H. Gorki

Anticoagulation management during multivessel coronary artery bypass grafting: a randomized trial comparing individualized heparin management and conventional hemostasis management.

Individualized heparin management (IHM) uses heparin dose–response curves to improve hemostasis management during cardiac surgery as compared with activated clotting time‐based methods.

Similarity of coagulation and inflammation despite different surgical revascularization strategies – a prospective randomized trial

Background: Supposedly, minimized extracorporeal circulation or off-pump revascularization as alternatives to conventional extracorporeal circulation (ONCAB) reduce inflammation and coagulation disturbances. Methods: One hundred and twenty coronary artery bypass graft (CABG) patients were prospectively randomized for three surgical techniques. Coagulation and inflammation markers were measured up to 72 hours postoperatively. Results: Coagulation factors I, II, V, X, antithrombin III and C-reactive protein did not differ perioperatively between the groups and increased, as did several other markers, 12 to 72 hours postoperatively. Compared to its alternatives, ONCAB showed the most obvious transient increase in thrombin-antithrombin complexes (p<0.0001), D-dimers (p=0.0059), tissue factor pathway inhibitor (p=0.0005), factor VIII (p=0.0041) and tumor necrosis factor α (p=0.0300) during the operation and up to 12 hours postoperatively. Furthermore, ONCAB generated lower leukocyte and platelet counts and higher values of soluble P-selectin and soluble intercellular adhesion molecule 1 at some time points. Conclusions: With similarity in pivot coagulation factors, a specific detrimental influence of ONCAB on common coagulation pathways was excluded. Higher perioperative concentrations of products from the coagulation cascade most likely indicate activation of pericardial blood – recirculated only in ONCAB. Furthermore, with only temporary differences in markers of inflammation, the alternatives to ONCAB altogether were without advantage at 72 hours postoperatively. In the general answer to surgical trauma, the part of modern extracorporeal circulation is possibly overestimated. The study is registered at the German Clinical Trial Registry. Registration number DRKS00007580. URL: https://drks-neu.uniklinik-freiburg.de/drks_web/ URL: http://apps.who.int/trialsearch/

On-Pump Nonrobotic Total Endoscopic Coronary Artery Bypass Grafting: An Animal Study

BACKGROUND  Total endoscopic coronary artery bypass grafting (TECAB) is currently performed exclusively with the help of a telemanipulator. After extensive practice in a biomechanical model, the operation was performed as a nonrobotic approach in an animal study. METHODS  Six large domestic pigs were anesthetized and intubated. Port access and endoscopic vision were used exclusively during the intrathoracic procedure. In five animals, an internal mammary artery was harvested, extracorporeal circulation was established via peripheral vessel access, and the ascending aorta occluded with an intraluminal balloon. In cardioplegic arrest, an anastomosis of internal mammary artery and left anterior descending coronary artery was performed with shortened 7-0 monofil thread running suture. As a terminal study, the animals were humanely killed and the quality of the anastomoses was checked. RESULTS  After a steady learning curve, the fifth animal was operated on successfully and a satisfactory anastomosis was documented. CONCLUSION  Despite demanding differences to humans as shape of thoracic cavity and size of peripheral access vessels, the viability of the nonrobotic TECAB concept was documented in a living animal model.

Laser fluorescence angiography reveals perfusion defects in retrograde cardioplegia.

Background: Adequate perfusion of the right ventricle with retrograde cardioplegia has always been questioned. However, clinical studies suggested sufficient protection and, up to now, intraoperative assessment of cardioplegia distribution has been difficult. Methods: As a pilot study in 14 patients, we used indocyanine green laser fluorescence angiography (ICGLA) to assess vascular and myocardial perfusion of different areas of the right anterior ventricular wall. Regions of interest were analyzed quantitatively using a new software package. Results: ICGLA allowed rapid and reliable visualization of cardioplegic flow and distribution. Retrograde cardioplegia revealed perfusion defects in the territory of the right anterior cardiac veins when compared to antegrade delivery and to areas close to the left anterior descending vein(s), confirmed by quantitative analyses of maximal fluorescence intensity. Five patients were excluded from quantitative analyses. The learning curve, pitfalls, limitations and special image details are described. Conclusion: A larger study is necessary to examine the relevance of perfusion defects to metabolic changes in affected myocytes and to global right ventricular function.

Postoperative Bleeding after CABG - does Individualized Heparin Management Save Blood?

Objectives: To compare routine activated clotting time (ACT) based hemostasis management to individualized heparin management (IHM) in terms of postoperative bleeding, platelet function, and coagulation markers. Methods: 120 CABG patients (≥ 3 distal anastomoses) were enrolled in a prospective trial and were randomized for hemostasis management (ACT versus IHM). With a target ACT of 400 second conventional hemostasis management antagonized heparin with protamine in a ratio of 1:>0.8, whereas in IHM protamine dosages were calculated from residual heparin concentrations. Hemostasis was analyzed immediately post-OP by thrombelastometry, aPTT, INR, and a range of coagulation markers. Results: A total of 112 patients (ACT: 56, IHM: 56) were included. Median heparin dosages were equivalent in both groups, whereas IHM patients received significantly less protamine. INR did not differ significantly, but aPTT values were significantly higher in HM patients. INTEM clotting times were elevated in IHM patients, whereas HEPTEM clotting times did not differ. Most coagulation markers (antithrombin III, d-dimers, fibrinogen, factors II/V/VIII/X, tissue factor pathway inhibitor, platelet counts) did not differ between groups, whereas thrombin-antithrombin complexes (TATs) were higher in ACT patients (29.69 [15.14–42.19] versus 18.50 [12.14–29.22] µg/l, p = 0.005), indicating recovered coagulation capacities. TATs correlated significantly with protamine doses (p = 0.022). Blood losses were slightly but significantly higher in IHM patients within the first 12 hour which balanced at 24 hour and which did not lead to more blood transfusions (40 PRBC in 15 patients versus 44/17, p = 0.926). Conclusions: IHM patients did not benefit from allegedly reduced coagulation factor activation mainly because heparin dosages were unexpectedly identical in both groups. On the contrary, postoperative parameters indicated an incomplete heparin antagonization in IHM patients.