Recognition and management of patients with antiphospholipid antibody syndrome undergoing cardiac surgery

Sheikh, Farhan; Lechowicz, Andre; Setlur, Rangaraj; Rauch, Alan E.; Dunn, Harry G.

doi:10.1016/s1053-0770(97)90173-7

Cited by 34 publications

(29 citation statements)

References 9 publications

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“…Thirteen of the patients in these series underwent cardiac surgery. Individual case reports of cardiac surgical patients frequently describe thrombotic or haemorrhagic complications including early graft occlusion [93] haemothorax [94], pulmonary emboli, and limb ischaemia [95,96]. More optimistically, the literature includes several case reports of uneventful cardiac surgery [97,98].…”

Section: Outcomes Of Cardiac Surgery In Apls Patientsmentioning

confidence: 99%

Antiphospholipid syndrome; its implication in cardiovascular diseases: a review

Koniari

Siminelakis

Baikoussis

et al. 2010

J Cardiothorac Surg

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Antiphospholipid syndrome (APLS) is a rare syndrome mainly characterized by several hyper-coagulable complications and therefore, implicated in the operated cardiac surgery patient. APLS comprises clinical features such as arterial or venous thromboses, valve disease, coronary artery disease, intracardiac thrombus formation, pulmonary hypertension and dilated cardiomyopathy. The most commonly affected valve is the mitral, followed by the aortic and tricuspid valve. For APLS diagnosis essential is the detection of so-called antiphospholipid antibodies (aPL) as anticardiolipin antibodies (aCL) or lupus anticoagulant (LA). Minor alterations in the anticoagulation, infection, and surgical stress may trigger widespread thrombosis. The incidence of thrombosis is highest during the following perioperative periods: preoperatively during the withdrawal of warfarin, postoperatively during the period of hypercoagulability despite warfarin or heparin therapy, or postoperatively before adequate anticoagulation achievement. Cardiac valvular pathology includes irregular thickening of the valve leaflets due to deposition of immune complexes that may lead to vegetations and valve dysfunction; a significant risk factor for stroke. Patients with APLS are at increased risk for thrombosis and adequate anticoagulation is of vital importance during cardiopulmonary bypass (CPB). A successful outcome requires multidisciplinary management in order to prevent thrombotic or bleeding complications and to manage perioperative anticoagulation. More work and reporting on anticoagulation management and adjuvant therapy in patients with APLS during extracorporeal circulation are necessary.

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Section: Outcomes Of Cardiac Surgery In Apls Patientsmentioning

confidence: 99%

Antiphospholipid syndrome; its implication in cardiovascular diseases: a review

Koniari

Siminelakis

Baikoussis

et al. 2010

J Cardiothorac Surg

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“…(a) Administration of at least as much heparin as usual, add extra doses to double the baseline ACT [113] or to reach an ACT twice the upper limit of normal [101]. (b) Preoperative titration of the ACT response to different doses of heparin in a sample of the patients blood, adjust the dose of heparin to be given according to the established target ACT (assuming a heparin concentration of >3 U/ml blood sufficient for an effective anticoagulation during CPB) [105].…”

Section: Intraoperative Management Of Coagulation -A Crucial Problem mentioning

confidence: 99%

“…(e) Application of less protamine, e.g. by giving half of the calculated dose or no protamine at all [95,98,99,113,126].…”

Section: Intraoperative Management Of Coagulation -A Crucial Problem mentioning

confidence: 99%

“…Protamine to antagonise heparin should be administered only in a stepwise manner or in low dose continuously intravenous, e.g. 50 mg/h [113] until the bleeding tendency slows down to an acceptable amount. Of uppermost importance is a scrutinised operative technique and haemostasis to avoid any unnecessary surgical bleeding site.…”

Section: Intraoperative Management Of Coagulation -A Crucial Problem mentioning

confidence: 99%

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The antiphospholipid syndrome and heart valve surgery

Gorki¹,

Malinovski²,

Stanbridge³

2008

European Journal of Cardio-Thoracic Surgery

125

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The antiphospholipid syndrome (APLS) is a complex autoimmune disease often connected to systemic lupus erythematodes. Main features are thromboses, fetal loss and specific antibodies. The involved autoantibodies are directed against plasma proteins such as beta2glycoprotein1 (beta2GPI) or prothrombin which depend on negatively charged phospholipids. Direct antibodies against phospholipids are of no importance for APLS. Clotting tests such as activated partial thromboplastin time or diluted Russell's viper venom test (dRVVT) can show a prolonged time for coagulation despite a prothrombotic state in vivo but the investigator needs awareness about disturbing phospholipid sources and other influential factors. Enzyme linked immuno sorbent assay tests for antibodies against cardiolipin, beta2GPI and prothrombin are valuable solid phase tests with different specificity. Antiphospholipid, anticardiolipin or lupus anticoagulant are misnomers in connection with APLS. They are preserved as a reminiscence of the pioneering work on the way to the still not exactly revealed basics of APLS. Valve operations in APLS patients seem to be rare; a meta-analysis of 57 cases proves that the perioperative management is, at the moment, an empirical approach with high morbidity and mortality in these young patients.

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“…In some studies, either the standard dose (3 mg/kg) or an increased dose (5 mg/kg) of heparin was used regardless of the ACT [8]. Sheikh et al [9] recommended a heparin dose that doubles the baseline ACT level. The use of the ACT as means to measure blood coagulation is accompanied by a number of problems, namely: (1) there may be patients with increased baseline ACT levels; (2) half of APS patients may have thrombocytopenia; and (3) the heparin response may vary due to a patient's low level of antithrombin III.…”

Section: Discussionmentioning

confidence: 99%

Anesthetic management of antiphospholipid syndrome patients who underwent cardiac surgery: three cases report

Cho

Jeon

Hong

et al. 2014

Korean J Anesthesiol

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Antiphospholipid syndrome (APS) is a rare disease in which patients display prolonged coagulation test results in vitro, but usually develop thrombotic symptoms in vivo. Patients with APS are at increased risk of valvular heart disease or coronary vascular disease, conditions that often necessitate cardiac surgery via bypass. The management of anticoagulation during cardiopulmonary bypass (CPB) is particularly challenging in these patients because of the unique features of APS. Patients with APS are constantly at risk of arterial and venous thrombotic events. Therefore it is very important to maintain proper anticoagulation perioperatively, especially during CPB. In this paper, we present three successful cases of APS patients who underwent cardiac surgery with CPB.

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Recognition and management of patients with antiphospholipid antibody syndrome undergoing cardiac surgery

Cited by 34 publications

References 9 publications

Antiphospholipid syndrome; its implication in cardiovascular diseases: a review

Antiphospholipid syndrome; its implication in cardiovascular diseases: a review

The antiphospholipid syndrome and heart valve surgery

Anesthetic management of antiphospholipid syndrome patients who underwent cardiac surgery: three cases report

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