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CARDIOVASCULAR ANESTHESIA

Activation of Hemostasis After Coronary Artery Bypass Grafting With or Without Cardiopulmonary Bypass

Bernard Lo, MD^*, Rob Fijnheer, MD PhD, Domenico Castigliego, Cornelius Borst, MD PhD, Cor J. Kalkman, MD PhD^*, and Arno P. Nierich, MD PhD

*Department of Anesthesiology, Department of Hematology, and Heart-Lung Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands; and Department of Thoracic Anesthesiology and Intensive Care, Isala Clinics, Zwolle, The Netherlands

Address correspondence and reprint requests to Rob Fijnheer, MD, PhD, Department of Hematology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands. Address e-mail to r.fijnheer{at}azu.nl

Activation of coagulation, fibrinolysis, and the vascular endothelium occurs after heart surgery with cardiopulmonary bypass (CPB), but the effects of eliminating CPB in patients undergoing coronary artery bypass grafting (CABG) are unknown. Therefore, we compared the hemostatic profiles of off-pump and on-pump CABG patients. Two groups of consecutive patients participating in a larger trial (the Octopus Trial) were randomly allocated to undergo CABG with (n = 20) or without (n = 20) CPB. Platelet numbers and plasma concentrations of P-selectin, prothrombin fragment 1.2 (F1.2), soluble fibrin, D-dimers, and von Willebrand factor (as a marker of endothelial cell activation) were measured and corrected for hemodilution. Compared with the on-pump CABG group, F1.2 and D-dimer levels were significantly lower (P = 0.004 and P = 0.03, respectively) in patients having CABG surgery performed off-pump. In the CPB group, F1.2 (median [interquartile range], 450% of baseline [233%–847%]) and D-dimer (538% [318%–1192%]) peaked in the immediate postoperative period and remained increased until Day 4, whereas in the off-pump group, F1.2 and D-dimer levels increased more gradually and peaked on Day 4 (342% [248%–515%] and 555% [387%–882%], respectively). In both groups, von Willebrand factor concentrations were increased until Day 4 (CPB, 308% [228%–405%]; off-pump, 288% [167%–334%]). Despite heparinization, CABG surgery with CPB was associated with excessive thrombin generation and fibrinolytic activity immediately after surgery. The off-pump group demonstrated a delayed postoperative response that became equal in magnitude to the CPB in the later (20–96 h) postoperative period.

IMPLICATIONS: Coronary artery bypass grafting with cardiopulmonary bypass is associated with excessive thrombin generation and fibrinolytic activity immediately after surgery compared with off-pump procedures. However, after off-pump coronary surgery, patients demonstrated a delayed postoperative response that became equal in magnitude to that of those having on-pump procedures in the later (20–96 h) postoperative period.

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