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Heparin reversal in off-pump coronary artery bypass surgery: complete, partial, or no reversal?
1Cardiac Surgery Department, Casa di Cura 'Villa Torri'-Clinica accreditata, viale Filopanti 12, 40126, Bologna, Italy. giusep.gatti@tiscali.it
Insights
Protamine administration during off-pump coronary artery bypass surgery significantly reduces postoperative bleeding and packed red blood cell transfusions. Partial heparin reversal with protamine may offer benefits without increasing bleeding risk.
Area of Science:
- Cardiovascular Surgery
- Anesthesiology
- Hematology
Background:
- Avoiding cardiopulmonary bypass is known to reduce postoperative bleeding.
- The role of protamine in managing heparin anticoagulation during off-pump coronary artery bypass surgery requires further investigation.
Purpose of the Study:
- To determine if protamine administration during off-pump coronary artery bypass surgery significantly reduces postoperative bleeding.
Main Methods:
- Sixty patients undergoing off-pump coronary artery bypass surgery were prospectively randomized into three groups.
- Group A received 1 mg protamine/100 IU heparin, Group B received 0.5 mg protamine/100 IU heparin, and Group C received no protamine.
- Patients were analyzed for preoperative cardiac function, coagulation profiles, intraoperative variables, and postoperative bleeding.
Main Results:
- No significant differences were observed in preoperative cardiac function or pre/intraoperative coagulation profiles across groups.
- Group A showed significantly lower postoperative bleeding, packed red blood cell use, and pericardial effusion compared to Group C.
- No significant differences in bleeding were found between Group A and Group B.
Conclusions:
- Heparin reversal with protamine is recommended in off-pump coronary artery bypass surgery to mitigate increased postoperative bleeding risk.
- Partial heparin reversal may reduce dose-dependent protamine adverse effects without elevating bleeding risk.
Abstract:
Several clinical studies have reported that avoiding cardiopulmonary bypass reduces postoperative bleeding. The purpose of this study is to verify that protamine during off-pump coronary artery bypass surgery produces significant reduction of postoperative bleeding. Sixty consecutive patients undergoing off-pump coronary artery bypass surgery were prospectively randomized in three groups: Group A received 1 mg of protamine every 100 IU of heparin, Group B 0.5 mg of protamine every 100 IU of heparin, and Group C none. The three groups were analyzed for differences in preoperative cardiac function, pre-, intra-, and postoperative coagulation profile, intraoperative variables, and postoperative bleeding. In the three study groups, no statistically significant difference was found in preoperative cardiac function, pre- and intraoperative coagulation profile, and prothrombin time, activated partial thromboplastin time, platelet count in the first postoperative day. In Group A, total postoperative bleeding, use of packed red blood cells, and mild pericardial effusion prevalence at discharge were significantly lower only when compared to Group C, but they were not significantly different when compared to Group B. In off-pump coronary artery bypass surgery, heparin should be reverted with protamine, otherwise the postoperative bleeding risk might increase. Partial heparin reversal might not increase postoperative bleeding risk, but it may reduce dose-dependent protamine adverse effects.