Patients with infective endocarditis undergoing cardiac surgery have distinct ROTEM profiles and more bleeding complications compared to patients without infective endocarditis

Abstract

Background The coagulation system is crucial in the pathogenesis of infective endocarditis and undergoes significant changes during course of the disease. However, little is known about the implications of those changes in the perioperative period. Aim of the present study was to delineate the specific coagulation patterns and their clinical consequence in patients undergoing cardiac surgery due to infective endocarditis. Methods In this single-centre, exploratory, prospective observational study, we investigated the incidence and degree of coagulopathy in patients with (n = 31) and without infective endocarditis (n = 39) undergoing cardiac valve surgery. The primary outcome was the differences between these two groups in rotational thromboelastometry (ROTEM) results before, during and after surgery. The secondary outcomes were the differences between the groups in heparin sensitivity, bleeding complications, and transfusion requirements. Results Most ROTEM parameters in EXTEM, INTEM and FIBTEM assays were significantly altered in patients with infective endocarditis. Clotting time in the EXTEM assay was significantly prolonged in the endocarditis group at all time-points, while all clot firmness parameters (A5, A10 and MCF) were significantly increased. The heparin sensitivity index was significantly lower in the endocarditis group (median index 0.99 vs 1.17s. IU-1.kg-1, p = .008), indicating increased heparin resistance. Patients with infective endocarditis had more bleeding complications as assessed by the universal definition of perioperative bleeding score (OR 3.0, p = .018), and more patients with endocarditis underwent early re-exploration (p = .018). Conclusions The findings of this exploratory investigation show significantly altered coagulation profiles in patients with infective endocarditis, with concomitant hyper- and hypocoagulability. Furthermore, the incidence of bleeding complications and transfusion requirements were increased in patients with endocarditis. These results show the potential of ROTEM to detect coagulation abnormalities in patients with infective endocarditis. Existing point-of-care coagulation testing guided algorithms for optimizing perioperative coagulation management possibly need to be adjusted for these high-risk patients undergoing cardiac surgery.

A combination of clot formation abnormalities in thromboelastometry has a high prognostic value in patients with acute-on-chronic liver failure

“…Different 'hypocoagulable' profiles evaluated by pointof-care hemostatic devices in other settings of diseases and conditions had been considered to consist valuable predictors of poor outcome in critically ill patients [36,37].…”

Perioperative Complications in Infective Endocarditis

“…Furthermore, it is not entirely clear whether cardiac surgery for IE is per se associated with an increased risk of bleeding. While the transfusion rate is indeed higher in IE [79], after correction for risk factors such as age, sex, BMI, or anemia, IE was not independently associated with blood transfusion [84]. The incidence of DIC is between 1and 20%, and the occurrence of DIC is associated with increased mortality [12,85].…”

“…However, during cardiac surgery for IE, the occurrence of severe coagulopathy and bleeding is common. Intraoperative coagulopathy and bleeding in IE can result from various factors, including the patient's underlying coagulation status, the use of anticoagulant agents, surgical trauma, and infection-related factors such as platelet dysfunction and disseminated intravascular coagulation (DIC) [79,80]. Furthermore, many antibiotics that are used to treat IE can affect coagulation, either by direct interaction with the coagulation system or via drug-drug interaction, such as, e.g., between cefazoline and vitamin k antagonists [3].…”

Transfusion of blood products in cardiac surgery for endocarditis: predictors and consequences

“…A preoperative lower fibrinogen (Huang et al, 2019) and a greater loss of fibrinogen during surgery, with decreased firmness of blood clots, was associated with an increased need for transfusion (Huang et al, 2019). Apart from preoperative coagulopathy, anemia and renal failure associated with IE were also held accountable for transfusion need (Breel et al, 2023;Huang et al, 2019). The best predictor for the transfusion of RBC was preoperative hemoglobin level (de Boer et al, 2016).…”

“…In six series of varying size, IE itself led to hemostatic problems leading to an increased need for transfusion (Breel et al, 2023;Czerwinska-Jelonkiewicz et al, 2023;de Boer et al, 2016), especially with active IE (Huang et al, 2019), prosthetic valve IE (Salem et al, 2021) or when coagulase negative staphylococcus aureus was involved (Polzin et al, 2022). In one report, IE itself had no effect but its potential consequence, the need for complex aortic valve surgery was associated with this increased need for transfusion.…”