requiring Temporary Mechanical Circulatory Support. J Card Fail 2024; 30:1343-1354. [PMID: 39389745 DOI: 10.1016/j.cardfail.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/07/2024] [Accepted: 07/11/2024] [Indexed: 10/12/2024]
Abstract
Cardiogenic shock (CS) is a syndrome of low cardiac output resulting in critical end-organ hypoperfusion and hypoxia. The mainstay of management involves optimizing preload, afterload and contractility. In medically refractory cases, temporary percutaneous mechanical support (MCS) is used as a bridge to recovery, surgical ventricular assist device, or transplant. Anticoagulation is recommended to prevent device-related thromboembolism. However, MCS can be fraught with hemorrhagic complications, compounded by incident multisystem organ failure often complicating CS. Currently, there are limited data on optimal anticoagulation strategies that balance the risk of bleeding and thrombosis, with most centers adopting local antithrombotic stewardship practices. In this review, we detail anticoagulation protocols, including anticoagulation agents, therapeutic monitoring, and complication mitigation in CS requiring MCS. This review is intended to provide an evidence-based framework in this population at high risk for in-hospital bleeding and mortality.
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Affiliation(s)
- Chirag Mehta
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Brian Osorio
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Neel R Sodha
- Division of Cardiothoracic Surgery, Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI; Lifespan Cardiovascular Institute, Providence, RI
| | - Halley C Gibson
- Department of Pharmacy, Rhode Island Hospital, Providence, RI
| | | | - Athena Poppas
- Lifespan Cardiovascular Institute, Providence, RI; Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Omar N Hyder
- Lifespan Cardiovascular Institute, Providence, RI; Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Marwan Saad
- Lifespan Cardiovascular Institute, Providence, RI; Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Rachna Kataria
- Lifespan Cardiovascular Institute, Providence, RI; Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - J Dawn Abbott
- Lifespan Cardiovascular Institute, Providence, RI; Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Saraschandra Vallabhajosyula
- Lifespan Cardiovascular Institute, Providence, RI; Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI.
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13
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Swan D, Turner R, Douketis J, Thachil J. How to undertake procedures while on antiplatelet agents: a hematologist's view. Res Pract Thromb Haemost 2024; 8:102539. [PMID: 39318772 PMCID: PMC11419924 DOI: 10.1016/j.rpth.2024.102539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/28/2024] [Accepted: 06/27/2024] [Indexed: 09/26/2024] Open
Abstract
Cardiovascular diseases (CVDs) are the leading cause of mortality globally while also contributing to excess health system costs. Significant advancements have been made in the understanding and prevention of deaths from CVD. In addition to risk factor modifications, one of the key developments in this area is the appropriate prescribing of antiplatelet medications for secondary prevention of CVD. With the advent of vascular devices, there has been an increased use of potent antiplatelet agents to mitigate thrombosis risk. A well-recognized, albeit rare complication of antiplatelet drugs is the heightened risk of bleeding. This adverse effect is particularly relevant when a patient receiving these medications may require an urgent surgery. In addition, for elective surgeries, although these drugs can be withheld, there may be some situations when interruption of antiplatelet agents, even for short duration, may lead to thrombotic events. There are no robust guidelines on how to manage these clinical scenarios, although there have been some important studies published recently in this area. In this review, we provide our approach to patients on antiplatelet drugs who may require urgent surgeries or surgical interventions.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, Austin Health, Melbourne, Victoria, Australia
| | - Robert Turner
- Department of Intensive Care, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - James Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, Ontario, Canada
| | - Jecko Thachil
- Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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14
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Vervoort D, Sud M, Zeis TM, Haouzi AA, An KR, Rocha R, Eikelboom R, Fremes SE, Tamis-Holland JE. Do the Few Dictate Care for the Many? Revascularisation Considerations That Go Beyond the Guidelines. Can J Cardiol 2024; 40:275-289. [PMID: 38181974 DOI: 10.1016/j.cjca.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 01/07/2024] Open
Abstract
The burden of coronary artery disease (CAD) is large and growing, commonly presenting with comorbidities and older age. Patients may benefit from coronary revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), yet half of patients with CAD who would benefit from revascularisation fall outside the eligibility criteria of trials to date. As such, the choice of revascularisation procedures varies depending on the CAD anatomy and complexity, surgical risk and comorbidities, the patient's preferences and values, and the treating team's expertise. The recent American guidelines on coronary revascularisation are comprehensive in describing recommendations for PCI, CABG, or conservative management in patients with CAD. However, individual challenging patient presentations cannot be fully captured in guidelines. The aim of this narrative review is to summarise common clinical scenarios that are not sufficiently described by contemporary clinical guidelines and trials in order to inform heart team members and trainees about the nuanced considerations and available evidence to manage such cases. We discuss clinical cases that fall beyond the current guidelines and summarise the relevant evidence evaluating coronary revascularisation for these patients. In addition, we highlight gaps in knowledge based on a lack of research (eg, ineligibility of certain patient populations), underrepresentation in research (eg, underenrollment of female and non-White patients), and the surge in newer minimally invasive and hybrid techniques. We argue that ultimately, evidence-based medicine, patient preference, shared decision making, and effective heart team communications are necessary to best manage complex CAD presentations potentially benefitting from revascularisation with CABG or PCI.
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Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Maneesh Sud
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Tessa M Zeis
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alice A Haouzi
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Eikelboom
- Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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15
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Abstract
Viscoelastic testing methods examine the real-time formation of a clot in a whole blood sample, and include thromboelastography (TEG), rotational thromboelastometry (ROTEM), and several other testing platforms. They allow for concurrent assessment of multiple aspects of clotting, including plasmatic coagulation factors, platelets, fibrinogen, and the fibrinolytic pathway. This testing is rapid and may be performed at the point-of-care, allowing for prompt identification of coagulopathies to guide focused and rational administration of blood products as well as the identification of anticoagulant effect. With recent industry progression towards user-friendly, cartridge-based, portable instruments, viscoelastic testing has emerged in the 21st century as a powerful tool to guide blood transfusions in the bleeding patient, and to identify and treat both bleeding and thrombotic conditions in many operative settings, including trauma surgery, liver transplant surgery, cardiac surgery, and obstetrics. In these settings, the use of transfusion algorithms guided by viscoelastic testing data has resulted in widespread improvements in patient blood management as well as modest improvements in select patient outcomes. To address the increasingly wide adoption of viscoelastic methods and the growing number of medical and laboratory personnel tasked with implementing, performing, and interpreting these methods, this chapter provides an overview of the history, physiology, and technology behind viscoelastic testing, as well as a practical review of its clinical utility and current evidence supporting its use. Also included is a review of testing limitations and the contextual role played by viscoelastic methods among all coagulation laboratory testing.
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Affiliation(s)
- Timothy Carll
- Department of Pathology, University of Chicago, Chicago, IL, United States.
