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The Journal of Thoracic and Cardiovascular Surgery, Vol 102, 505-514, Copyright © 1991 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
W Dietrich, M Spannagl, W Schramm, W Vogt, A Barankay and JA Richter
The effect of preoperative anticoagulant therapy on intraoperative heparin
response in patients undergoing cardiac operations was examined in a
prospective study. The study included 45 patients with different
preoperative anticoagulant treatments: 10 patients received treatment with
phenprocoumon (a warfarin analogue) (group M), 12 patients received
treatment with intravenous heparin (group Hiv), and 13 patients received
treatment with subcutaneous heparin (group Hsc). The control group
consisted of 10 patients who did not receive anticoagulant therapy before
operation (group C). Preoperative antithrombin III activity was highest in
group M (85% +/- 6%) and lowest in group Hiv (70% +/- 15%, p less than
0.05). The activated clotting time, determined 10 minutes after bolus
injection of 250 IU (group M) or 375 IU heparin (all other groups), was 529
+/- 109 seconds in group C, greater than 1000 seconds in group M, 483 +/-
99 seconds in group Hsc, and 406 +/- 63 seconds in group Hiv (p less than
0.05). Heparin consumption during cardiopulmonary bypass varied between 4.6
+/- 1.4 IU/kg.min (group Hiv) and 2.6 +/- 0.9 IU/kg.min (group M) (p less
than 0.05). Despite this increased heparin consumption, the patients who
had received heparin before operation demonstrated increased activation of
coagulation at the end of cardiopulmonary bypass (thrombin-antithrombin III
complex, 19 +/- 4.1 ng/ml in group M and 61 +/- 7 ng/ml in group Hsc, p
less than 0.05; cross-linked fibrin fragments, 257 +/- 92 ng/ml in group M
and 875 +/- 152 ng/ml in group Hiv, p less than 0.05). Increased platelet
activation was also found in patients with preoperative heparin therapy
(beta-thromboglobulin at the end of cardiopulmonary bypass was 585 +/- 88
ng/ml in group M versus 1341 +/- 190 ng/ml in group Hsc, p less than 0.05).
Drainage from the chest tube 24 hours after operation was 815 +/- 305 ml in
group C, 644 +/- 238 ml in group M, 1133 +/- 503 ml in group Hsc, and 950
+/- 505 ml in group Hiv (p less than 0.05 for group M versus group Hsc).
This study suggests that patients who receive heparin therapy before
operation face a high risk of insufficient anticoagulation during
cardiopulmonary bypass if standard heparin doses are used. Therefore, for
patients who receive preoperative heparin therapy, a larger (500 IU/kg)
initial bolus of heparin is recommended before cardiopulmonary bypass. On
the other hand, patients who undergo preoperative treatment with
phenprocoumon receive sufficient anticoagulative effect with a heparin
bolus of 250 IU/kg.(ABSTRACT TRUNCATED AT 400 WORDS)
ARTICLES
The influence of preoperative anticoagulation on heparin response during cardiopulmonary bypass
Institute for Anesthesiology, German Heart Center, Munich.
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