Scrascia Giuseppe, Rotunno Crescenzia, Guida Piero, Conte Manuela, Amorese Lillà, Margari Vito, Schinosa Luigi de Luca Tupputi, Paparella Domenico
Division of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy.
Interact Cardiovasc Thorac Surg. 2013 May;16(5):636-42. doi: 10.1093/icvts/ivs525. Epub 2013 Jan 18.
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.
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(®).
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.
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.
比较非体外循环冠状动脉搭桥手术与应用封闭的磷酸胆碱涂层体外循环系统患者的凝血和纤溶激活情况。体外循环可诱导凝血和纤溶系统激活，这与术中血液稀释一起增加了术后出血和输血制品的风险。
前瞻性纳入36例行非体外循环冠状动脉搭桥手术患者和36例行冠状动脉搭桥术且使用带有封闭可折叠静脉储血器的封闭磷酸胆碱涂层体外循环系统（生理组）的患者。通过评估术前（T0）、肝素给药后30分钟（T1）、鱼精蛋白给药后15分钟（T2）、鱼精蛋白给药后3小时（T3）以及术后第1天（T4）和第5天（T5）的凝血酶原片段1.2和纤溶酶 - 抗纤溶酶复合物的释放情况，来评估凝血和纤溶系统的激活。通过血小板功能分析仪100(®)评估血小板功能。
手术期间，生理组的凝血酶原片段1.2和纤溶酶 - 抗纤溶酶水平略高，但差异无统计学意义。在非体外循环冠状动脉搭桥组中，凝血酶原片段1.2在T3（618.7±282.7对416.6±250.2 pmol/l；P = 0.006）、T4（416.7±278.8对310.2±394.6 pmol/l；P < 0.001）和T5（629.3±295.2对408.4±409.7 pmol/l；P = 0.002）时显著更高，纤溶酶 - 抗纤溶酶在T4（）731.1±790对334±300.8 ng/ml；P = 0.019）和T5（1744.4±820.7对860.1±488.4 ng/ml；P = 0.003）时显著更高。生理组患者在T3时血小板功能分析仪100®的封闭时间值显著更高（131.3±105.7对215.6±58.9秒；P = 0.002）。非体外循环冠状动脉搭桥患者的胸腔引流管引流量更多（874.3±371.5对629.1±334.5毫升；P = 0.005）。生理组的平均预充量为1240±215毫升。由于术中输血率更高（6对15例患者；P = 0.016），更多生理组患者接受了红细胞输血（14对25例患者；P = 0.009）。尽管术前血红蛋白水平相似（13±1.2对12.6±1.4 g/dl；P = 0.2），但生理组的术后血红蛋白水平显著更低。
与非体外循环冠状动脉搭桥相比，生理体外循环方法在手术期间不会显著改变止血情况，在术后能减少激活并减少胸腔引流管引流量。然而，需要进一步减少预充量以减少术中红细胞输血。
