Effect of anticoagulation protocol on outcome in patients undergoing CABG with heparin-bonded cardiopulmonary bypass circuits
Effect of anticoagulation protocol on outcome in patients undergoing CABG with heparin-bonded cardiopulmonary bypass circuits
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DOI：
10.1016/s0003-4975(97)01347-7
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发表时间：
1998-02-01
影响因子：
4.6
通讯作者：
Shemin, RJ
中科院分区：
文献类型：
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作者：
Aldea, GS;O'Gara, P;Shemin, RJ
背景我们已经证明，使用肝素结合心肺转流回路（HBC）结合较低的抗凝方案作为综合血液保护策略的辅助措施，可以降低同种输血的发生率和程度，并改善接受初次冠状动脉旁路移植术的患者的临床结局。目前尚不清楚是否是较低的抗凝方案影响了接受HBCs治疗的患者的结局。此外，HBCs使用低抗凝的血栓形成风险仍有争议。为了回答这些问题，进行了一项前瞻性随机研究，其中244名接受直接冠状动脉旁路移植术的患者接受HBC治疗，并随机接受完整（活化凝血时间，>450秒）或较低（活化凝血时间，>250秒）的抗凝方案。除了临床结局外，还通过测量凝血酶-抗凝血酶复合物和凝血酶原片段1.2，在58例患者的连续亚组中评估了心肺转流术期间和之后的凝血酶生成标志物水平（完全抗凝特征= 28，较低抗凝特征= 30）。这些标志物的水平也与体外循环期间的活化凝血时间相关。两组的术前和术中风险特征和其他特征相似，超过60%的患者接受非选择性手术。与完整抗凝方案组相比，较低抗凝方案组患者需要血液制品的可能性较低（分别为24.2%和35.8%; p = 0.047），接受的同源供体单位显著较少（分别为0.50 +/- 0.92和1.08 +/- 2.10 U; p = 0.005）。两个治疗组的临床结局一致出色（但相似），较低抗凝方案组的住院时间适度缩短（分别为5.26 +/- 1.23 vs 5.63 +/- 1.73天; p = 0.05）。使用低抗凝方案的HBC与任何不良临床事件无关。两个治疗组在体外循环期间凝血酶生成增加，但与抗凝方案或活化凝血时间无关（r（2）= 0.03）。在体外循环期间经颅多普勒分析检测到的微栓子数量（n = 40）或术后神经学和神经心理学结局（n = 30）方面，充分抗凝方案组和低抗凝方案组之间没有差异。本研究明确表明，当使用得当时，接受HBC和低抗凝方案治疗的患者的同种输血发生率和程度较低，并且不会增加临床、血液学（凝血酶-抗凝血酶复合物和片段1.2测量）或显微镜（经颅多普勒分析）血栓栓塞并发症或神经或神经心理缺陷的风险。
Background. We have demonstrated that the use of heparin-bonded cardiopulmonary bypass circuits (HBCs) combined with a lower anticoagulation protocol as an adjunct to an integrated blood conservation strategy decreases the incidence and magnitude of homologous transfusion and improves clinical outcome in patients undergoing primary coronary artery bypass grafting. It is not known whether it is the lower anticoagulation protocol that influences outcome in patients treated with HBCs. Furthermore, the thrombogenic risk of using lower anticoagulation with HBCs still is debated.Methods. To answer these questions, a prospective randomized study was conducted in which 244 patients undergoing primary coronary artery bypass grafting were treated with HBCs and randomized to undergo either a full (activated clotting time, >450 seconds) or a lower (activated clotting time, >250 seconds) anticoagulation protocol. In addition to clinical outcome, levels of thrombin generation markers during and after cardiopulmonary bypass were assessed in a consecutive subset of 58 patients (full anticoagulation profile = 28, lower anticoagulation profile = 30) by measuring thrombin-antithrombin complexes and prothrombin fragment 1.2. Levels of these markers also were correlated with the activated clotting time during cardiopulmonary bypass.Results. Preoperative and intraoperative risk profiles and other characteristics were similar in both groups, with more than 60% of patients undergoing nonelective operation. Compared with the full anticoagulation protocol group, patients in the lower anticoagulation protocol group were less likely to require blood products (24.2% versus 35.8%, respectively; p = 0.047) and received substantially fewer homologous donor units (0.50 +/- 0.92 versus 1.08 +/- 2.10 U, respectively; p = 0.005). Clinical outcomes were uniformly outstanding (but similar) in both treatment groups, with a modest reduction in the length of the hospital stay in the lower anticoagulation protocol group (5.26 +/- 1.23 versus 5.63 +/- 1.73 days, respectively; p = 0.05). The use of HBCs with a lower anticoagulation protocol was not associated with any adverse clinical events. Thrombin generation increased during cardiopulmonary bypass in both treatment groups, but was unrelated to the anticoagulation protocol or the activated clotting time (r(2) = 0.03). No differences between the full and lower anticoagulation protocol groups were noted in the number of microemboli detected by transcranial Doppler analyses during cardiopulmonary bypass (n = 40) or in the postoperative neurologic and neuropsychologic outcomes (n = 30).Conclusions. This study definitively demonstrates that, when used appropriately, patients who are treated with HBCs and a lower anticoagulation protocol have a lower incidence and magnitude of homologous transfusion and are not at any added risk for clinical, hematologic (thrombin-antithrombin complex and fragment 1.2 measurements), or microscopic (transcranial Doppler analyses) thromboembolic complications or for neurologic or neuropsychologic deficits.