Closed cardiopulmonary bypass circuits suppress thrombin generation during coronary artery bypass grafting☆

Abstract

Thrombin generation is considered unavoidable during cardiac surgery using cardiopulmonary bypass (CPB). We compared the effects of open and closed circuits on coagulation and fibrinolysis under identical conditions of priming volume, heparin-coating, and anticoagulation and transfusion protocols. Thirty coronary surgery patients were randomized to surgery using open circuits with open reservoirs and cardiotomy suction (open group, n=15) or closed circuits without either (closed group, n=15). In the closed group, a cell-saving device was used instead of cardiotomy suction. Blood samples were collected at eight time points from before the operation to the first postoperative morning. Thrombin-antithrombin III (TAT), fibrinogen degradation products, and D-dimer were not elevated during CPB in the closed group, but were significantly increased in the open group (P<0.0001 for all markers). The peak TAT value at the termination of CPB in the open group was significantly correlated with CPB time (r(2)=0.879, P=0.037) and the simultaneous peak D-dimer value (r(2)=0.640, P=0.040). In conclusion, the use of closed circuits maximally suppressed thrombin generation and coagulofibrinolytic activation during coronary artery bypass grafting. The respective contribution of open reservoirs and cardiotomy suction to the perioperative thrombin generation remains to be elucidated.

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“…Moreover, several studies have reported positive correlations between CPB duration and a negative influence on coagulation variables such as increased thrombin inhibition and fibrinolysis 18. Indeed, coagulopathy and increased bleeding are serious complications, particularly occurring after prolonged CPB,19,20 which is also associated with an increased risk of morbidity and mortality 21,22.…”

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“…58 Miniaturized circuits are associated with substantial reductions in neurologic injury, number of patients requiring transfusion of blood products, and peak cardiac troponin release.…”

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“…D-dimer was used as a surrogate marker for fibrinolysis in this study [14]. As could be expected, according to the changes in serum levels of TAT, D-dimer levels developed in parallel.…”

“…The TATas an indirect marker of thrombin generation, was chosen as a surrogate for coagulation activation in our setting [14]. Two hours after surgery, TAT was significantly higher in the Smart group as compared with the C.A.T.S.…”