Complete Heparin Reversal by Protamine during Off-Pump Coronary Artery Bypass Surgery (OPCAB): A Necessity or Myth?

In our country majority of the coronary artery bypass surgery (CABG) are done off-pump and was reported having excellent clinical outcome along with cost efficiency by various investigators. Heparin is commonly used as most effective anticoagulant, and protamine sulfate is now generally used to reverse the anticoagulant action of heparin. While under dosing of protamine may result in incomplete heparin reversal and prolonged anticoagulation, protamine overdosing is associated with impaired clot formation exerted by the intrinsic anti-coagulation properties of protamine itself, moreover protamine administration is associated with mild to severe cardiovascular and pulmonary complications. Apart from traditional full neutralization of heparin now-a-days, half dose protamine was also introduced showing good outcome regarding lower activated clotting time (ACT), overall, less surgical bleeding with less transfusion. This comparative study was designed to detect differences between traditional and decreased protamine dosing in Off-Pump Coronary Artery Bypass (OPCAB) surgery. Four hundred (400) patients who underwent Off-Pump Coronary Artery Bypass Surgery (OPCAB) surgery at our institution over a period of 12 months were analyzed and were divided into two groups. Group A- received 0.5mg of protamine per 100 unit of heparin; Group B-received 1.0mg of protamine per 100 unit of heparin. ACT, blood loss, hemoglobin and platelet count units of blood and blood product transfusion requirements, clinical outcome and hospital stay were assessed in each patient. This study showed that 0.5mg of protamine per 100 unit of heparin was always able to reverse the anticoagulant effect of heparin with no significant difference in hemodynamic parameters, amount of blood loss and requirements of blood transfusion in between the groups. A standard protamine dosing formula (protamine-heparin at ratio of 1:1) adequate for on-pump cardiac surgical procedures significantly overestimates protamine requirements for OPCAB. Patients treated with decreased protamine do not appear to have adverse outcomes in terms of post-operative bleeding.