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Antithrombin replacement and outcome in cardiac surgery

Published online by Cambridge University Press:  01 June 2007

A. Koster
A. Koster*
Affiliation:
Department of Anesthesia Deutsches Herzzentrum Berlin, Germany
*
Correspondence to: Andreas Koster, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin. E-mail: Koster@dhzb.de; Tel: +49 30 4593 2600; Fax: +49 30 4593 2700
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Summary

Background and objective

Antithrombin levels during cardiac surgery critically decrease, due to both hemodilution and consumption. This factor prompted the question of whether improved attenuation of hemostatic activation can be achieved by high dose treatment with antithrombin. The aim of this review is to present the currently available pre-clinical and clinical data on the use of antithrombin in cardiac surgery.

Methods

Review of the available literature searched using the terms ‘AT’ or ‘Antithrombin’ and ‘Cardiac surgery’ or ‘CPB’ or ‘Cardiopulmonary bypass’.

Results

Antithrombin has been proposed in cardiac operations both as purified concentrates and as recombinant human preparations. The main clinical field where antithrombin supplementation is proposed is in case of heparine resistance (failure to achieve adequate anticoagulation following a standard heparin dose). However, other clinical scenarios have been investigated (modulation of inflammatory reaction; pulmonary vasodilation; prevention of thromboembolic complications).

Conclusions

Many studies suggest that antithrombin supplementation during and after cardiac surgery may be beneficial to correct abnormally low values. One article found an association between low values of antithrombin activity at the end of the operation and adverse postoperative outcomes. However, a large prospective, randomized trial is still needed to finally set the role of antithrombin supplementation in cardiac surgery.

Keywords

Cardiopulmonary bypassCoagulationInflammation
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 24 , Issue S40 , June 2007 , pp. 67 - 70
Copyright
Copyright © European Society of Anaesthesiology 2007

