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Figure 1. Normal hemostasis. 1, Initial plug formation begins with von Willebrand factor (VWF) binding to collagen in the wound and platelets
(plt) adhering to VWF. 2, Coagulation is initiated by small amounts of active factor VII (FVIIa) in blood binding to the exposed tissue factor (TF)
in the wound, leading to activation of factor IX (FIXa) and factor X (FXa), which in turn initiates the conversion of prothrombin to thrombin.
Thrombin creates a positive feedback loop by activating factors VIII (FVIIIa) and V (FVa), which increases FIXa and FXa’s conversion of
prothrombin to thrombin. This local burst of thrombin production at the wound site converts soluble fibrinogen into a fibrin mesh that stabilizes
the initial plug. 3, Clot formation away from the site of injury is prevented by antithrombin (AT), which destroys thrombin and FXa, FIXa, and
FXIa, activated protein C (APC), which destroys FVIIIa and FVa, and tissue factor pathway inhibitor (TFPI), which destroys TF-VIIa complexes.
4, Additionally, the endothelium (endo) secretes tissue plasminogen activator (tPA), which binds to fibrin and converts plasminogen to plasmin,
which in turn lyses the fibrin. Once a stable clot is formed and the wounded tissue is no longer exposed, the regulatory proteins and fibrinolytic
proteins prevent further thrombus formation.
minutes), the concentration of the marker in blood will activation data as marker level versus sample number with
change in parallel with the formation rate and is essentially no reference to time or hemodilution effects (Fig. 4). With
a direct measure of the formation rate of the marker.7–10 If this kind of data, it is difficult to gauge what the underlying
the marker has a longer half-life and slower clearance such rate of activation is. One approach is correction for hemodi-
as prothrombin activation peptide F1.2 (t1/2 90 minutes) or lution, that is, dividing results by the average percent
d-dimer (t1/2 8 hours), the concentration of the marker change in stable factor levels to give an indication of what
during CPB is cumulative, thus the change or slope of the the marker level would be if hemodilution had not oc-
concentration versus time curve is proportional to the curred.26 If hemodilution-corrected results are plotted ver-
formation rate, not the concentration itself.11,12 Most sus sample time, it is possible to get a sense of the
activation markers are proteins or protein fragments that magnitude and rate of change in the system (Fig. 4). The
are cleared by the liver. The clearance rate remains the problem with correction for hemodilution is that it pro-
same even when marker production is increased.8 In duces a set of values that are not the actual measured
most patients, liver blood flow is well maintained during values from the patient, but adjusted values based on a
CPB and marker clearance seems to be similar to preop- simple dilution model.
erative values.13 Another approach to the analysis of hemostatic data is to
The surgical wound produces increased hemostatic use a computer to account for changes in marker levels
thrombin and fibrin at the wound site, but has little caused by alternations of patient blood volume, hemodilu-
systemic effect.6,7,14,15 Immediately after going on CPB, tion, blood loss, blood transfusion, timing of samples, and
hemodilution by the priming fluid in the bypass circuit clearance of proteins. In most studies, none of these factors
reduces all factors in blood including coagulation factors, is accounted for when presenting raw measurements of
inhibitors, and activation markers, by approximately 30% marker levels in blood, yet conclusions are drawn from
to 40% (Fig. 3).16 –23 Changes during CPB in stable factor changes in the marker levels as if these effects were known.
