Chest

Chest

Volume 128, Issue 1, July 2005, Pages 229-236
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Clinical Investigations
Surgery
Coagulation Activation and Organ Dysfunction Following Cardiac Surgery

https://doi.org/10.1378/chest.128.1.229Get rights and content

Study objectives

Cardiac surgery with cardiopulmonary bypass (CPB) is associated with major inflammatory triggers that cause marked activation of the microcirculation. This inflammatory response is associated with significant organ dysfunction. How this response causes organ dysfunction is not well understood; consequently, few interventions exist to prevent or treat it. In other acute inflammatory conditions, such as sepsis, increased coagulation activation in the microcirculation may be a cause of organ injury. We documented the association between coagulation activation and organ dysfunction to investigate whether coagulation activation also plays a role in organ injury following cardiac surgery with CPB.

Design

Prospective study of 30 patients undergoing cardiac surgery with CPB. Prothrombin fragment (PTF) 1 + 2 and plasminogen activator inhibitor (PAI) activity were measured, and levels correlated with postoperative measures of organ function including the left-ventricular stroke work index, the Pao2/fraction of inspired oxygen (Fio2) ratio, and creatinine levels.

Results

PTF levels increased eightfold (p < 0.05), and PAI activity increased threefold (p < 0.05) over the first 4 h after CPB. PTF levels were correlated with deteriorations in the left-ventricular stroke work index (p = 0.04), the Pao2/Fio2 ratio (p = 0.02), and creatinine levels (p = 0.02).

Conclusions

Levels of coagulation activation are associated with markers of postoperative organ dysfunction. Additional studies are warranted to investigate whether strategies that limit coagulation activation are associated with reductions in postoperative organ dysfunction.

Section snippets

Materials and Methods

Prothrombin fragment (PTF) 1 + 2 (a marker of coagulation activation) and PAI activity (a marker of inhibition of fibrinolysis) were measured, and levels correlated with postoperative measures of organ function including the left-ventricular stroke work index (LVSWI), the Pao2/fraction of inspired oxygen (Fio2) ratio, and creatinine levels. The Pao2/Fio2 ratio and serum creatinine levels were chosen because these markers have been widely used and validated in previous scoring systems of organ

Patients Studied

Thirty patients were studied. Baseline patient characteristics are shown in Table 1. Their average age was 67 years (63% were male), and baseline left ventricular function was well preserved. One patient was administered preoperative IV heparin. This patient also received aspirin 4 days before surgery. No other patient received preoperative aspirin, heparin, warfarin, or a nonsteroidal antiinflammatory drug. All patients were in sinus rhythm at baseline. Eleven patients required cardiac pacing

Discussion

Cardiac surgery with CPB is associated with major inflammatory triggers including contact of blood with the foreign surface of the bypass circuit and ischemic-reperfusion injury to the heart and lungs.12 These insults activate the microcirculation throughout the body,34567891011 and this results in organ dysfunction in the immediate postoperative period.121314 Microvascular activation may cause organ dysfunction due to microvascular thrombosis. Inflammation up-regulates microvascular expression

Conclusion

We found marked increases in coagulation activation and inhibition of fibrinolysis following cardiac surgery with CPB. Levels of coagulation activation were associated with deteriorations in cardiac, pulmonary, and renal functions. Additional studies are warranted to investigate whether strategies that limit coagulation activation are associated with reductions in postoperative organ dysfunction.

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    • Cited by (0)

    The study was supported by St. Vincent's Hospital Research Endowment Fund and a Medical Post-Graduate Research Award from the National Health and Medical Research Council of Australia.

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    Copyright © 2005 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.