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CARDIOVASCULAR ANESTHESIA

Anticoagulation for Cardiac Surgery in Patients Receiving Preoperative Heparin: Use of the High-Dose Thrombin Time

Linda Shore-Lesserson, MD^*, Heather E. Manspeizer, MD, Maria Bolastig, MD^*, Donna Harrington, RN^*, Frances Vela-Cantos, RN^*, and Marietta DePerio, RN^*

*Department of Anesthesiology, Mount Sinai Medical Center; and Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, New York

Address correspondence and reprint requests to Linda Shore-Lesserson, MD, Department of Anesthesiology, One Gustave L. Levy Place, Box 1010, New York, NY 10029.

Patients receiving heparin infusions have an attenuated activated clotting time (ACT) response to heparin given for cardiopulmonary bypass (CPB). We compared patients receiving preoperative heparin (Group H) to those not receiving heparin (REF group) with respect to ACT, high-dose thrombin time (HiTT), and markers of thrombin generation during CPB. Sixty-five consecutive patients (33 Group H, 32 REF group) undergoing elective CPB were evaluated. ACT and HiTT were measured at multiple time points. Plasma levels of thrombin-antithrombin III complex and fibrin monomer were determined at baseline, during CPB, and after protamine administration. Transfusion requirements and postoperative blood loss were measured and compared. ACT values after heparinization increased less in Group H and were significantly lower than those in the REF group (P < 0.01). HiTT values did not differ significantly between the two groups. Blood loss and transfusion requirements were not significantly different between the two groups. Plasma levels of thrombin-antithrombin III complexes and fibrin monomer also did not differ between groups at any time, despite a lower ACT in Group H after heparinization and during CPB. Our data suggest that thrombin formation and activity are not enhanced in patients receiving heparin therapy, despite a diminished ACT response to heparin. The utility of ACT and the threshold values indicative of adequate anticoagulation for CPB are relatively undefined in patients receiving preoperative heparin. HiTT should be investigated as a safe and accurate monitor of anticoagulation for CPB in patients receiving preoperative heparin therapy.

Implications: The diminished activated clotting time response to heparin, in patients receiving preoperative heparin therapy, poses difficulties when attempting to provide adequate anticoagulation for cardiopulmonary bypass. Current data suggest that heparin resistance is not observed when high-dose thrombin time is used to monitor anticoagulation and that a lower activated clotting time value in these patients may be safe.

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				M. C. Engoren, R. H. Habib, A. Zacharias, T. A. Schwann, C. J. Riordan, and S. J. Durham Effect of blood transfusion on long-term survival after cardiac operation Ann. Thorac. Surg., October 1, 2002; 74(4): 1180 - 1186. [Abstract] [Full Text] [PDF]

				L. Shore-Lesserson Monitoring the Hematologic Complications of Cardiopulmonary Bypass Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 2001; 5(3): 207 - 216. [Abstract] [PDF]

				A. H. E. Ean, T. S. Yan, T. Chan, E. James, and O. B. Chi Centrifugation of salvaged pump blood is useful in reducing the amount of heparin re-infused into the patient Perfusion, July 1, 2001; 16(4): 309 - 312. [Abstract] [PDF]

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999