PMID- 12698397
OWN - NLM
STAT- MEDLINE
DCOM- 20031212
LR  - 20181130
IS  - 1053-0770 (Print)
IS  - 1053-0770 (Linking)
VI  - 17
IP  - 2
DP  - 2003 Apr
TI  - Management of heparin resistance during cardiopulmonary bypass: the effect of 
      five different anticoagulation strategies on hemostatic activation.
PG  - 171-5
AB  - OBJECTIVE: Attenuation of hemostatic activation is a central goal during CPB. 
      However, this poses a problem in patients insensitive to heparin. The present 
      investigation was performed to assess different strategies of managing patients 
      with heparin resistance during CPB. DESIGN: A randomized, prospective clinical 
      investigation. SETTING: A major European heart center. PARTICIPANTS: Five groups 
      with 20 patients each were investigated. INTERVENTIONS: The groups were handled 
      as follows: (1). maintenance of a target ACT, (2). maintenance of the target 
      unfractionated heparin (UFH) level and supplementation of a UFH level-based 
      strategy with (3). AT III, (4). the direct thrombin inhibitor r-hirudin, or (5). 
      the short-acting platelet glycoprotein (GP) IIb/IIIa antagonist tirofiban. 
      Platelet count and generation of contact factor XIIa, thrombin, and soluble 
      fibrin were assessed. Samples were obtained before CPB and after CPB before 
      protamine infusion. MEASUREMENTS AND MAIN RESULTS: There were no differences 
      observed in the generation of factor XIIa. The UFH-based strategy and 
      supplementation with AT III, r-hirudin, and tirofiban resulted in significantly 
      reduced (p < 0.05) thrombin generation compared with ACT management. A 
      significant reduction of fibrin formation was seen only in patients who received 
      AT III, r-hirudin, or tirofiban supplementation to the UFH. The administration of 
      tirofiban resulted in a significant preservation of the platelet count compared 
      with the other groups. There were no significant differences in the postoperative 
      blood loss. CONCLUSIONS: Activation of hemostasis during CPB in heparin-resistant 
      patients most likely has to be attributed to stimulation of the tissue factor 
      pathway. Even the sole use of high concentrations of UFH does not effectively 
      inhibit this activation. Therefore, in these patients anticoagulation during CPB 
      with UFH should be supplemented with either AT III, a short-acting direct 
      thrombin inhibitor, or a short-acting platelet glycoprotein IIb/IIIa antagonist.
CI  - Copyright 2003 Elsevier Inc. All rights reserved.
FAU - Koster, Andreas
AU  - Koster A
AD  - Department of Anesthesia, Deutsches Herzzentrum Berlin, Germany. Koster@dhzb.de
FAU - Fischer, Thomas
AU  - Fischer T
FAU - Gruendel, Marcus
AU  - Gruendel M
FAU - Mappes, Andreas
AU  - Mappes A
FAU - Kuebler, Wolfgang M
AU  - Kuebler WM
FAU - Bauer, Matthias
AU  - Bauer M
FAU - Kuppe, Herman
AU  - Kuppe H
LA  - eng
PT  - Clinical Trial
PT  - Journal Article
PT  - Randomized Controlled Trial
PL  - United States
TA  - J Cardiothorac Vasc Anesth
JT  - Journal of cardiothoracic and vascular anesthesia
JID - 9110208
RN  - 0 (Anticoagulants)
RN  - 0 (Antithrombins)
RN  - 0 (Blood Coagulation Factors)
RN  - 0 (Fibrinolytic Agents)
RN  - 42HK56048U (Tyrosine)
RN  - 9005-49-6 (Heparin)
RN  - GGX234SI5H (Tirofiban)
SB  - IM
MH  - Aged
MH  - Anticoagulants/*therapeutic use
MH  - Antithrombins/therapeutic use
MH  - Blood Coagulation Factors/drug effects
MH  - *Cardiopulmonary Bypass
MH  - Drug Resistance/*physiology
MH  - Female
MH  - Fibrinolytic Agents/therapeutic use
MH  - Hemostasis/*drug effects
MH  - Heparin/*therapeutic use
MH  - Hirudin Therapy
MH  - Humans
MH  - Male
MH  - Middle Aged
MH  - Platelet Count
MH  - Prospective Studies
MH  - Tirofiban
MH  - Tyrosine/*analogs & derivatives/therapeutic use
EDAT- 2003/04/17 05:00
MHDA- 2003/12/13 05:00
CRDT- 2003/04/17 05:00
PHST- 2003/04/17 05:00 [pubmed]
PHST- 2003/12/13 05:00 [medline]
PHST- 2003/04/17 05:00 [entrez]
AID - S1053077003000168 [pii]
AID - 10.1053/jcan.2003.42 [doi]
PST - ppublish
SO  - J Cardiothorac Vasc Anesth. 2003 Apr;17(2):171-5. doi: 10.1053/jcan.2003.42.