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16
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Schoerghuber M, Bärnthaler T, Prüller F, Mantaj P, Cvirn G, Toller W, Klivinyi C, Mahla E, Heinemann A. Supplemental fibrinogen restores thrombus formation in cardiopulmonary bypass-induced platelet dysfunction ex vivo. Br J Anaesth 2023; 131:452-462. [PMID: 37087333 PMCID: PMC10485366 DOI: 10.1016/j.bja.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Major cardiac surgery related blood loss is associated with increased postoperative morbidity and mortality. Platelet dysfunction is believed to contribute to post-cardiopulmonary bypass (CPB)-induced microvascular bleeding. We hypothesised that moderately hypothermic CPB induces platelet dysfunction and that supplemental fibrinogen can restore in vitro thrombus formation. METHODS Blood from 18 patients, undergoing first-time elective isolated aortic valve surgery was drawn before CPB, 30 min after initiation of CPB, and after CPB and protamine administration, respectively. Platelet aggregation was quantified by optical aggregometry, platelet activation by flow-cytometric detection of platelet surface expression of P-selectin, annexin V, and activated glycoprotein IIb/IIIa, thrombus formation under flow and effect of supplemental fibrinogen (4 mg ml-1) on in vitro thrombogenesis. RESULTS Post-CPB adenosine-diphosphate and TRAP-6-induced aggregation decreased by 40% and 10% of pre-CPB levels, respectively (P<0.0001). Although CPB did not change glycoprotein IIb/IIIa receptor expression, it increased the percentage of unstimulated P-selectin (1.2% vs 7%, P<0.01) positive cells and annexin V mean fluorescence intensity (15.5 vs 17.2, P<0.05), but decreased percentage of stimulated P-selectin (52% vs 26%, P<0.01) positive cells and annexin V mean fluorescence intensity (508 vs 325, P<0.05). Thrombus area decreased from 6820 before CPB to 5230 after CPB (P<0.05, arbitrary units [a.u.]). Supplemental fibrinogen increased thrombus formation to 20 324 and 11 367 a.u. before CPB and after CPB, respectively (P<0.001), thereby restoring post-CPB thrombus area to levels comparable with or higher than pre-CPB baseline. CONCLUSIONS Single valve surgery using moderately hypothermic CPB induces partial platelet dysfunction. Thrombus formation was restored in an experimental study design by ex vivo supplementation of fibrinogen.
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Affiliation(s)
- Michael Schoerghuber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Bärnthaler
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria.
| | - Florian Prüller
- Clinical Institute of Medical Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Polina Mantaj
- Department of Cardiac Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Cvirn
- Otto Loewi Research Center, Division of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Christoph Klivinyi
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Akos Heinemann
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria
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17
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 129] [Impact Index Per Article: 64.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Hartmann J, Curzen N. Modified Thromboelastography for Peri-interventional Assessment of Platelet Function in Cardiology Patients: A Narrative Review. Semin Thromb Hemost 2023; 49:192-200. [PMID: 36252602 PMCID: PMC9894686 DOI: 10.1055/s-0042-1757545] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Viscoelastic testing (VET), such as thromboelastography, can measure whole blood coagulation dynamics in real time and is used across a range of clinical settings, including cardiac surgery, liver transplant, and trauma. The use of modified thromboelastography with platelet function assessment (TEG(R) PlateletMapping(R) Assay) can provide an analysis of platelet contribution to hemostasis, including the contribution of the P2Y12 receptor and thromboxane pathway to platelet function. The TEG PlateletMapping Assay has shown high correlation with the current gold standard test of platelet function, light transmission aggregometry, to measure arachidonic acid and adenosine diphosphate agonist-induced platelet activation. Studies have also shown comparable results with other whole blood platelet function tests. In this review, we explore the clinical applications of modified thromboelastography with platelet function assessment. This includes guiding dual antiplatelet therapy in relation to cardiac procedures, such as percutaneous coronary interventions, transcatheter aortic valve replacement, and left atrial appendage closure. We also explore the developing use of thromboelastography in the emergency care setting of coronavirus disease 2019, which is commonly associated with a hypercoagulable and hypofibrinolytic state. Despite a general lack of high-quality, grade 1 evidence regarding the use of modified thromboelastography with platelet function assessment in these disease areas, the ability of the TEG PlateletMapping Assay to measure global hemostasis and platelet reactivity rapidly and to view and evaluate results at the point of care makes it a promising area for further study for managing patient treatment and optimizing hemostatic therapy.
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Affiliation(s)
| | - Nick Curzen
- Faculty of Medicine, University of Southampton & Cardiothoracic Department, University Hospital Southampton, United Kingdom
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19
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Kumar K, Kumar R. The routine use of platelet function tests in elective coronary artery bypass grafting: A prospective observational trial. J Card Surg 2022; 37:4006-4007. [PMID: 36116055 DOI: 10.1111/jocs.16946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Kantash Kumar
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Rohit Kumar
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
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20
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 441] [Impact Index Per Article: 147.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Hassan K, Thielmann M, Easo J, Kamler M, Wendt D, Haidari Z, Deliargyris E, El Gabry M, Ruhparwar A, Geidel S, Schmoeckel M. Removal of Apixaban during Emergency Cardiac Surgery Using Hemoadsorption with a Porous Polymer Bead Sorbent. J Clin Med 2022; 11:5889. [PMID: 36233756 PMCID: PMC9572487 DOI: 10.3390/jcm11195889] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Patients on direct oral anticoagulants are at high risk of perioperative bleeding complications. We analyzed the results of intraoperative hemoadsorption (HA) in patients undergoing cardiac surgery who were also on concurrent therapy with apixaban. Methods: we included 25 consecutive patients on apixaban who underwent cardiac surgery with the use of cardio-pulmonary bypass (CPB) at three sites. The first 12 patients underwent surgery without hemoadsorption (controls), while the next 13 consecutive patients were operated with the Cytosorb® (Princeton, NJ, USA) device integrated into the CPB circuit (HA group). The primary outcome was perioperative bleeding assessed by the Bleeding Academic Research Consortium (BARC) definition and secondary outcomes included 24 h chest-tube-drainage (CTD) and need for 1-deamino-8-d-arginine-vasopressin (desmopressin (DDAVP)) administration to achieve hemostasis. Results: Preoperative mean daily dose of apixaban was higher in the HA group (8.5 ± 2.4 vs. 5.6 ± 2.2 mg, p = 0.005), while time since last apixaban dose was longer in the controls (1.3 ± 0.9 vs. 0.6 ± 1.2 days, p < 0.001). No BARC-4 bleeding events and no repeat-thoracotomies occurred in the HA group compared with 3 and 1, respectively, in the controls. Postoperative 24 h CTD volume was significantly lower in the HA group (510 ± 152 vs. 893 ± 579 mL, p = 0.03) and there was no need for DDAVP compared to controls, who received an average of 10 ± 13.6 mg (p = 0.01). Conclusions: In patients on apixaban undergoing emergent cardiac surgery, the intraoperative use of hemoadsorption was feasible and safe. Compared to patients operated on without hemoadsorption, BARC-4 bleeding complications did not occur and the need for 24 h CTD and DDAVP was significantly lower.
