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J Thorac Cardiovasc Surg 2006;131:963-968
© 2006 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

Fatal pulmonary microthrombi during surgical therapy for end-stage heart failure: Possible association with antifibrinolytic therapy

John R. Cooper, Jr, MD a , Jacki Abrams, MD b , O.H. Frazier, MD c , d , * , Rajko Radovancevic, MD c , Branislav Radovancevic, MD c , Arthur W. Bracey, MD b , Michel J. Kindo, MD c , Igor D. Gregoric, MD c , d

a Department of Cardiovascular Anesthesiology, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Tex.
b Department of Pathology, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Tex.
c Department of Cardiovascular Surgery, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Tex.
d Cardiovascular Surgical and Transplant Research, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Tex.

Received for publication May 25, 2005; revisions received November 10, 2005; accepted for publication January 10, 2006.

* Address for reprints: O. H. Frazier, MD, P.O. Box 20345, MC 3-147, Houston, TX 77225-0345. (Email: knowlin{at}heart.thi.tmc.edu).

BACKGROUND: Maintaining hemostasis in patients with end-stage heart failure undergoing cardiac surgery is always challenging. These patients have chronic hepatic insufficiency, resulting in derangement of coagulation. In addition, they are commonly receiving both systemic anticoagulation (warfarin or heparin) and antiplatelet therapy. The introduction of antifibrinolytics has had a significant effect on postoperative coagulopathy. We report fatal pulmonary microthrombi in patients receiving antifibrinolytics who developed suprasystemic pulmonary artery pressures and right heart failure that was impossible to overcome despite insertion of a right ventricular assist device.

METHODS: We reviewed the surgical procedure and autopsy reports to identify patients with high pulmonary artery pressures caused by pulmonary microthrombi after a cardiac surgical procedure for end-stage heart failure. Patient demographics and preoperative, intraoperative, and postoperative variables were collected from a retrospective review of the patients' medical records.

RESULTS: We identified 9 patients (7 men and 2 women; mean age, 45 ± 16 years) who died of pulmonary microthrombi after cardiac surgery between January 1997 and January 2004. Surgical procedures included 5 left ventricular assist device implantations, 2 heart transplantations, and 2 left ventricular reconstructions with mitral valve repair or replacement. Eight patients received aprotinin, and 1 patient received {varepsilon}-aminocaproic acid immediately before and during cardiopulmonary bypass. All patients had severe suprasystemic pulmonary artery pressures after protamine administration for heparin reversal, a complication that proved fatal in all cases. Intraoperative wedge biopsy of the lungs revealed multiple microthrombi within capillaries and in the small- and medium-sized pulmonary arterioles.

CONCLUSION: We report 9 cases for which fatal pulmonary microthrombi might be associated with the use of prophylactic antifibrinolytic therapy. Mortally ill patients with multiorgan failure who are receiving systemic anticoagulation and undergoing surgical procedures require careful perioperative monitoring to identify potential hazards. Anticoagulation and antifibrinolytic therapy protocols may require adjustment in such patients.

Abbreviations and Acronyms ACT = activated clotting time; ATIII = antithrombin III; CPB = cardiopulmonary bypass; DIC = disseminated intravascular coagulopathy; EACA = {varepsilon}-aminocaproic acid; FFP = fresh frozen plasma; IABP = intra-aortic balloon pump; kACT = kaolin-activated clotting time; KIU = kallikrein inactivation unit; LVAD = left ventricular assist device; RVAD = right ventricular assist device






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