Kaplon R J, Gillinov A M, Smedira N G, Kottke-Marchant K, Wang I W, Goormastic M, McCarthy P M
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Ohio 44195, USA.
J Heart Lung Transplant. 1999 Apr;18(4):346-50. doi: 10.1016/s1053-2498(98)00066-7.
Despite advances in left ventricular assist device (LVAD) design that permit support without anticoagulation, LVAD recipients often suffer profound bleeding complications. This bleeding diathesis may be attributable to pre-operative right-ventricular failure with concomitant hepatic dysfunction. The purpose of this study was to characterize coagulation abnormalities in LVAD recipients and determine the impact of pre-operative vitamin K administration on the incidence of postoperative bleeding.
Hemostatic and liver function profiles were obtained in 66 recipients of the Heartmate LVAD; 39 of these patients received perioperative vitamin K.
During LVAD support, hepatic synthetic function improved as evidenced by increases in clotting factors II, V, VII, XI. There was ongoing fibrinolysis with elevation of fibrinopeptide A and D-dimers and diminution of fibrinogen; however, plasminogen levels did not decline suggesting that systemic disseminated intravascular coagulation (DIC) did not occur. Bleeding requiring re-exploration more than 48 hours postimplantation occurred in 9 of 66 patients (13.6%). Prior to implantation, patients that bled had decreased levels of factor II (52.2 +/- 27.1% vs 69.7 +/- 26.6%; p = 0.048) and prolonged prothrombin times (16.5 +/- 2.4 seconds vs 13.8 +/- 3.1 seconds; p = 0.005) compared to patients that did not bleed. Seven of 27 patients (25.9%) not treated with vitamin K bled, while only 2 of 39 (5.1%) patients treated with vitamin K required re-exploration for bleeding (p = 0.026).
We conclude that: (1) Liver synthetic function improves during LVAD support resulting in increased levels of circulating coagulation factors; (2) ongoing fibrinolysis occurs but likely only represents remodeling of fibrin on the LVAD surface; (3) perioperative vitamin K reduces nonsurgical bleeding in LVAD recipients.
尽管左心室辅助装置（LVAD）的设计取得了进展，允许在不进行抗凝的情况下提供支持，但LVAD接受者仍经常遭受严重的出血并发症。这种出血倾向可能归因于术前右心室衰竭伴肝功能不全。本研究的目的是描述LVAD接受者的凝血异常情况，并确定术前给予维生素K对术后出血发生率的影响。
对66例Heartmate LVAD接受者进行了止血和肝功能检查；其中39例患者在围手术期接受了维生素K治疗。
在LVAD支持期间，肝脏合成功能有所改善，凝血因子II、V、VII、XI水平升高即为证据。存在持续的纤维蛋白溶解，纤维蛋白肽A和D - 二聚体升高，纤维蛋白原减少；然而，纤溶酶原水平并未下降，这表明未发生全身性弥散性血管内凝血（DIC）。66例患者中有9例（13.6%）在植入后48小时以上需要再次手术止血。与未出血的患者相比，出血患者在植入前的因子II水平降低（52.2±27.1%对69.7±26.6%；p = 0.048），凝血酶原时间延长（16.5±2.4秒对13.8±3.1秒；p = 0.005）。未接受维生素K治疗的27例患者中有7例（25.9%）出血，而接受维生素K治疗的39例患者中只有2例（5.1%）因出血需要再次手术（p = 0.026）。
我们得出以下结论：（1）在LVAD支持期间肝脏合成功能改善，导致循环凝血因子水平升高；（2）发生持续的纤维蛋白溶解，但可能仅代表LVAD表面纤维蛋白的重塑；（3）围手术期给予维生素K可减少LVAD接受者的非手术性出血。