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Affiliation(s)
- Kambiz Hassan
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, 20099 Hamburg, Germany
| | - Matthias Thielmann
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
| | - Jerry Easo
- Department of Cardiac Surgery Essen-Huttrop, University of Essen, 45138 Essen, Germany
| | - Markus Kamler
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
- Department of Cardiac Surgery Essen-Huttrop, University of Essen, 45138 Essen, Germany
| | - Daniel Wendt
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
- CytoSorbents, Princeton, NJ 08540, USA
| | - Zaki Haidari
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
| | | | - Mohamed El Gabry
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
| | - Stephan Geidel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, 20099 Hamburg, Germany
| | - Michael Schmoeckel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, 20099 Hamburg, Germany
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22
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Volod O, Wegner J. Viscoelastic Testing in the Management of Adult Patients on Mechanical Circulatory Support Devices with Focus on Extracorporeal Membrane Oxygenation. Semin Thromb Hemost 2022; 48:814-827. [DOI: 10.1055/s-0042-1756303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractThromboembolic and hemorrhagic complications continue to remain frequent complications that significantly impact the morbidity and mortality of patients implanted with mechanical circulatory support devices (MCSDs). The severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2) has resulted in a number of COVID-19 patients being supported by MCSDs, specifically extracorporeal membrane oxygenation (ECMO), which in turn has created a crucial need for rapid assessment of hemostatic status in these patients to avoid bleeding and thrombotic complications. Currently, conventional plasma-based coagulation assays such as prothrombin time and activated partial thromboplastin time (aPTT) are used to assess hemostasis, and the activated clotting time (ACT) and aPTT are the most common tests used to monitor heparin anticoagulation in patients on ECMO. Unfractionated heparin remains the mainstay anticoagulation therapy for patients on ECMO. Extracorporeal Life Support Organization (ELSO) offers little guidance on the subject but does state that each institution should create its internal anticoagulation protocols. Viscoelastic assays (VEAs) are increasingly recognized by ELSO and ECMO community for their potential to assess hemostatic derangements in patients implanted with MCSDs as well as guidance for appropriate hemostatic therapy. This review focuses on the evidence for the use of viscoelastic assays to assess overall hemostasis and to guide the treatment of adult patients connected to an ECMO circuit. Limitations of the use of conventional assays, ACT, and VEA are also discussed.
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Affiliation(s)
- Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Julie Wegner
- College of Health Professions, South University Online, Savannah, Georgia
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23
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Soh S, Shin YR, Song JW, Choi JH, Kwak YL, Shim JK. Platelet Reactivity and Outcomes after Off-Pump Coronary Surgery in Acute Coronary Syndrome Patients. J Clin Med 2022; 11:jcm11123285. [PMID: 35743360 PMCID: PMC9224657 DOI: 10.3390/jcm11123285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/02/2022] [Accepted: 06/06/2022] [Indexed: 11/18/2022] Open
Abstract
Ischemic and hemorrhagic complications are major determinants of survival in acute coronary syndrome (ACS) patients undergoing coronary surgery. We investigated the association of preoperative platelet reactivity to P2Y12 antagonists with ischemic and hemorrhagic complications after Off-Pump Coronary Artery Bypass surgery (OPCAB) in ACS patients who received dual anti-platelet therapy (DAPT) within 5 days prior to surgery. This prospective, observational study with 177 patients compared the incidence of perioperative major bleeding and major adverse cardiac events (MACEs) in relation to the tertile distribution of the % inhibitory response to P2Y12 antagonists, as measured by a thromboelastography platelet mapping assay. The incidences of perioperative major bleeding and MACEs were similar in relation to the tertile distribution of inhibitory response to P2Y12 antagonists. The % inhibitory responses to P2Y12 antagonists between patients who did or did not exhibit MACEs, and with or without major bleeding, were 58 ± 20% and 56 ± 20% (p = 0.578) and 57 ± 19% and 56 ± 21% (p = 0.923), respectively. In ACS patients who received DAPT close to OPCAB, the platelet inhibitory response to P2Y12 antagonists was not associated with ischemic or hemorrhagic complications. OPCAB may obviate the need for routine platelet function testing for ACS patients requiring DAPT and surgical revascularization. Clinical Registration Number: NCT02184884.
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Affiliation(s)
- Sarah Soh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul 03722, Korea; (S.S.); (J.-W.S.); (J.H.C.); (Y.-L.K.)
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul 03722, Korea
| | - Yu Rim Shin
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul 03722, Korea;
| | - Jong-Wook Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul 03722, Korea; (S.S.); (J.-W.S.); (J.H.C.); (Y.-L.K.)
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul 03722, Korea
| | - Jun Hyug Choi
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul 03722, Korea; (S.S.); (J.-W.S.); (J.H.C.); (Y.-L.K.)
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul 03722, Korea; (S.S.); (J.-W.S.); (J.H.C.); (Y.-L.K.)
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul 03722, Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul 03722, Korea; (S.S.); (J.-W.S.); (J.H.C.); (Y.-L.K.)
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul 03722, Korea
- Correspondence: ; Tel.: +82-2-2228-8500
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Gurbel PA, Navarese EP, Myat A, Tantry US. Peri‐procedural Platelet Function Testing in Risk Stratification and Clinical Decision Making. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Hensley NB, Ariyo PT, Holmes SD, Williams MS, Joseph Robert Whitman G, Ad N, Metkus TS. Center Variation in Use of Preoperative Dual Antiplatelet Therapy and Platelet Function Testing at the Time of Coronary Artery Bypass Grafting in Maryland. Anesth Analg 2022; 135:567-575. [PMID: 35426835 DOI: 10.1213/ane.0000000000005964] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Patients presenting with acute coronary syndrome are administered a P2Y12 inhibitor and aspirin before coronary catheterization to prevent further myocardial injury from thrombosis. Guidelines recommend a standard waiting period between the time patients are administered dual antiplatelet therapy (DAPT) and elective cardiac surgery. Since 25% to 30% of the population may be considered nonresponders to clopidogrel, platelet function testing can be utilized for timing of surgery and to assess bleeding risks. The extent to which a standard waiting period or platelet function testing is used across centers is not established, representing an important opportunity to standardize practice. METHODS We conducted a retrospective cohort study from 2011 to 2020 using data from the Maryland Cardiac Surgical Quality Initiative, a consortium of all 10 hospitals in the state performing cardiac surgery. The proportion of patients administered DAPT within 5 days of surgery was examined by hospital over the time period. Mixed-effects multivariable logistic regressions were used to examine the association of preoperative DAPT with ischemic and bleeding outcomes. Centers were surveyed on use or nonuse of preoperative platelet function testing, and bleeding outcomes were compared. RESULTS There was significant heterogeneity of preoperative DAPT usage across centers ranging from 2% to 54% (P < .001). DAPT within 5 days of isolated coronary artery bypass grafting (CABG) was associated with higher odds of reoperation for bleeding (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.19-2.01; P = .001), >2 units of red blood cells (RBCs) transfused (OR, 1.62; 95% CI, 1.44-1.81; P < .001), and >2 units of non-RBCs transfused (OR, 1.79; 95% CI, 1.60-2.00; P < .001). In the 5 hospitals using preoperative platelet function testing to guide timing of surgery, there were greater odds for DAPT within 5 days (OR, 1.33; 95% CI, 1.22-1.45; P < .001), fewer RBCs >2 units transfusions (22% vs 33%; P < .001), and non-RBCs >2 units (17% vs 28%; P < .001) transfusions within DAPT patients. CONCLUSIONS There is significant variability in DAPT usage within 5 days of CABG between hospital centers. Preoperative platelet function testing may allow for earlier timing of surgery for those on DAPT without increased bleeding risks.
