Okita Y, Takamoto S, Ando M, Morota T, Yamaki F, Matsukawa R, Kawashima Y
National Cardiovascular Center, Suita, Osaka, Japan.
Circulation. 1997 Nov 4;96(9 Suppl):II-376-81.
Coagulation and fibrinolysis parameters were compared between two strategies of heparinization during cardiopulmonary bypass (CPB) in patients who underwent aortic surgery with deep hypothermic circulatory arrest (DHCA) and retrograde cerebral perfusion (RGCP) with aprotinin.
From January 1994 to January 1996, 94 patients underwent aortic surgery with DHCA with aprotinin; replacement of the ascending aorta took place in 14 patients, arch in 69, and descending aorta in 11. Two million units of aprotinin was administrated in the priming of CPB, and 3 mg/kg heparin was given before CPB. During CPB, 49 patients had an additional 1 mg/kg/h heparin regardless of activated clotting time (ACT) [group A], whereas 45 patients had an additional 1 mg/kg/h heparin when ACT was less than 500 seconds [group B]. ACT, PT, aPTT, fibrinogen, AT-3, plasminogen, alpha2-PI (plasmin inhibitor), fibrin/fibrinogen degradation products (FDP), DD (D dimer), TAT (thrombin-antithrombin complex), PIC (plasmin-plasmin inhibitor complex), beta-TG (thromboglobulin), and PF-4 (platelet factor-4) were assayed. No difference was detected between the two groups regarding the duration of operation, CPB, aortic cross-clamping, DHCA, RGCP, and time from the end of CPB to admission to ICU. The heparin dose was greater in group A, but the protamine dose was similar. There was no difference in bleeding after perfusion or in ICU. Levels of TAT, fibrinogen, and DD were lower in group A. PIC, alpha-PI, and FDP value showed no difference. PF-4 and beta-TG were lower in group A, and the platelet count at the end of operation and the day after the operation was higher in group A.
Platelets were better preserved and activation of the coagulation system during CPB was less severe in patients who had a regular additional constant heparin regimen irrespective of ACT in surgery for the aortic aneurysm with DHCA and aprotinin usage. An accurate monitoring system for heparinization is necessary to maintain appropriate anticoagulation during CPB in patients who are undergoing aortic surgery with DHCA using aprotinin.
在接受主动脉手术并采用深低温停循环（DHCA）及逆行脑灌注（RGCP）并使用抑肽酶的患者中，比较了体外循环（CPB）期间两种肝素化策略下的凝血和纤溶参数。
1994年1月至1996年1月，94例患者接受了使用抑肽酶的DHCA主动脉手术；其中14例行升主动脉置换，69例行主动脉弓置换，11例行降主动脉置换。CPB预充液中加入200万单位抑肽酶，CPB前给予3mg/kg肝素。CPB期间，49例患者无论活化凝血时间（ACT）如何，均额外追加1mg/kg/h肝素（A组），而45例患者在ACT小于500秒时额外追加1mg/kg/h肝素（B组）。检测了ACT、PT、aPTT、纤维蛋白原、抗凝血酶-Ⅲ（AT-3）、纤溶酶原、α2-纤溶酶抑制物（α2-PI）、纤维蛋白/纤维蛋白原降解产物（FDP）、D-二聚体（DD）、凝血酶-抗凝血酶复合物（TAT）、纤溶酶-纤溶酶抑制物复合物（PIC）、β-血小板球蛋白（β-TG）和血小板第4因子（PF-4）。两组在手术时间、CPB时间、主动脉阻断时间、DHCA时间、RGCP时间以及从CPB结束至入住重症监护病房（ICU）的时间方面均未检测到差异。A组肝素剂量更大，但鱼精蛋白剂量相似。灌注后及在ICU内的出血情况无差异。A组的TAT、纤维蛋白原和DD水平较低。PIC、α2-PI和FDP值无差异。A组的PF-4和β-TG较低，且手术结束时及术后第一天A组的血小板计数较高。
在使用抑肽酶并进行DHCA的主动脉瘤手术中，无论ACT如何，采用常规额外持续肝素方案的患者在CPB期间血小板保存更好，凝血系统激活程度较轻。对于使用抑肽酶并进行DHCA的主动脉手术患者，在CPB期间维持适当抗凝需要准确的肝素化监测系统。