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References

1.Paparella, D, Brister, SJ, Buchanan, MR. Coagulation disorders of cardiopulmonary bypass: a review. Intensive Care Med 2004; 30: 1873–1881.CrossRefGoogle ScholarPubMed
2.Raymond, PD, Marsh, NA. Alterations to haemostasis following cardiopulmonary bypass and the relationship of these changes to neurocognitive morbidity. Blood Coagul Fibrinolysis 2001; 12: 601–618.CrossRefGoogle ScholarPubMed
3.Hirsh, J, Raschke, R. Heparin and low molecular weight heparin: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004; 126: 188S–203S.CrossRefGoogle ScholarPubMed
4.Raivo, P, Kuitinen, A, Suojaranta-Ylinen, R, Lassila, R, Petaja, J. Thrombin generation during reperfusion after coronary artery bypass associates with postoperative myocardial damage. J Thromb Haemost 2006; 4: 1523–1529.CrossRefGoogle Scholar
5.Maksan, SM, Maksan, MO, Gebhard, MM, Herfath, C, Klar, E. Reduction of reperfusion injury by antithrombin III and aprotinin. Transpl Int 2000; 13 Suppl 1: S562–S564.CrossRefGoogle ScholarPubMed
6.Okano, K, Kokudo, Y, Okajima, K et al. . Protective effects of antithrombin III supplementation on warm ischemia and reperfusion injury in rat liver. World J Surg 1996; 20: 1069–1075.CrossRefGoogle ScholarPubMed
7.Harada, N, Okajima, K, Kushimoto, S, Isobe, H, Tanaka, K. Antithrombin reduces ischemia/reperfusion injury of rat liver by increasing the hepatic level of prostacyclin. Blood 1999; 93: 157–164.CrossRefGoogle ScholarPubMed
8.Rinder, CS, Rinder, HM, Smith, MJ et al. . Antithrombin reduces monocyte and neutrophil CD11b up regulation in addition to blocking platelet activation during extracorporeal circulation. Transfusion 2006; 46: 1130–1137.CrossRefGoogle ScholarPubMed
9.Jormalainen, M, Vento, AE, Wartiovaara-Kauto, U et al. . Antithrombin reduces pulmonary hypertension during reperfusion after cardiopulmonary bypass in a pig. Acta Anaesthesiol Scand 2007; 51: 178–188.CrossRefGoogle ScholarPubMed
10.Ranucci, M, Frigiola, A, Menicanti, L et al. . Risk factors for fatal myocardial infarction after coronary bypass grfat surgery. Eur J Anesthesiol 2001; 18: 322–329.CrossRefGoogle Scholar
11.JrLemmer, JH, Despotis, GJ. Antithrombin III concentrates to treat heparin resistance in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2002; 123: 213–217.CrossRefGoogle ScholarPubMed
12.Koster, A, Fischer, T, Gruendel, M et al. . Management of heparin résistance during cardiopulmonary bypass: the effect of five different anticoagulation strategies on hemostatic activation. J Cardiothorac Vasc Anesth 2003; 17: 171–175.CrossRefGoogle ScholarPubMed
13.Avidan, MS, Levy, JH, vanAken, H et al. . 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: 107–113.CrossRefGoogle ScholarPubMed
14.Avidan, MS, Levy, JH, Scholz, J et al. . A phase III, double blind, placebo-controlled, multicenter study on the efficacy of recombinant human antithrombin in heparin-resistant patients scheduled to undergo cardiac surgery necessitating cardiopulmonary bypass. Anesthesiology 2005; 102: 276–284.CrossRefGoogle ScholarPubMed
15.Conley, JC, Plunket, PF. Antithrombin III in cardiac surgery: an outcome study. J Extra Corpor Technol 1998; 30: 178–183.CrossRefGoogle ScholarPubMed
16.Koster, A, Fischer, T, Praus, M et al. . Hemostatic activation and inflammatory response during cardiopulmonary bypass: impact of heparin management. Anesthesiology 2002; 97: 837–841.CrossRefGoogle ScholarPubMed
17.Ranucci, M, Frigiola, A, Menicanti, L, Ditta, A, Boncilli, A, Brozzi, S. Postoperative antithrombin levels and outcome in cardiac operations. Crit Care Med 2005; 33: 355–360.CrossRefGoogle ScholarPubMed
18.Slaughter, TF, Mark, JB, El-Moalem, H et al. . Hemostatic effects of antithrombin III supplementation during cardiac surgery: results of a prospective randomized investigation. Blood Coagul Fibrinolysis 2001; 12: 25–31.CrossRefGoogle ScholarPubMed
19.Koster, A, Chew, D, Kuebler, W et al. . High antithrombin III levels attenuate hemostatic activation and leukocyte activation during cardiopulmonary bypass. J Thorac Cardiovasc Surg 2003; 126: 906–907.CrossRefGoogle ScholarPubMed
20.Rossi, M, Martinelli, L, Storti, S et al. . The role of antithrombin III in the perioperative management of the patient with unstable angina. Ann Thorac Surg 1999; 68: 2231–2236.CrossRefGoogle ScholarPubMed
21.Sonzongi, V, Bellavita, P, Carrara, B et al. . The effect of antithrombin III concentrations during cardiopulmonary surgery. Minerva Anesthesiol 2000; 66: 17–23.Google Scholar
22.Koster, A, Spiess, BD, Chew, DP et al. . Effectiveness of bivalirudin as a replacement for heparin during cardiopulmonary bypass in patients undergoing coronary artery bypass grafting. Am J Cardiol 2004; 93: 356–359.CrossRefGoogle ScholarPubMed
23.Koster, A, Yeter, R, Buz, S et al. . Assessment of hemostatic activation during cardiopulmonary bypass for coronary artery bypass grafting with bivalirudin: results of a pilot study. J Thorac Cardiovasc Surg 2005; 129: 1391–1394.CrossRefGoogle ScholarPubMed
24.Dyke, CM, Smedira, N, Koster, A et al. . A comparison of bivalirudin to heparin wit protamine reversal in patients undergoing cardiac surgery with cardiopulmonary bypass: the EVOLUTION-ON study. J Thorac Cardiovasc Surg 2006; 131: 533–539.CrossRefGoogle Scholar