levels with long half-lives, such as albumin, coagulation Computer analysis or modeling allows the reader to know
proteins, and antithrombin (AT), primarily reflect hemodi- the specific assumptions made in analyzing the data, what
lution, blood loss, and transfusion with consumption hav- was accounted for, and what was not. As new information
ing only a minor role.16,18,21,23 is developed, the model can be updated to improve the
Hemodilution tends to obscure the underlying changes analysis. When all of the factors affecting marker levels are
occurring in the hemostatic system during CPB.24,25 Be- accounted for, it is possible to estimate the formation rate in
cause all proteins in the blood are diluted equally at the vivo of thrombin or other factors. It is further possible to
start of CPB, any factor that does not decrease must be validate the estimate of formation rate by comparing rates
undergoing a rapid increase in formation to maintain its based on different markers that measure the same process
concentration at preoperative levels. Most studies present but have different clearance rates and thus marker patterns
Figure 4. Computer model of in vivo thrombin production. This figure shows 2 approaches used to analyze in vivo thrombin production during
cardiopulmonary bypass (CPB). The top row of graphs shows the original measured levels of thrombin activation markers. The second row shows
hemodilution corrected marker levels versus sampling time, a better indicator of the magnitude and rate of marker changes. Using both F1.2 and
thrombin-antithrombin complex data, the bottom graph shows the estimated in vivo thrombin generation rate in the patient based on analysis of the
data using a computer model of the patient’s vascular system that accounted for hemodilution, blood loss, transfusion, and marker clearance. The
2 peaks correlate with commencement of CPB and release of the aortic cross-clamp. (This research was originally published in Blood. Chandler WL,
Velan T. Estimating the rate of thrombin and fibrin generation in vivo during cardiopulmonary bypass. Blood 2003;101:4355– 4362. © the American
Society of Hematology.)
that it measures the ability of plasma to produce throm- that the test cannot be run in the presence of heparin or
bin in vitro, which is not the same as thrombin genera- direct thrombin inhibitors (DTIs).
tion in vivo, hence the term thrombin “potential,” and
MECHANISMS OF ACTIVATION
Hemostatic system activation occurs via several mecha-
nisms including the contact system, fibrinolysis, inflamma-
tion, and platelets. This is summarized in Figure 6 and
detailed in the sections below.
of consumption and binding to the CPB circuit.47 Brady- surgery, its secretion is increased 15-fold.66,72–74 This in-
kinin levels increase 10-fold due to increased HMWK crease may continue into the first postoperative day, which
cleavage as well as reduced lung clearance because pulmo- is associated with an increased risk of coronary graft
nary blood flow is minimal.46,48 This has important impli- occlusion.75 Similar to tPA levels, there is some variability
cations for fibrinolysis because elevated bradykinin levels with approximately one-third of patients showing no post-
induce secretion of tissue plasminogen activator (tPA) (see operative PAI-1 increase.59 This individual variability is
below).49,50 one of the reasons it is difficult to predict which patients are
The role of FXIIa in activation of the hemostatic system at risk for bleeding versus thrombosis.
remains unclear.51 Besides producing kallikrein, FXIIa has
been shown to convert FXI to FXIa in vitro, thus initiating the Inflammation
intrinsic pathway of coagulation. However, FXII-deficient The coagulation and immune responses are linked; a break
patients do not have hemostatic defects, indicating that FXIIa in the vasculature not only must be fixed, but also any
does not normally have a role in hemostasis.52 Indeed, FXII foreign invaders neutralized. Inflammation has multiple
deficiency does not stop the increase in thrombin generation mediators that can create profound amplification, some-
during CPB.53,54 However, FXIIa has been shown to activate times resulting in an out-of-proportion response to the
plasminogen to plasmin in vitro, suggesting its possible role stimulating event and causing pathologic conditions in the
in inducing fibrinolysis during CPB.55,56 Additionally, FXIIa host. A sepsis-like clinical picture that often results from
and other fragments of FXII activate the classic complement CPB, termed the systemic inflammatory response syn-
cascade, accounting for some of the “crosstalk” between drome, can be linked to “crosstalk” with the coagulation
coagulation and inflammation. system and has been extensively reviewed elsewhere.76 – 80
A few key points will be emphasized here.