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Affiliation(s)
- Nadia B Hensley
- From the Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Promise T Ariyo
- From the Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sari D Holmes
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Marlene S Williams
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Joseph Robert Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Niv Ad
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.,Division of Cardiac Surgery, Adventist Health Care White Oak Medical Center, Silver Spring, Maryland
| | - Thomas Stephen Metkus
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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26
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Wang Z, Zou Y, Xia L, Li X, Yao Y, Ye Y, Lv Q. Does thromboelastography predict bleeding in patients treated with clopidogrel or ticagrelor in off-pump coronary artery bypass grafting? Thromb Res 2022; 213:145-153. [DOI: 10.1016/j.thromres.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
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Moster M, Bolliger D. Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00511-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abstract
Purpose of Review
Multiple guidelines and recommendations have been written to address the perioperative management of antiplatelet and anticoagulant drugs. In this review, we evaluated the recent guidelines in non-cardiac, cardiac, and regional anesthesia. Furthermore, we focused on unresolved problems and novel approaches for optimized perioperative management.
Recent Findings
Vitamin K antagonists should be stopped 3 to 5 days before surgery. Preoperative laboratory testing is recommended. Bridging therapy does not decrease the perioperative thromboembolic risk and might increase perioperative bleeding risk. In patients on direct-acting oral anticoagulants (DOAC), a discontinuation interval of 24 and 48 h in those scheduled for surgery with low and high bleeding risk, respectively, has been shown to be saved. Several guidelines for regional anesthesia recommend a conservative interruption interval of 72 h for DOACs before neuraxial anesthesia. Finally, aspirin is commonly continued in the perioperative period, whereas potent P2Y12 receptor inhibitors should be stopped, drug-specifically, 3 to 7 days before surgery.
Summary
Many guidelines have been published from various societies. Their applicability is limited in emergent or urgent surgery, where novel approaches might be helpful. However, their evidence is commonly based on small series, case reports, or expert opinions.
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Sadeghi R, Haji Aghajani M, Miri R, Kachoueian N, Jadbabaei AN, Mahjoob MP, Omidi F, Ghazanfarabadi M, Sarveazad A. Dual antiplatelet therapy before coronary artery bypass grafting in patients with myocardial infarction: a prospective cohort study. BMC Surg 2021; 21:449. [PMID: 34972501 PMCID: PMC8720217 DOI: 10.1186/s12893-021-01436-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/16/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) in patients with MI who are candidates for early coronary artery bypass grafting (CABG) can affect intraoperative and postoperative outcomes. Therefore, the aim of this study was to evaluate the effect of DAPT up to the day before CABG on the outcomes during and after surgery in patients with MI. METHODS In this prospective cohort study, 224 CABG candidate patients with and without MI were divided into two groups: (A) patients without MI who were treated with aspirin 80 mg/day before surgery (noMI-aspirin group; n = 124) and (B) patients with MI who were treated with aspirin 80 mg/day before surgery and clopidogrel (Plavix brand) at a dose of 75 mg/day (MI-DAPT group; n = 120). Dual or mono-antiplatelet therapy continued until the day before surgery. Patients were followed to assess in-hospital and 6-months outcomes. RESULTS The in-hospital mortality in MI-DAPT group was similar with noMI-aspirin group (OR 4.2; 95% CI 0.9-20.5; p = 0.071). The prevalence of CVA (p = 0.098), duration of hospital stay (p = 0.109), postoperative ejection fraction level (p = 0.693), diastolic dysfunction grade (p = 0.651) and postoperative PAP level (p = 0.0364) did not show difference between two groups. No mild or severe bleeding was observed in the patients. Six-month follow up showed that number of readmissions (p = 0.801), number of cases requiring angiography (p = 0.100), cases requiring re-PCI (p = 0.156), need for re-CABG (p > 0.999) and CVA (p > 0.999) did not differ between the two groups. During the 6-month follow-up, out-hospital mortality did not differ significantly between the two groups (p = 0.446). CONCLUSIONS A 6-month follow-up showed that DAPT with aspirin and clopidogrel before CABG in patients with MI has no effect on postoperative outcomes more than mono-APT with aspirin. Therefore, DAPT is recommended in the preoperative period for these patients.
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Affiliation(s)
- Roxana Sadeghi
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Haji Aghajani
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Miri
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Naser Kachoueian
- Department of Cardiac Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Nasser Jadbabaei
- Department of Cardiac Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Parsa Mahjoob
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Omidi
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Ghazanfarabadi
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran.
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Early Surgery with Neuraxial Anaesthesia in Patients on Chronic Antiplatelet Therapy with a Proximal Femur Fracture: Multicentric Randomised Clinical Trial. J Clin Med 2021; 10:jcm10225371. [PMID: 34830654 PMCID: PMC8624584 DOI: 10.3390/jcm10225371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Our goal was to perform early surgery under neuraxial anaesthesia when indicated by the platelet function test. Methods: We conducted a multicentre randomised open-label parallel clinical trial. Patients were randomised to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Early surgery was programmed when the functional platelet count (as measured by Plateletworks) was >80 × 109/L. The primary outcome was the emergency admission-to-surgery interval. Secondary outcomes were platelet function, postoperative bleeding, medical and surgical complications, and mortality. Results: A total of 156 patients were randomised, with 78 in each group, with a mean (SD) age of 85.96 (7.9) years, and 67.8% being female. The median (IQR) time to surgery was 2.3 (1.5–3.7) days for the experimental group and 4.9 (4.4–5.6) days for the control group. One-third of patients did not achieve the threshold functional platelet count on the first day of admission, requiring more than one test. There was no difference in clinical outcomes between groups. Conclusions: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy.
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The impact of dual antiplatelet therapy administration on the risk of bleeding complications during coronary artery bypass surgery. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 18:145-151. [PMID: 34703471 PMCID: PMC8525274 DOI: 10.5114/kitp.2021.109407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/18/2021] [Indexed: 11/17/2022]
Abstract
Introduction Dual antiplatelet therapy reduces the risk of cardiovascular death, myocardial infarction and recurrence of adverse ischemic events in patients affected by acute coronary syndromes, but in patients urgently needing coronary artery surgery it can increase the risk of severe perioperative bleeding complications. Aim We evaluated the impact of dual antiplatelet therapy (DAPT) based on acetylsalicylic acid plus clopidogrel or ticagrelor in patients undergoing coronary artery bypass grafting (CABG). Material and methods Three hundred and thirty-three patients underwent coronary artery bypass grafting with DAPT discontinuation > 72 hours or 3–4 days (group A, n = 159), 48–72 hours or 2–3 days (group B, n = 126), < 24 hours or 0–1 day (group C, n = 24) prior to CABG. Results Operative mortality was 1.87% (group A), 0.79% (group B), absent (group C). The incidence of mediastinal re-exploration was 1.25% or 2 patients (group A), 1.59% or 2 patients (group B), 8.33% or 4 patients (group C) (p = 0.01). Group C showed postoperatively a greater incidence of a blood loss greater than 500 ml at 6 hours and a blood loss from chest tube drainages significantly higher at 6 and 24 hours (p < 0.01). Multivariate analysis showed that ongoing ticagrelor intake in group C (HR = 42.4; p = 0.02) and group C (HR = 6.9; p = 0.04) were the only independent predictors of surgical re-exploration. In group C, surgical re-exploration was 2.56% or 1/39 patients taking clopidogrel, 33.3% or 3/9 patients taking ticagrelor (p = 0.002). Conclusions Dual antiplatelet therapy ongoing until 1 day or 24 hours before CABG showed a significantly increased risk of bleeding complications in comparison with its discontinuation at 2–3 and > 3–4 days before, respectively. Major blood loss and surgical re-exploration were not associated with increased risk of operative all-cause or bleeding-related mortality. As expected, taking ticagrelor compared with clopidogrel in the short interval confers a higher risk of bleeding complications.
