Abstract
Backgrounds Antithrombin (AT) drop during cardiac surgery has been described. The causes and the effects of this phenomenon are not clear. The objective of the study is to evaluate the relationship of AT postoperative values on short and mid-term outcome after cardiac surgery. Methods Between January and June 2005, 405 patients, who underwent cardiac operations at our Institution had AT values available preoperatively and postoperatively. Using Receiver Operating Characteristic curves, a cut-off equal to 63.7% for ICU-arrival AT was chosen in order to divide the entire population in two groups (117 patients with ICU-arrival AT < 63.7%, Low AT group, and 288 patients with ICU-arrival AT ≥ 63.7%, High AT group). Objective of the study was to evaluate the predictive role of ICU-arrival AT < 63.7% on in-hospital mortality and morbidity and on 18 months follow-up after cardiac surgery. Results ICU-arrival AT was significantly lower than preoperative AT (90.7 ± 16.3% vs. 71.2 ± 15.1%, P < 0.0001). Patients in the Low AT group were older, more often female, had a worse Euroscore and required longer CPB duration and cross clamp time. They had significantly higher preoperative and postoperative d-dimer levels. ICU arrival AT < 63.7% was not associated with increased in-hospital mortality but it was an independent risk factor for longer mechanical ventilation, need of inotropic support, excessive bleeding and blood products transfusion. ICU arrival-AT < 63.7% was associated with worse survival during 18 months follow up (92.3% vs. 85.4% in the High AT and Low AT group, respectively, P = 0.05). Conclusions Low AT after cardiac surgery is associated with higher incidences of peri-operative complications and worse survival in the mid-term. Future studies should clarify the pathophysiologic mechanism of this findings and possible therapeutic directions.
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References
Lorente JA, Garcia-Frade LJ, Landin L et al (1993) Time course of hemostatic abnormalities in sepsis and its relation to outcome. Chest 103:1536–1542
Hashimoto K, Yamagishi M, Sasaki T, Nakano M, Kurosawa H (1994) Heparin and antithrombin III levels during cardiopulmonary bypass: correlation with subclinical plasma coagulation. Ann Thorac Surg 58:799–804
Zahler S, Massoudy P, Hartl H, Hahnel C, Meisner H, Becker BF (1999) Acute cardiac inflammatory response to postischemic reperfusion during cardiopulmonary bypass. Cardiovasc Res 41:722–730
Aldea GS, Soltow LO, Chandler WL et al (2002) Limitation of thrombin generation, platelet activation, and inflammation by elimination of cardiotomy suction in patients undergoing coronary artery bypass grafting treated with heparin-bonded circuits. J Thorac Cardiovasc Surg 123:742–755
Brister SJ, Ofosu FA, Buchanan MR (1993) Thrombin generation during cardiac surgery: is heparin the ideal anticoagulant? Thromb Haemost 70:259–262
Ranucci M, Frigiola A, Menicanti L, Ditta A, Boncilli A, Brozzi S (2005) Postoperative antithrombin levels and outcomes in cardiac operations. Crit Care Med 33:355–360
Mammen EF (1998) Antithrombin: its physiological importance and role in DIC. Semin Thromb Hemost 27:619–631
Roemisch J, Gray E, Hoffman JN, Wiedermann CJ (2002) Antithrombin: a new look at the actions of a serine protese inhibitor. Blood Coagul Fibrinolysis 13:657–670
Rinder CS, Rinder HM, Smith MJ et al (2006) Antithrombin reduces monocyte and neutrophil CD11b up regulation in addition to blocking platelet activation during extracorporeal circulation. Transfusion 46:1130–1137
Martinez MA, Pena JM, Fernandez A et al (1999) Time course and prognostic significance of hemostatic changes in sepsis: relation to tumor necrosis factor-alpha. Crit Care Med 27:1303–1308
Baudo F, Caimi TM, de Cataldo F et al (1998) Antithrombin III (ATIII) replacement therapy in patients with sepsis and/or postsurgical complications: a controlled double blind, randomized, multicenter study. Intensive Care Med 24:336–342
Eisele B, Lamy M, Thijs LG et al (1998) Antithrombin III in patients with severe sepsis. a randomized, placebo controlled, double blind multicenter trial plus a meta-analysis on all randomized, placebo controlled, double-blind trials with antithrombin III in severe sepsis. Intensive Care Med 24:663–672
Warren BL, Eid A, Singer P I et al (2001) Caring for the critically ill patient. High dose antithrombin III in severe sepsis: a randomized controlled trial. JAMA 286:1869–1878
Ranucci M, Isgro G, Cazzaniga A et al (2002) Different patterns of heparin resistance: therapeutic implications. Perfusion 17:199–204
Lemmer JH Jr, Despotis GJ (2002) Antithrombin III concentrate to treat heparin resistance in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 123:213–217
Pabinger I, Schneider B (1996) Thrombotic risk in hereditary antithrombin III, protein C, or protein S deficiency. A cooperative, retrospective study. Arterioscler Thormb Vasc Biol 16:742–748
Slaughter TF, Mark JB, El-Mooalem H et al (2001) Hemostatic effects of antithrombin III supplementation during cardiac surgery: results of a prospective randomized investigation. Blood Coagul Fibrinolysis 12:25–31
Rossi M, Martinelli M, Storti S, Corrado M, Schiavello R (1999) The role of antithrombin III in the perioperative management of patients with unstable angina. Ann Thorac Surg 68:2231–2236
Brister SJ, Ofosu FA, Buchanan MR (1993) Thrombin generation during cardiac surgery: is heparin the ideal anticoagulant? Thromb Haemost 70:259–262
Paparella D, Al Radi OO, Meng QH, Venner T, Teoh K, Young E (2005) The effects of high-dose heparin on inflammatory and coagulation parameters following cardiopulmonary bypass. Blood Coagul Fibrinolysis 16:323–328
Despotis GJ, Joist JH, Hogue CW Jr et al (1996) 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 76:902–908
Paparella D, Galeone A, Venneri MT et al (2006) Activation of the coagulation system during coronary artery bypass grafting: comparison between on-pump and off-pump techniques. J Thorac Cardiovasc Surg 131:290–297
Parolari A, Mussoni L, Frigerio M et al (2005) Increased prothrombotic state lasting as long as one month after on-pump and off-pump coronary surgery. J Thorac Cardiovasc Surg 130:303–308
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Appendix A: Areas under the curves of ICU-arrival AT
Appendix A: Areas under the curves of ICU-arrival AT
In hospital mortality = 0.65 ± 0.08, 6-months mortality = 0.63 ± 0.06, Mechanical ventilation > 24 h = 0.67 ± 0.04 , ICU stay > 48 h = 0.59 ± 0.04, In hospital stay > 7 gg = 0.61 ± 0.03, Need of inotropic support = 0.72 ± 0.05, Acute renal failure = 0.58 ± 0.07, Atrial fibrillation = 0.61 ± 0.03, Stroke = 0.57 ± 0.10, Sepsis = 0.59 ± 10, Sternal wound infections = 0.54 ± 0.06, Excessive bleeding (>75th percentile = 920 ml) = 0.67 ± 0.04, Blood transfusion = 0.75 ± 0.03, all blood products transfusion = 0.72 ± 0.02.
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Paparella, D., Cappabianca, G., Scrascia, G. et al. Antithrombin after cardiac surgery: implications on short and mid-term outcome. J Thromb Thrombolysis 27, 105–114 (2009). https://doi.org/10.1007/s11239-007-0191-9
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DOI: https://doi.org/10.1007/s11239-007-0191-9