Leukocytes, including neutrophils and monocytes, bind
The Fibrinolytic System to and are activated by the surface of the bypass cir-
Endothelial cell release of tPA is a major activator of cuit,64,81– 88 which leads to an increase in TF expression,
plasminogen, turning it into fibrin-degrading plasmin. On procoagulant activation, and thrombin generation on these
average, CPB stimulates a 5-fold increase in tPA secretion cells.83– 85,89 Shed blood contains increased numbers of
and active tPA levels,15,57,58 although there is some vari- activated leukocytes and levels of TF bound to cells and
ability and approximately one-third of patients may show microparticles, as well as soluble TF.81,82,90 –92 CPB also
no change.59 Although active thrombin has been shown to alters the protein C system. Protein C is activated by the
release tPA in vitro,60 human in vivo studies are lacking binding of thrombin to thrombomodulin expressed on
and it is more likely that bradykinin is the main stimulus. endothelial cells. This normally functions to suppress fur-
Indeed, tPA release has been shown to be reduced by ther thrombin formation away from the wound by destroy-
blocking bradykinin receptors or reducing its production ing FVIIIa and FVa. Activated protein C also binds with
by inhibiting kallikrein.61,62 endothelial protein C receptors to downregulate cytokine
Increased tPA alone does not increase fibrinolytic activ- production and decrease vascular permeability.93,94 In ad-
ity if no fibrin is present. d-dimer levels, an indicator of dition to hemodilution, CPB further decreases protein C
fibrin degradation, do not change under normal conditions, levels by downregulating thrombomodulin and endothelial
even when tPA levels are transiently increased 10-fold.63 In protein C receptor expression of the endothelium. Overall,
the setting of CPB, however, soluble and circuit-bound systemic inflammatory response syndrome caused by CPB
fibrin provide a huge surface for plasminogen activation to increases TF expression while simultaneously depressing
occur.56,64,65 There is a 10- to 100-fold increase in plasmin protein C activation, thereby favoring the production of
generation shortly after the commencement of CPB, and thrombin.
plasmin generation, along with fibrin degradation, remain
increased 10- to 20-fold throughout the duration of CPB.66 Platelets
Normally only 1% of fibrin is degraded by the fibrinolytic Fibrinogen bound to the CPB circuit provides a large
system, with the remainder being removed by cells during binding site for platelets through their GPIIb/IIIa receptors.
wound healing. During CPB, however, fibrin formation Once platelets bound to either the vascular system or to the
and degradation rates are nearly equal, indicating that circuit are activated, they spread pseudopods, express
much of the fibrin degradation is not at the sites of vascular receptors, release granules and microparticles, and support
injury. This hyperfibrinolytic state consumes fibrinogen, thrombin formation.64,95–101 Additionally, there is some
leaving less available for coagulation postoperatively. Ad- evidence that leukocytes may stimulate TF release directly
ditionally, large amounts of plasmin can damage platelets from platelets.102 CPB increases platelet activation markers
through cleavage of their glycoprotein (GP)Ib receptor,67,68 including -thromboglobulin, platelet factor 4, soluble and
and partially activate them (see below), making them less platelet P-selectin, and platelet GMP140 (granule mem-
responsive to further activation with agonists such as brane protein 140).16,30,32,34,69,103–108 Shed blood shows
adenosine diphosphate and arachidonic acid.69 –71 evidence of platelet activation including reduced platelet
It is important to recognize that a hypofibrinolytic state levels, increased platelet activation markers, increased mi-
can also occur postoperatively. Plasminogen activator in- croparticles, and decreased platelet responsiveness.32,108 –110
hibitor 1 (PAI-1) prevents the formation of plasmin. Al- When shed blood is reinfused, part, but not all, of the
though levels on CPB are initially much less than tPA, increase in systemic platelet activation markers can be
PAI-1 is an acute phase reactant and, by 2 hours after accounted for by markers in the shed blood. However,
platelet activation still occurs during CPB even when shed retransfusion of cardiotomy suction blood, reduces expo-
blood is not reinfused.32,34,111–113 sure to allogeneic blood products when used throughout
During CPB, platelets are activated, platelet thrombin the entire surgical procedure.129 The results of all of these
receptor responsiveness is reduced, and platelet protease- studies must be interpreted with the caveat that study
activated receptor 1 (PAR1) cleavage is increased. This populations were almost exclusively first-time CABG pa-
suggests that thrombin generated during CPB is activating tients with CPB runs in the 2-hour range and blood volumes
platelets through PAR1.114,115 Plasmin formed by activa- of approximately 1000 mL being processed through the cell
tion of the fibrinolytic system can damage and directly saver. More-complex operations result in higher hemostatic
activate platelets through PAR4, causing them to aggregate activation,113 and longer CPB exposure resulting in higher
and release ␣ and dense granule contents.116 –119 Use of cell-saver use would likely result in more coagulation
tranexamic acid (TXA) during CPB preserves platelet aden- factors and platelets being washed out.