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Levy JH, Tanaka KA. Can We Use Viscoelastic Testing to Evaluate Microvascular Dysfunction in Acute Myocardial Infarction? JACC Basic Transl Sci 2021; 6:762-764. [PMID: 34754990 PMCID: PMC8559315 DOI: 10.1016/j.jacbts.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kenichi A. Tanaka
- Department of Anesthesiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA
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32
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Tantry US, Hartmann J, Neal MD, Schöechl H, Bliden KP, Agarwal S, Mason D, Dias JD, Mahla E, Gurbel PA. The role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. Platelets 2021; 33:520-530. [PMID: 34369848 DOI: 10.1080/09537104.2021.1961709] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We carried out a literature search in MEDLINE (PubMed) and EMBASE literature databases to provide a concise review of the role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. The search identified 130 articles that were relevant for the review, covering the basic science of VHA and VHA in clinical settings including cardiac surgery, cardiology, neurology, trauma, non-cardiac surgery, obstetrics, liver disease, and COVID-19. Evidence from these articles is used to describe the important role of VHAs and platelet function testing in various peri-interventional setups. VHAs can help us to comprehensively assess the contribution of platelets and coagulation dynamics to clotting at the site-of-care much faster than standard laboratory measures. In addition to standard coagulation tests, VHAs are beneficial in reducing allogeneic transfusion requirements and bleeding, in predicting ischemic events, and improving outcomes in several peri-interventional care settings. Further focused studies are needed to confirm their utility in the peri-interventional case.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jan Hartmann
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Matthew D Neal
- Department of General Surgery, The University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert Schöechl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria.,AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Seema Agarwal
- Department of Anaesthesia, Manchester University Foundation Trust, Manchester, UK
| | - Dan Mason
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Joao D Dias
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Elisabeth Mahla
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
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Görlinger K, Gandhi A. Utility of Platelet Function Testing in Cardiac Surgery in 2021. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1732839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Klaus Görlinger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Medical Affairs, TEM Innovations GmbH, Munich, Germany
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Mason GA, Rabbolini DJ. The Current Role of Platelet Function Testing in Clinical Practice. Semin Thromb Hemost 2021; 47:843-854. [PMID: 34130344 DOI: 10.1055/s-0041-1728786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Platelet dysfunction, whether hereditary or acquired, may increase an individual's risk of spontaneous, posttraumatic, or postoperative bleeding. Conversely, increased platelet reactivity on antiplatelet agents following vascular (in particular, coronary vascular) intervention may increase the risk of thrombosis and adverse vascular events. The aim of platelet function testing is to identify and characterize platelet dysfunction in these settings to inform bleeding/ thrombosis risk and guide perioperative prophylactic management strategies. A vast array of screening and diagnostic tests is available for this purpose. The successful clinical application of platelet function tests depends on the knowledge of their analytical strengths and limitations and the correct extrapolation of derived results to a particular clinical scenario. This review critically appraises traditional and contemporary platelet function testing focusing on their role in clinical practice.
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Affiliation(s)
- George A Mason
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - David J Rabbolini
- Lismore Cancer and Haematology Unit, Lismore Base Hospital, Lismore, New South Wales, Australia.,The University of Sydney Northern Clinical School and the Rural Clinical School, Sydney, Australia
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Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review. J Clin Med 2021; 10:jcm10112454. [PMID: 34205971 PMCID: PMC8198483 DOI: 10.3390/jcm10112454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022] Open
Abstract
About 15 years ago, Patient Blood Management (PBM) emerged as a new paradigm in perioperative medicine and rapidly found support of all major medical societies and government bodies. Blood products are precious, scarce and expensive and their use is frequently associated with adverse short- and long-term outcomes. Recommendations and guidelines on the topic are published in an increasing rate. The concept aims at using an evidence-based approach to rationalize transfusion practices by optimizing the patient's red blood cell mass in the pre-, intra- and postoperative periods. However, elegant as a concept, the implementation of a PBM program on an institutional level or even in a single surgical discipline like cardiac surgery, can be easier said than done. Many barriers, such as dogmatic ideas, logistics and lack of support from the medical and administrative departments need to be overcome and each center must find solutions to their specific problems. In this paper we present a narrative overview of the challenges and updated recommendations for the implementation of a PBM program in cardiac surgery.
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Dias JD, Pottgiesser T, Hartmann J, Duerschmied D, Bode C, Achneck HE. Comparison of three common whole blood platelet function tests for in vitro P2Y12 induced platelet inhibition. J Thromb Thrombolysis 2021; 50:135-143. [PMID: 31620937 PMCID: PMC7293977 DOI: 10.1007/s11239-019-01971-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In the context of interventional cardiology, platelet function testing may identify patients treated with P2Y12-inhibitors at an increased risk of mortality, thrombosis and bleeding. Several whole blood point-of-care platelet function analyzers are available; however, inter-device differences have not been examined systematically. To compare three platelet function tests under standardized in vitro conditions. Healthy volunteer (n = 10) blood samples were spiked with increasing concentrations of ticagrelor (0–7500 ng/mL) and/or ASA (0–3280 ng/mL), measured on three platelet function analyzers (TEG®6s, Multiplate®, and VerifyNow®) and respective Effective Concentration (EC) levels EC10, EC50 and EC90 were calculated. Repeatability was assessed in a separate group of pooled blood samples (n = 10) spiked with ticagrelor at EC10, EC50 and EC90. ASA had no impact on ADP-activated channels for all three devices. TEG®6s was able to distinguish (p ≤ 0.05) between all ticagrelor EC zones; VerifyNow® and Multiplate® were able to distinguish between three and two zones, respectively. Multiplate® showed the largest window between EC10 and EC90 (19–9153 ng/mL), followed by TEG®6s (144–2589 ng/mL), and VerifyNow® (191–1100 ng/mL). Drug effect models distribution of disagreements were identified for TEG®6s (5.0%), VerifyNow® (8.3%), and Multiplate® (13.3%). TEG®6s showed the smallest average coefficient of variation between EC conditions (5.1%), followed by Multiplate® (14.1%), and VerifyNow® (17.7%). Linear models could be generated between TEG®6s and Multiplate®, but not VerifyNow®. Significant differences were found between whole blood point-of-care platelet function analyzers and the clinical impact of these differences needs to be further investigated.
