High mortality associated with intracardiac and intrapulmonary thromboses after cardiopulmonary bypass
- First Online:
Intrapulmonary or intracardiac thrombosis is a rare but catastrophic event following complex cardiothoracic surgery. Although there have been multiple cases reported in the literature, the causes of these events are largely unknown. In this retrospective review, we attempt to identify risk factors and propose possible mechanisms of thromboses after cardiopulmonary bypass (CPB).
A literature search was conducted using the MEDLINE and EMBASE with these keywords: (intra)pulmonary thrombosis, pulmonary embolism, pulmonary infarction, lung embolism, (intra)cardiac thrombosis, cardiac thrombi, in combination with CPB, extracorporeal membrane oxygenation, deep hypothermic circulatory arrest, or cardiac surgery. Putative risk factors were compiled from reported cases.
We identified 34 cases of massive intrapulmonary and/or intracardiac thromboses. All but 2 cases (94.1%) were fatal. Clinical presentations were systemic hypotension and/or pulmonary hypertension, right ventricular failure, and cardiogenic shock in 32 (94.1%) cases. The timing was immediate (<10 min) following hemostatic intervention in 16 cases (47.1%), within 45 min in 8 cases (23.5%), and not reported in the rest. Putative risk factors included antifibrinolytic use (88.2%), congestive heart failure (55.9%), prolonged CPB use (>2 h) (41.1%), and low activated clotting time (<400 s) after initial heparinization (20.6%). The administration of tissue plasminogen activator in 5 cases was ineffective.
Massive thrombosis following cardiac surgery is a highly lethal event with limited treatment options. Particular attention should be paid to the status of thrombin regulatory proteins before protamine and other hemostatic interventions in patients undergoing complex cardiac surgery with antifibrinolytic agents.
KeywordsIntrapulmonary thrombosis Intracardiac thrombosis Antithrombin Cardiopulmonary bypass Transfusion
- 15.Alderman EL, Levy JH, Rich JB, Nili M, Vidne B, Schaff H, Uretzky G, Pettersson G, Thiis JJ, Hantler CB, Chaitman B, Nadel A. Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE) trial. J Thorac Cardiovasc Surg. 1998;116:716–30.CrossRefPubMedGoogle Scholar
- 19.Bui JD, Despotis GD, Trulock EP, Alexander Patterson G, Goodnough LT. Fatal thrombosis after administration of activated prothrombin complex concentrates in a patient supported by extracorporeal membrane oxygenation who had received activated recombinant factor VII. J Thorac Cardiovasc Surg. 2002;124:852–4.CrossRefPubMedGoogle Scholar
- 21.Lukauskis K, Banks D. Factor IX complex: help or harm? (abstract). In: 33rd Annual Meeting of Society of Cardiovascular Anesthesiologists in Savannah, GA, USA. 2011.Google Scholar
- 22.Apostolidou I, Sweeney MF, Missov E, Joyce LD, John R, Prielipp RC. Acute left atrial thrombus after recombinant factor VIIa administration during left ventricular assist device implantation in a patient with heparin-induced thrombocytopenia. Anesth Analg. 2008;106:404–8.CrossRefPubMedGoogle Scholar
- 25.Alvarez JM, Goldstein J, Mezzatesta J, Flanagan B, Dodd M. Fatal intraoperative pulmonary thrombosis after graft replacement of an aneurysm of the arch and descending aorta in association with deep hypothermic circulatory arrest and aprotinin therapy. J Thorac Cardiovasc Surg. 1998;115:723–4.CrossRefPubMedGoogle Scholar
- 28.Ramsey MAE, Marcel RJ, Capehart J, Cheung EH, Ring WS. Massive intravascular thrombosis and thromboembolism after cardiopulmonary bypass. Internet J Thorac Cardiovasc Surg. 2003;5. http://www.ispub.com.
- 29.Lagare JF, Arora R, Wood JW. Massive intracavitary clot formation during cardiopulmonary bypass. Can J Cardiol. 2004;20:825–6.Google Scholar
- 36.Trigo P, Stone M, Fisher G. A patient presenting for concurrent thoracoabdominal aortic aneurysm repair and left ventricular assist device placement (abstract). In: 33rd Annual Meeting of Society of Cardiovascular Anesthesiologists in Savannah, GA, USA. 2011.Google Scholar
- 38.Cooper JR Jr, Abrams J, Frazier OH, Radovancevic R, Radovancevic B, Bracey AW, Kindo MJ, Gregoric ID. Fatal pulmonary microthrombi during surgical therapy for end-stage heart failure: possible association with antifibrinolytic therapy. J Thorac Cardiovasc Surg. 2006;131:963–8.CrossRefPubMedGoogle Scholar
- 44.Ogawa S, Szlam F, Chen EP, Nishimura T, Kim H, Roback JD, Levy JH, Tanaka KA. A comparative evaluation of rotation thromboelastometry and standard coagulation tests in hemodilution-induced coagulation changes after cardiac surgery. Transfusion. 2011. doi:10.1111/j.1537-2995.2011.03241.x
- 59.Despotis GJ, Joist JH, Hogue CW, Alsoufiev A, Joiner-Maier D, Santoro SA, Spitznagel E, Weitz JI, Goodnough LT. More effective suppression of hemostatic system activation in patients undergoing cardiac surgery by heparin dosing based on heparin blood concentrations rather than ACT. Thromb Haemost. 1996;76:902–8.PubMedGoogle Scholar
- 60.Avidan MS, Levy JH, Van Aken H, Feneck RO, Latimer RD, Ott E, Martin E, Birnbaum DE, Bonfiglio LJ, Kajdasz DK, Despotis GJ. Recombinant human antithrombin III restores heparin responsiveness and decreases activation of coagulation in heparin-resistant patients during cardiopulmonary bypass. J Thorac Cardiovasc Surg. 2005;130:107–13.CrossRefPubMedGoogle Scholar
- 64.Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011;91:944–82.CrossRefPubMedGoogle Scholar
- 66.Wahlander K, Larson G, Lindahl TL, Andersson C, Frison L, Gustafsson D, Bylock A, Eriksson BI. Factor V Leiden (G1691A) and prothrombin gene G20210A mutations as potential risk factors for venous thromboembolism after total hip or total knee replacement surgery. Thromb Haemost. 2002;87:580–5.PubMedGoogle Scholar
- 73.Fergusson DA, Hebert PC, Mazer CD, Fremes S, MacAdams C, Murkin JM, Teoh K, Duke PC, Arellano R, Blajchman MA, Bussieres JS, Cote D, Karski J, Martineau R, Robblee JA, Rodger M, Wells G, Clinch J, Pretorius R, Investigators B. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008;358:2319–31.CrossRefPubMedGoogle Scholar