osine diphosphate levels, and use of aprotinin during CPB
reduces platelet activation, preserves PAR1 function, and
reduces platelet GPIb cleavage.67,104,115,120 –122 Increasing Circuit Biocompatibility
As mentioned above, the large foreign surface of the CPB
circuit provides ample space for the deposition of fibrin
REDUCING ACTIVATION and other proteins that activate platelets and leukocytes.
Ideally, hemostatic activation should be minimized during Efforts to increase the biocompatibility of these circuits
CPB and then quickly maximized after its termination. have focused on either incorporating heparin into the
Placing the system in a sort of “hibernation” until needed tubing or modifying the surface polymers to decrease
would not only maintain required fluidity and reduce protein adsorption.130 Heparin-bonded circuits have been
thrombotic risk, but also prevent the unproductive con- around the longest and are the best studied. One random-
sumption of coagulation factors, fibrinogen, and platelets. ized trial with high-risk patients, including those with
Efforts to achieve this goal have focused both on modifying preexisting lung or kidney impairment, showed a de-
the conduct of CPB and its circuit, as well as pharmacologic creased incidence of postoperative renal dysfunction and
methods to reduce the patient’s response to these insults. fewer days of mechanical ventilation.131 In a meta-analysis
of heparin-bonded circuits versus conventional tubing, the
Limiting Use of Cardiotomy Suction authors showed a modest decrease in bleeding and red cell
During conventional CPB, blood in the surgical field is transfusion with heparin circuits.132 Other than heparin,
typically removed using cardiotomy suction (“pump suck-
circuits have been coated with polymethoxyethylacrylate,
ers”) and returned to the venous reservoir where it can be
phosphorylcholine, and siloxane in an attempt to make the
oxygenated and reinfused into the patient via arterial
tubing less favorable for cell binding.133–136 None of the
inflow. Advantages include returning red cells and coagu-
coatings, however, has demonstrated in vivo reductions in
lation factors back to the patient. However, shed blood that
hemostatic activation.137 A more recent systematic review
has been exposed to wounded tissue surfaces has already
of biocompatible CPB circuits concluded that although they
started to activate hemostatic proteins, albeit appropriately.
may offer some benefit in reducing red cell transfusions, a
Pericardial blood in particular shows increased levels of
decreased incidence of atrial fibrillation, and shorter inten-
F1.2, TAT, fibrin degradation products, and elevated levels
sive care unit (ICU) stays, high-quality studies are limited
of TF.81,82,92,123–125 From a purely research perspective,
and the surfaces alone do little to contain hemostatic
reinfusing the already activated blood complicates data activation without implementing additional measures.138
analysis by increasing the measured level of activation
markers in the patient, although it may not represent
“new” formation of the markers.26,32 From a clinical stand- Decreasing CPB Circuit Size
point, shed blood contains fibrin and fibrin degradation So-called “miniaturized” CPB has been developed with the
products that can stimulate increased activity of tPA and idea of reducing blood contact with foreign material and air
contribute to platelet dysfunction.33,117 Thus, use of the by using low prime-volume tubing and eliminating the
cardiotomy suction may contribute to both “true” and venous reservoir and cardiotomy suction. In general, prim-
“false” increases in nonhemostatic thrombin formation. ing volume for miniaturized CPB systems is on the order of
Small observational studies showed a reduction in he- 500 mL versus the 1500 to 2000 mL in conventional circuits,
mostatic activation if shed blood was not reinfused, or if the and virtually all systems use some type of heparin-bonded
cells were washed (i.e., “cell saver” was used in lieu of tubing. Lower levels of thrombin activation have been
cardiotomy suction). Four recent studies ranging from 29 to reported with the use of miniaturized CPB.139,140 Two
75 on-CPB coronary artery bypass graft (CABG) patients recent meta-analyses of randomized trials confirmed a
have shown lower markers of inflammation and platelet reduced need for blood-product transfusions using the
