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Published on: September 15, 2023
Haemostasis alterations in coronary artery bypass grafting: comparison between the off-pump technique and a closed
Giuseppe Scrascia1, Crescenzia Rotunno, Piero Guida
1Division of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy.
Insights
Off-pump coronary artery bypass surgery showed increased coagulation and fibrinolysis activation compared to the Physio cardiopulmonary bypass system. The Physio system reduced postoperative bleeding but required further optimization to decrease red blood cell transfusions.
Area of Science:
- Cardiovascular Surgery
- Hemostasis and Thrombosis
- Biomaterials
Background:
- Cardiopulmonary bypass (CPB) activates coagulation and fibrinolysis, increasing bleeding risk.
- Off-pump coronary artery bypass (OPCAB) aims to mitigate CPB-related complications.
- Phosphorylcholine-coated CPB systems are designed to improve biocompatibility.
Purpose of the Study:
- To compare coagulation and fibrinolysis activation between OPCAB and a phosphorylcholine-coated CPB system (Physio group).
- To evaluate the impact of these techniques on postoperative bleeding and transfusion requirements.
Main Methods:
- Prospective study of 36 OPCAB and 36 Physio group patients.
- Assessed prothrombin fragment 1.2 and plasmin-antiplasmin complex levels preoperatively and postoperatively.
- Evaluated platelet function using Platelet Function Analyzer 100®.
Main Results:
- OPCAB group showed significantly higher prothrombin fragment 1.2 and plasmin-antiplasmin levels postoperatively.
- Physio group had better platelet function and less chest tube drainage.
- Physio group required more red blood cell transfusions due to higher intraoperative transfusion rates.
Conclusions:
- The Physio CPB approach reduces postoperative hemostatic activation and bleeding compared to OPCAB.
- Further reduction in priming volume is needed for the Physio system to decrease intraoperative transfusions.
- The Physio system offers a promising alternative for managing hemostasis during cardiac surgery.
Objectives:
To compare coagulation and fibrinolysis activation in off-pump coronary artery bypass operation and in patients in whom a closed phosphorylcholine-coated cardiopulmonary bypass system was applied. Cardiopulmonary bypass induces activation of coagulative and fibrinolytic systems, which together with intraoperative haemodilution augment the risk of postoperative bleeding and transfusion of blood products.
Methods:
Thirty-six off-pump coronary artery bypass and 36 coronary artery bypass grafting patients in whom a closed, phosphorylcholine-coated cardiopulmonary bypass system with a closed-collapsible venous reservoir (Physio group) was used were prospectively enrolled. Activation of coagulation and fibrinolytic systems was assessed evaluating the release of prothrombin fragment 1.2 and plasmin-antiplasmin complex preoperatively (T0), 30 min after heparin administration (T1), 15 min after protamine administration (T2), 3 h after protamin administration (T3) and on postoperative days 1 (T4) and 5 (T5). Platelet function was evaluated through Platelet Function Analyzer 100(®).
Results:
During the operation, prothrombin fragment 1.2 and plasmin-antiplasmin levels were slightly higher in the Physio group, the difference being not statistically significant. In the off-pump coronary artery bypass group, prothrombin fragment 1.2 was significantly higher at T3 (618.7 ± 282.7 vs 416.6 ± 250.2 pmol/l; P = 0.006), T4 (416.7 ± 278.8 vs 310.2 ± 394.6 pmol/l; P < 0.001) and T5 (629.3 ± 295.2 vs 408.4 ± 409.7 pmol/l; P = 0.002), and plasmin-antiplasmin was significantly higher at T4 (731.1 ± 790 vs 334 ± 300.8 ng/ml; P = 0.019) and T5 (1744.4 ± 820.7 vs 860.1 ± 488.4 ng/ml; P = 0.003). Platelet Function Analyzer 100® closure time values were significantly higher in the Physio group patients at T3 (131.3 ± 105.7 vs 215.6 ± 58.9 s; P = 0.002). The off-pump coronary artery bypass patients had greater chest tube drainage (874.3 ± 371.5 vs 629.1 ± 334.5 ml; P = 0.005). The mean priming volume was 1240 ± 215 ml in the Physio group. Much more Physio patients received red blood cell transfusions (14 vs 25 patient; P = 0.009), because of higher intraoperative transfusion rates (6 vs 15 patients; P = 0.016). Despite similar preoperative haemoglobin levels (13 ± 1.2 vs 12.6 ± 1.4 g/dl; P = 0.2), postoperative haemoglobin levels were significantly lower in the Physio group.
Conclusions:
The Physio cardiopulmonary bypass approach does not significantly alter haemostasis during the operation compared with off-pump coronary artery bypass providing a reduced activation in the postoperative period reducing also chest tube drainage. However, further priming volume reduction is required to decrease intraoperative red blood cell transfusion.