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Affiliation(s)
| | - Torben Pottgiesser
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | | | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
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Does Platelet Reactivity Testing Predict Post-Operative Bleeding Risk? J Am Coll Cardiol 2021; 77:1287-1289. [PMID: 33706869 DOI: 10.1016/j.jacc.2021.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 01/25/2023]
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Nakashima CAK, Dallan LAO, Lisboa LAF, Jatene FB, Hajjar LA, Soeiro AM, Furtado RHM, Dalçoquio TF, Baracioli LM, Lima FG, Giraldez RRCV, Silva BA, Costa MSS, Strunz CMC, Dallan LRP, Barbosa CJDG, Britto FAB, Farkouh ME, Gurbel PA, Nicolau JC. Platelet Reactivity in Patients With Acute Coronary Syndromes Awaiting Surgical Revascularization. J Am Coll Cardiol 2021; 77:1277-1286. [PMID: 33706868 DOI: 10.1016/j.jacc.2021.01.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/18/2020] [Accepted: 01/11/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Dual antiplatelet therapy is recommended for patients with acute coronary syndromes (ACS). Approximately 10% to 15% of these patients will undergo coronary artery bypass graft (CABG) surgery for index events, and current guidelines recommend stopping clopidogrel at least 5 days before CABG. This waiting time has clinical and economic implications. OBJECTIVES This study aimed to evaluate if a platelet reactivity-based strategy is noninferior to standard of care for 24-h post-CABG bleeding. METHODS In this randomized, open label noninferiority trial, 190 patients admitted with ACS with indications for CABG and on aspirin and P2Y12 receptor inhibitors, were assigned to either control group, P2Y12 receptor inhibitor withdrawn 5 to 7 days before CABG, or intervention group, daily measurements of platelet reactivity by Multiplate analyzer (Roche Diagnostics GmbH, Vienna, Austria) with CABG planned the next working day after platelet reactivity normalization (pre-defined as ≥46 aggregation units). RESULTS Within the first 24 h of CABG, the median chest tube drainage was 350 ml (interquartile range [IQR]: 250 to 475 ml) and 350 ml (IQR: 255 to 500 ml) in the intervention and control groups, respectively (p for noninferiority <0.001). The median waiting period between the decision to undergo CABG and the procedure was 112 h (IQR: 66 to 142 h) and 136 h (IQR: 112 to 161 h) (p < 0.001), respectively. In the intention-to-treat analysis, a 6.4% decrease in the median in-hospital expenses was observed in the intervention group (p = 0.014), with 11.2% decrease in the analysis per protocol (p = 0.003). CONCLUSIONS A strategy based on platelet reactivity-guided is noninferior to the standard of care in patients with ACS awaiting CABG regarding peri-operative bleeding, significantly shortens the waiting time to CABG, and decreases hospital expenses. (Evaluation of Platelet Aggregability in the Release of CABG in Patients With ACS With DAPT; NCT02516267).
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Affiliation(s)
- Carlos A K Nakashima
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luis A O Dallan
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luiz A F Lisboa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fabio B Jatene
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ludhmila A Hajjar
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Alexandre M Soeiro
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Remo H M Furtado
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil; Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Talia F Dalçoquio
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luciano M Baracioli
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Felipe G Lima
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Roberto R C V Giraldez
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bianca A Silva
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Mateus S S Costa
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Celia M C Strunz
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luis R P Dallan
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Flavia A B Britto
- Hospital das Clinicas, Faculdade de Medicina, Universidade Federal de Uberlandia, Minas Gerais, Brazil; Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | - Michael E Farkouh
- Hospital das Clinicas, Faculdade de Medicina, Universidade Federal de Uberlandia, Minas Gerais, Brazil; Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.
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Datta SS, De D, Bose S. Thromboelastography Platelet Mapping—A Useful Preoperative Tool to Reduce Transfusion Requirement by Determining Timing of Coronary Artery Bypass Graft Surgery in Patients taking Dual Antiplatelet Medication: A Pilot Study from Eastern India. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1723622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractIn this pilot study, we proposed an algorithm to use thromboelastography platelet mapping (TEG-PM) as an effective preoperative platelet function assessment tool in coronary artery bypass graft surgery (CABG) to reduce the transfusion requirement by determining timing of surgery in patients who are on dual antiplatelet therapy (DAPT). Total 15 elective CABG patients who were receiving DAPT were tested by TEG-PM assay after 72 hours’ stoppage of both medications. Four patients who had < 50% inhibition with agonists (arachidonic acid [AA] and adenosine diphosphate [ADP]) were operated within 24 hours of assay. Eight patients who had > 70% inhibition with AA/ADP, surgery was deterred till 48 hours, and 3 patients with > 50% but < 70% inhibition were operated within 24 hours after preoperative prophylactic platelet transfusion. Transfusion requirement was recorded and compared with the previous transfusion data for CABG cases operated without TEG-PM. Distribution of ADP inhibition was 67.54 ± 30.03% and AA inhibition was 60.69 ± 30.14%, showing a variable offset of the effect of both medications starting after 72 hours of cessation. Overall transfusion requirement was decreased by using TEG-PM algorithm. Preoperative platelet function testing to determine the timing of surgery by TEG-PM assay in DAPT-treated patients may be a useful strategy to reduce transfusion requirement in CABG.
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Affiliation(s)
- Suvro Sankha Datta
- Department of Transfusion Medicine, The Mission Hospital, Durgapur, West Bengal, India
| | - Dibyendu De
- Department of Clinical Hematology, The Mission Hospital, Durgapur, West Bengal, India
| | - Satyajit Bose
- Department of Cardio-Vascular Surgery, The Mission Hospital, Durgapur, West Bengal, India
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Tam DY, Fremes SE. Commentary: Microvesicles, personalized surgery, and tailored medical therapy to improve coronary artery bypass grafting outcomes. J Thorac Cardiovasc Surg 2020; 163:701-702. [PMID: 33422325 DOI: 10.1016/j.jtcvs.2020.11.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Derrick Y Tam
- Division of Cardiac Surgery, Schulich Heart Centre, and Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, and Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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41
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Wang Z, Xia L, Li X, Shen J, Xu Q, Ji Q, Lv Q. Genetic Polymorphisms and Perioperative Bleeding in Off-Pump Coronary Artery Bypass Grafting Surgery. Ann Thorac Surg 2020; 112:116-123. [PMID: 33075321 DOI: 10.1016/j.athoracsur.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 08/07/2020] [Accepted: 08/13/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Clopidogrel use before coronary artery bypass graft surgery may increase risk for perioperative hemorrhage. The effect of genetic polymorphisms related to clopidogrel responses on bleeding during or after off-pump coronary artery bypass graft surgery is unknown. METHODS This prospective study included 206 coronary artery disease patients scheduled for off-pump coronary artery bypass graft surgery. Genotypes were determined using Sequenom MassARRAY system. Severe bleeding was defined by the universal definition of perioperative bleeding in cardiac surgery. RESULTS Patients carrying the ABCB1 3435 wild-type genotype (CC) had a higher risk of severe perioperative bleeding compared with patients carrying the variant genotype (CT or TT; 33.9% vs 16.5%, P = .009). Low baseline hemoglobin level (odds ratio 0.944; 95% confidence interval, 0.917 to 0.972; P < .001), low baseline estimated glomerular filtration rate (odds ratio 0.977; 95% confidence interval, 0.956 to 0.999; P = .041), discontinuing clopidogrel 5 days or less before surgery (odds ratio 2.458; 95% confidence interval, 1.044 to 5.786; P = .039), and the ABCB1 wild-type genotype (CC; odds ratio 2.941; 95% confidence interval, 1.250 to 6.944; P = .014) were independent risk factors for severe perioperative bleeding. CONCLUSIONS Patients carrying the ABCB1 wild-type genotype (CC) had a higher rate of severe perioperative bleeding compared with patients carrying the variant genotype (CT or TT). Discontinuation of clopidogrel 5 days or less before surgery and the ABCB1 wild-type genotype (CC) were independent risk factors for severe perioperative bleeding.