activation in patients in whom cardiotomy suction blood smaller circuits.141,142 However, this would be expected
was not retransfused.112,126 –128 de Haan et al.,33 who con- given the significant reduction in hemodilution using lower
ducted a study with 40 on-CPB CABG patients, demon- prime volumes. Additionally, because reinfusion of shed
strated decreased blood loss and lower blood product blood alone has been shown to increase hemostatic activa-
consumption in patients who were not retransfused car- tion, it is not clear whether miniaturized CPB systems offer
diotomy suctioned blood. Likewise, in the latest meta- any benefit regarding hemostatic activation other than
analysis of cell-saver use during cardiac surgery from 1982 simply eliminating the cardiotomy suctions. It is likely that
to 2008, the authors concluded that cell-saver use, versus any combined approach using heparin-bonded circuits,
adequate antifibrinolytic therapy, and removal of car- inhibitor stores from the endothelium.157,158 Heparin-
diotomy suction will reduce hemostatic activation.35 induced thrombocytopenia (HIT), which has been exten-
sively reviewed elsewhere,159 –162 is a result of antibodies
Off-Pump Coronary Artery Bypass formed to the complex of heparin and platelet factor 4.
Of course, the ultimate reduction in CPB circuit size is to Approximately 25% to 50% of patients will develop the
eliminate CPB entirely. Although not practical for many antibodies 5 to 10 days after surgery, which can lead to
cardiac operations, off-pump coronary artery bypass thrombotic complications if heparin therapy is continued in
(OPCAB) currently comprises about 20% of coronary bypass the postoperative period.163
graft procedures, and has been shown to be a viable The above limitations of heparin have helped drive the
technique with regard to graft patency.143 Although the development of DTIs. A major advantage of DTIs is that AT
patient still undergoes thoracotomy, heparinization, and is not required and their smaller molecular size enables
grafting, there is no blood contact with foreign material and greater inhibition of thrombin bound to fibrin (i.e., clot-
blood in the surgical field is generally cleared using a bound versus free thrombin).164 More effective thrombin
cell-saver device because there is no cardiotomy suction. inhibition with less platelet activation would obviously be
The time course for hemostatic activation is somewhat desirable for decreasing hemostatic activation. Bivalirudin,
different for OPCAB. In general, there is no early peak of a DTI with a half-life of 25 minutes, has been shown to
thrombin generation, presumably because of the lack of adequately suppress hemostatic activation on CPB when
contact activation, and activation of the fibrinolytic system cardiotomy suction is not used.165 Interestingly, when
is less.106 However, there is equal activation of the TF cardiotomy suction was used, markers of activation such as
pathway, and thrombin generation and fibrinolytic activity d-dimer, TAT, and FPA levels were significantly increased.
are actually equal to CPB patients within 24 hours postop- This is likely attributable to the fact that stagnant blood
eratively.144 In general, studies have shown less platelet causes a tremendous amount of thrombin generation,
activation and dysfunction with OPCAB, leading to the which may locally overwhelm the reversible inhibition of
potential concern of a greater prothrombotic state in the the DTI. Multicenter trials using bivalirudin for CABG
early postoperative period.145,146 Increased prothrombotic patients both on and off CPB have demonstrated the same
states may last as long as 1 month after surgery for both safety and procedural efficacy as heparin anticoagulation,
OPCAB and standard CABG on CPB, and there does not although in the United States it is currently only approved
seem to be a greater risk of graft thrombosis at experienced for patients with HIT undergoing percutaneous coronary
OPCAB centers.147 interventions.166,167 Argatroban is another DTI that has
been used in the setting of HIT, although the development
Heparin Versus DTIs of intraoperative thrombi has been reported when used for
Unfractionated heparin (UFH) has been, and continues to CPB anticoagulation.168 –170 Use of DTIs in the setting of
be, the mainstay anticoagulant used for CPB, primarily CPB is also currently limited by lack of a neutralizing agent.
