Heparin-protamine complexes in the production of heparin rebound and other complications of extracorporeal bypass procedures.

Neutralization by protamine of the heparin activation of antithrombin III in plasma, in vitro, represents an equilibrium reaction in which by mass action heparin remains complexed only in the presence of an excess of protamine. Loss of this excess through enzymatic breakdown of the free protamine leads to instability of the complexes with liberation of the heparin, reestablishing antithrombin activity. This "heparin rebound" can also be produced by an increase in heparin levels or increased amounts of antithrombin III. These phenomena could occur after extracorporeal bypass procedures by an increase in heparin from whatever source or by added antithrombin III, through transfusions of fresh frozen plasma. A larger excess of protamine does not itself act as an anticoagulant but produces large heparin-protamine complexes that can still activate antithrombin III. Such large complexes, formed in vivo, could possibly block the pulmonary microcirculation and cause the acute pulmonary hypertension that has been reported after protamine infusions.