Fries Dietmar, Innerhofer Petra, Streif Werner, Schobersberger Wolfgang, Margreiter Josef, Antretter Herwig, Hörmann Christoph
Department of Anesthesia and Intensive Care Medicine, University of Innsbruck, Innsbruck, Austria.
Ann Thorac Surg. 2003 Nov;76(5):1593-7. doi: 10.1016/s0003-4975(03)01034-8.
The incidence of clinically significant thromboembolic events due to the use of cardiac assist device systems remains high. Despite the considerable advances in cardiac assist device technology, the monitoring and management of the hypercoagulable coagulation status, resulting from foreign surfaces of the assist device system, altered rheologic conditions, and blood stasis in the recipient heart remain a challenge. Moreover septic complications and insufficient anticoagulation are responsible for thromboembolic events.
In addition to standard coagulation analysis, functional coagulation tests were performed including the use of a thrombelastographic monitoring system (ROTEG) and a platelet function analyzer (PFA-100).
Severe biventricular ischemic heart failure developed in a 58-year-old man with acute myocardial infarction and he needed a biventricular assist device for a bridge to cardiac transplantation. Although the patient received acenocoumarol (Sintrom; Novartis Pharma, Vienna, Austria) and acetylsalicylic acid (Aspisol; Bayer AG, Leverkusen, Germany) as usual, ROTEG and the PFA-100 detected hypercoagulability while routine coagulation screening tests showed hypocoagulability. Moreover thrombus formation surrounding the canula of the left ventricular assist device was detected. Antithrombotic therapy with clopidogrel (Plavix) was initiated. Coagulation was closely monitored with modified thrombelastography and the PFA-100 to achieve sufficient but not overwhelming anticoagulation therapy. Three months after biventricular assist device implantation the patient underwent successful transplantation with no major blood loss.
Thrombelastography should be the standard form of monitoring in such patients to decrease the risk of thromboembolic events and prevent bleeding complications.
使用心脏辅助装置系统导致具有临床意义的血栓栓塞事件的发生率仍然很高。尽管心脏辅助装置技术取得了长足进步，但对于因辅助装置系统的异物表面、流变学条件改变以及受者心脏内血液淤滞导致的高凝状态的监测和管理仍然是一项挑战。此外，败血症并发症和抗凝不足也是血栓栓塞事件的原因。
除了标准凝血分析外，还进行了功能性凝血测试，包括使用血栓弹力图监测系统（ROTEG）和血小板功能分析仪（PFA - 100）。
一名58岁急性心肌梗死男性发生严重双心室缺血性心力衰竭，需要双心室辅助装置作为心脏移植的过渡。尽管患者像往常一样接受了醋硝香豆素（新抗凝；诺华制药，维也纳，奥地利）和乙酰水杨酸（阿西匹林；拜耳公司，勒沃库森，德国）治疗，但ROTEG和PFA - 100检测到高凝状态，而常规凝血筛查试验显示低凝状态。此外，还检测到左心室辅助装置插管周围形成血栓。开始使用氯吡格雷（波立维）进行抗栓治疗。通过改良血栓弹力图和PFA - 100密切监测凝血情况，以实现充分但不过度的抗凝治疗。双心室辅助装置植入三个月后，患者成功接受移植，无大出血情况。
血栓弹力图应成为此类患者的标准监测方式，以降低血栓栓塞事件风险并预防出血并发症。
