Acute Intracardiac Thrombosis and Pulmonary Thromboembolism After Cardiopulmonary Bypass: A Systematic Review of Reported Cases

Abstract

Intracardiac thrombosis (ICT) and pulmonary thromboembolism (PE) after cardiopulmonary bypass (CPB) are life-threatening events, but pathological mechanisms are not yet well defined. The aim of this review is to provide an update of case literature of a postbypass hypercoagulable state. Case commonalities among 48 ICT/PE events included congestive heart failure (50%), platelet transfusion (37.5%), CPB duration greater than 3 hours (37.5%), and aortic injury (27.1%). Preexisting thrombophilia was rarely reported, and 16.7% had low activated clotting time, ≤400 seconds during CPB. Mortality rate was very high (85.4%), despite attempted thrombectomy and supportive therapy. Thrombolytic therapy was infrequently used (5 of 48 times), but its efficacy is questionable due to common use of antifibrinolytic therapy (77.1% of cases). Acute ICT/PE events appear to rarely occur, but common features include prolonged CPB, depressed myocardial function, major vascular injury, and hemostatic interventions. Further efforts to elucidate pathomechanisms and optimize anticoagulation during CPB and hemostatic interventions after CPB are warranted.

Catastrophic Intracardiac Thrombosis During Emergency Repair of an Expanding Aortic Pseudoaneurysm: A Case Report

“…In conclusion, acute thrombosis is multifactorial in origin, likely conforming to the "Swiss cheese" model in which multiple factors must line up for the pathology to occur. We agree with the call by Tanaka and colleagues' 5 Virchow's triad consists of altered blood flow, vascular injury, and altered blood coagulability, which make up the column headings. Bolded items consist of general factors, and bulleted items specifically apply to the presented case.…”

“…A recent systematic review on this topic by Tanaka and colleagues, 5 which included cases of pulmonary embolism, compiled only 46 cases reported in the literature between 1990 and 2016. 5 Including 2 of their own institutional cases, they reported a 30-day mortality rate of 85.4%, with most patients expiring within 72 hours. Certain commonalities can be found among these cases, which Tanaka and colleagues 5 grouped into 3 themes based on Virchow's triad.…”

Toward Optimal Anticoagulation Monitoring During Cardiopulmonary Bypass: It Is Still A Tough “ACT”

“…2,9,10 It seems obvious that well-known influencing factors of the ACT measurements, such as diluted coagulation factors, hypothermia, low platelet count, or impaired platelet function, 7,8 might differently affect the 2 devices, leading to variable test results, especially with high heparin dosages 11 or prolonged CPB. 12 Technical differences between the ACT devices support the conclusion that Hemochron and iSTAT are not interchangeable. 9 They might further explain the variable behavior of ACT changes during CPB as reported in the present study.…”

“…In particular, heparin levels may not be adequately maintained when ACT values go out of range due to complex coagulopathy during prolonged CPB of more than 4 hours. 12 However, in the absence of real alternatives, we must rely on internationally suggested ACT values as a gold standard. The current practice of anticoagulation and its monitoring during CPB is supported by our daily experiences and recommendations that a heparin bolus of 300-to-400 U/kg, leading to an ACT between 400 and 500 seconds evaluated with different devices, is generally accepted safe enough to inhibit clot formation during CPB.…”

Dynamic Covalent Identification of an Efficient Heparin Ligand

“…[5] Thus, heparin is am acromolecular drug [6] commonly used as anticoagulant for blood vessels clot prevention [7] and some types of surgery. [8] From astructural point of view,heparin (1 in Figure 1A)i st he organic biomolecule with the highest anionic charge density, [9] and is usually obtained from natural sources as ap olydispersed polymer mixture. [10] Foru ses in both surgery and long-term diseases,t he modulation of the available heparin in plasma is essential to achieve ad elicate control of its pharmacological action while avoiding bleeding disorders and overdose.…”