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Affiliation(s)
- Zi Wang
- Department of Clinical Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Limin Xia
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoye Li
- Department of Clinical Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jinqiang Shen
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qing Xu
- Department of Clinical Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiuyi Ji
- Department of Clinical Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qianzhou Lv
- Department of Clinical Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China.
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Agarwal S, Abdelmotieleb M. Viscoelastic testing in cardiac surgery. Transfusion 2020; 60 Suppl 6:S52-S60. [PMID: 32955756 DOI: 10.1111/trf.16075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
Bleeding complications are common in cardiac surgery and lead to an increase in morbidity and mortality. This is multifactorial in aetiology including the effects of cardiopulmonary bypass, the drugs given to manipulate the coagulation system and the vascular nature of the surgery itself. Viscoelastic tests provide a point of care, rapid assessment of coagulation which offer the advantage of faster turnaround times and a nuanced view of the elements of the coagulation system allowing targeted therapy to be delivered quickly. Both thomboelastography (TEG)and thromboelastometry (ROTEM) have been recommended for use in cardiac surgery, both have shown a reduction in transfusion and bleeding when used as part of a testing algorithm. They are particularly useful in assessing residual heparinisation and fibrinogen levels. Additionally, TEG allows the evaluation of the effects of anti-platelet agents on platelet function. This review discusses the mechanisms by which bleeding occurs in cardiac surgery and explores three uses of viscoelastic testing in cardiac surgery: to predict bleeding, to assess platelet function and peri-operative testing to reduce transfusion.
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Affiliation(s)
- Seema Agarwal
- Department of Cardiothoracic Anaesthesia and ICM, Manchester University Foundation Trust, Manchester, UK
| | - Mohamed Abdelmotieleb
- Department of Cardiothoracic Anaesthesia and ICM, Manchester University Foundation Trust, Manchester, UK
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43
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Platelet Function Testing in Patients on Antiplatelet Therapy before Cardiac Surgery. Anesthesiology 2020; 133:1263-1276. [DOI: 10.1097/aln.0000000000003541] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Based on variable pharmacodynamic responsiveness and platelet reactivity recovery after discontinuation of P2Y12 receptor inhibitors, preoperative platelet function testing may individualize discontinuation and be a part of transfusion algorithm triggering targeted postpump hemostatic management.
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Viscoelastic properties of clot formation and their clinical impact in East Asian versus Caucasian patients with stable coronary artery disease: a COMPARE-RACE analysis. J Thromb Thrombolysis 2020; 51:454-465. [PMID: 32852671 DOI: 10.1007/s11239-020-02240-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Compared with Caucasian patients, East Asian patients with coronary artery disease (CAD) have demonstrated better clinical outcomes. We sought to compare the viscoelastic properties of clot formation and their impact on clinical outcomes in East Asian vs. Caucasian patients. We analyzed age- and sex-matched East Asian and Caucasian patients with stable CAD (n = 249 each). Viscoelastic properties of clot formation were assessed with thromboelastography (TEG), and 3-year clinical outcomes were recorded. Major adverse cardiovascular events (MACE) were defined as a composite of cardiovascular death, myocardial infarction, or stroke. Compared with Caucasians, East Asians showed lower platelet-fibrin clot strength (PFCS) (maximum amplitude [MA]: 61.8 ± 7.9 vs. 65.4 ± 5.0 mm, p < 0.001). In a multivariate analysis, high PFCS (defined as MA ≥ 68 mm) was significantly associated with MACE occurrence (odds ratio 6.27, 95% CI 2.41 to 16.30, p < 0.001). East Asians vs. Caucasians had lower prevalence of high PFCS (odds ratio 0.50, 95% CI 0.27 to 0.93, p = 0.028). In conclusion, this is the first study to demonstrate different viscoelastic properties of clot between East Asian and Caucasian patients with stable CAD. The platelet-fibrin clot strength was significantly associated with MACE in these patients and was significantly lower in East Asians. Future studies are warranted to further explore the mechanistic explanation and clinical importance of these findings.
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45
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Zhu P, Tang XF, Song Y, Zhang Y, Gao LJ, Gao Z, Chen J, Yang YJ, Gao RL, Xu B, Yuan JQ. Association of lipoprotein(a) with platelet aggregation and thrombogenicity in patients undergoing percutaneous coronary intervention. Platelets 2020; 32:684-689. [PMID: 32787598 DOI: 10.1080/09537104.2020.1802412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This study aimed to evaluate the association of lipoprotein(a) levels with platelet aggregation and thrombogenicity in patients undergoing percutaneous coronary intervention (PCI), and to investigate the ischemic outcome on this population. Lipoprotein(a) and modified thrombelastography were measured in 6601 consecutive patients underwent PCI on dual antiplatelet therapy. Cox proportional regression analysis was applied to illustrate the ischemic events in a 2-year follow up. The mean levels of lipoprotein(a) were 29.0 mg/dl. Patients with higher lipoprotein(a) levels had significantly accelerated fibrin generation (lower K time and bigger α angle) and greater clot strength (higher maximum amplitude (MA)) than patients with lower lipoprotein(a) levels (P < .001). Moreover, the higher lipoprotein(a) group also exhibited significantly higher adenosine diphosphate (ADP) induced platelet aggregation (MAADP) by thrombelastography platelet mapping assay than lower lipoprotein(a) group. Cox regression analyzes revealed that patients with higher lipoprotein(a) levels had a 16% higher risk of major adverse cardiovascular and cerebrovascular events (HR 1.159, 95%CI: 1.005-1.337, P = .042) compared with patients with lower lipoprotein(a) levels. This association persisted after adjustment for a broad spectrum of risk factors (HR 1.174, 95%CI: 1.017-1.355, P = .028). High plasma lipoprotein(a) levels were associated with increased platelet aggregation and ischemic events in patients underwent PCI. Lipoprotein(a) might indicate the need for prolonged antiplatelet therapy.
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Affiliation(s)
- Pei Zhu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiao-Fang Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ying Song
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yin Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Li-Jian Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhan Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jue Chen
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yue-Jin Yang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Run-Lin Gao
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jin-Qing Yuan
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Cao D, Chandiramani R, Capodanno D, Berger JS, Levin MA, Hawn MT, Angiolillo DJ, Mehran R. Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management. Nat Rev Cardiol 2020; 18:37-57. [PMID: 32759962 DOI: 10.1038/s41569-020-0410-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2020] [Indexed: 12/18/2022]
Abstract
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.
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Affiliation(s)
- Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rishi Chandiramani
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico", Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Jeffrey S Berger
- Center for the Prevention of Cardiovascular Disease, New York University Langone Health, New York, NY, USA
| | - Matthew A Levin
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary T Hawn
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Bolliger D, Lancé MD, Siegemund M. Point-of-Care Platelet Function Monitoring: Implications for Patients With Platelet Inhibitors in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:1049-1059. [PMID: 32807601 DOI: 10.1053/j.jvca.2020.07.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 12/13/2022]
Abstract
Although most physicians are comfortable managing the limited anticoagulant effect of aspirin, the recent administration of potent P2Y12 receptor inhibitors in patients undergoing cardiac surgery remains a dilemma. Guidelines recommend discontinuation of potent P2Y12 inhibitors 5- to- 7 days before surgery to reduce the risk of postoperative hemorrhage. Such a strategy might not be feasible before urgent surgery, due to ongoing myocardial ischemia or in patients at high risk for thromboembolic events. Recently, different point-of-care devices to assess functional platelet quality have become available for clinical use. The aim of this narrative review was to evaluate the implications and potential benefits of platelet function monitoring in guiding perioperative management and therapeutic options in patients treated with antiplatelets, including aspirin or P2Y12 receptor inhibitors, undergoing cardiac surgery. No objective superiority of one point-of-care device over another was found in a large meta-analysis. Their accuracy and reliability are generally limited in the perioperative period. In particular, preoperative platelet function testing has been used to assess platelet contribution to bleeding after cardiac surgery. However, predictive values for postoperative hemorrhage and transfusion requirements are low, and there is a significant variability between and within these tests. Further, platelet function monitoring has been used to optimize the preoperative waiting period after cessation of dual antiplatelet therapy before urgent cardiac surgery. Furthermore, studies assessing their value in therapeutic decisions in bleeding patients after cardiac surgery are scarce. A general and liberal use of perioperative platelet function testing is not yet recommended.
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Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
| | - Marcus D Lancé
- Department of Anesthesiology, Intensive Care Unit and Perioperative Medicine, Weill-Cornell Medicine-Qatar, Hamad Medical Corporation, Doha, Qatar
| | - Martin Siegemund
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
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48
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Tian L, Gao X, Yang J, Yao Y, Ji H. Association of Adenosine Diphosphate-Induced Platelet Maximum Amplitude With Postoperative Bleeding and Blood Transfusions in Patients Undergoing Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2020; 35:421-428. [PMID: 32758409 DOI: 10.1053/j.jvca.2020.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To investigate the association of adenosine diphosphate (ADP)-induced platelet maximum amplitude (MAADP) with postoperative bleeding and blood product transfusions in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). DESIGN This single-center observational study recruited 200 patients who underwent elective, first-time, isolated CABG with CPB. A rapid thromboelastography with platelet mapping test was conducted for all patients before the surgery. Patients were categorized by the preoperative MAADP into ≤50 mm (MAADP ≤50 group [n = 87]) and MAADP >50 mm (MAADP >50 group [n = 113]). The primary outcome was postoperative bleeding at 6 and 24 hours as measured by chest tube drainage volume. The perioperative blood product transfusions, postoperative complications, postoperative time course, and in-hospital mortality also were evaluated. SETTING University hospital. PARTICIPANTS Adult patients scheduled to undergo isolated primary CABG with CPB. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The study included 200 patients who underwent CABG with CPB. MAADP was >50 mm in 113 (56.5%) patients (MAADP >50 group). Compared with the MAADP >50 group, the postoperative chest tube drainage volume at 6 and 24 hours was significantly greater in the patients with MAADP ≤50 mm (476.90 ± 156.36 mL v 403.36 ± 133.24 mL; p < 0.001 and 935.86 ± 318.43 mL v 667.21 ± 222.75 mL; p < 0.001, respectively). The consumption of blood products in patients with MAADP ≤50 mm was significantly more than those with MAADP >50 mm. The durations of intensive care unit stay and length of postoperative hospital stay were markedly longer in the MAADP ≤50 group than in the MAADP >50 group (p = 0.001 and p = 0.005; respectively). There were no significant differences in adverse outcomes between the 2 groups except for the postoperative atrial fibrillation, which occurred more in the MAADP ≤50 group than in the MAADP >50 group (8.05% v 1.77%; p = 0.043). MAADP (area under the receiver operating characteristic curve of 0.767; p < 0.001) was demonstrated to have significant ability to predict bleeding tendency, with a sensitivity of 76.2% and a specificity of 69.0%. CONCLUSIONS Preoperative MAADP may play a potential role in the prediction of postoperative bleeding and allogeneic blood transfusions and guide clinicians in perioperative management of patients undergoing CABG with CPB.
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Affiliation(s)
- Lijuan Tian
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xurong Gao
- Department of Transfusion Medicine, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Yang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuntai Yao
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongwen Ji
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Transfusion Medicine, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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49
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Mazzeffi MA, Patel PA, Bolliger D, Erdoes G, Tanaka K. The Year in Coagulation: Selected Highlights From 2019. J Cardiothorac Vasc Anesth 2020; 34:1745-1754. [DOI: 10.1053/j.jvca.2020.01.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 01/27/2020] [Indexed: 12/26/2022]
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Platelet Mapping by Thromboelastography and Whole Blood Aggregometry in Adult Patients Supported by Mechanical Circulatory Support Device on Aspirin Therapy. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:13-21. [PMID: 32280140 DOI: 10.1182/ject-1900029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 02/24/2020] [Indexed: 11/20/2022]
Abstract
Patients on mechanical circulatory support (MCS) devices are placed on aspirin and may require platelet function testing (PFT) to monitor the adequacy of therapy. Routine laboratory PFT is performed using whole blood aggregation (WBA) which typically has a long turnaround time (4-5 hours) and may not be readily available. By contrast, platelet mapping by thromboelastography (TPM) can provide results within 45 minutes. The objective of this study was to compare the results of TPM with WBA. We compared platelet mapping maximal amplitude (MA) by TPM with that of arachidonic acid (AA) to WBA with AA by impedance. We analyzed paired samples where both TPM and WBA were available. Of 45 paired samples, 34 were from 29 MCS patients and 11 were from non-MCS patients. When applying institutional interpretation guidelines with an MAActivator cutoff of ≤40 mm, WBAAA vs TPM MAAA in non-MCS and MCS patients correlated well with an accuracy of 100 and 94.4%, respectively. MAActivator >40 had poor correlation with an accuracy of 37.5%. Irrespective of MAActivator value, TPM AA inhibition expressed in percent of inhibition had poor accuracy. When used with proper guidelines for interpretation, specifically when MAActivator ≤ 40 mm, TPM is a suitable and reliable test to use for MCS patients on aspirin.
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