because of its rapid effect and availability of a neutralizing Oral DTIs, such as dabigatran etexilate, have been devel-
agent (protamine). It is not a direct inhibitor of thrombin, oped as potential replacements for coumadin therapy, and
but instead enhances the effects of AT. It is this dependency may pose a bleeding risk when patients present to surgery.
on AT that partially accounts for the drug’s variable It is recommended that dabigatran therapy be discontinued
anticoagulation efficacy in individual patients and in vari- 2 to 4 days before cardiac surgery, and longer in patients
ous situations.25 However, AT levels alone cannot predict with impaired renal function.171
UFH’s ability to achieve a desired activated clotting time
(ACT) value.148 Other factors, such as the heterogeneity of AT Supplementation
UFH’s chain lengths and its variable binding to endothelial AT levels show a 30% to 50% decrease from baseline after
cells, macrophages, and plasma proteins, affect its bioavail- initiation of CPB, a consequence of both acute hemodilution
ability.149 It is this variability that makes frequent monitor- and typical heparin administration, then recover, although
ing necessary while on CPB, most commonly using the not fully, several hours postoperatively.23,172,173 However,
ACT. Yet, the ACT itself has significant limitations, begin- after prolonged CPB use, especially that associated with
ning with a lack of consensus as to what ACT value reflects deep hypothermic circulatory arrest, AT levels can decrease
adequate anticoagulation for CPB.150 ACT values do not even further and can take days to return to baseline
correlate well with actual heparin plasma concentra- levels.174 This can contribute to inadequate thrombin sup-
tions,151 and thrombin is still activated despite values pression with heparin, as well as potential thrombotic
⬎480.5,152 Efforts to dose UFH more effectively have cen- complications.175,176 Indeed, studies have shown that post-
tered on measuring heparin plasma levels and maintaining CPB patients with AT levels ⬍60% of normal have a greater
a constant concentration. Although some studies have risk of adverse neurologic and cardiac events in the ICU.177,178
shown decreased hemostatic activation using this strat- Most studies of low-dose AT supplementation during CPB
egy,153,154 others have shown no difference than ACT- have failed to show a decrease in thrombin generation,
based dosing.155 plasmin generation, or platelet activation.175,179 –182 Although
Aside from dosing problems, there are other issues that clinical trials have shown that AT supplementation cor-
prevent UFH from being an ideal anticoagulant. Heparin rects heparin resistance in patients with low AT activity
itself is known to cause platelet activation and stimulate and reduces the need for fresh frozen plasma, outcomes
fibrinolysis.156 Heparin-induced release of TF pathway have been similar to patients simply receiving additional
inhibitor occurs as well, potentially exhausting TF pathway heparin.183–185
7. Chandler WL, Velan T. Estimating the rate of thrombin and 26. van den Goor JM, Nieuwland R, Rutten PM, Tijssen JG, Hau
fibrin generation in vivo during cardiopulmonary bypass. C, Sturk A, Eijsman L, de Mol BA. Retransfusion of pericar-
Blood 2003;101:4355– 62 dial blood does not trigger systemic coagulation during
8. Bauer KA, Goodman TL, Kass BL, Rosenberg RD. Elevated cardiopulmonary bypass. Eur J Cardiothorac Surg 2007;31:
factor Xa activity in the blood of asymptomatic patients with 1029 –36
congenital antithrombin deficiency. J Clin Invest 1985;76: 27. Velan T, Chandler WL. Effects of surgical trauma and cardio-
826 –36 pulmonary bypass on active thrombin concentrations and the
9. Shifman M, Pizzo S. The in vivo metabolism of antithrombin rate of thrombin inhibition in vivo. Pathophysiol Haemost
III and antithrombin III complexes. J Biol Chem 1982;257: Thromb 2004;33:144 –56
3243– 8 28. Kalweit G, Bach J, Huwer H, Winning J, Hellstern P. The
10. Leonard B, Bies R, Carlson T, Reeve EB. Further studies of impact of cardiac ischemia and reperfusion on markers of
the turnover of dog antithrombin III: study of 131I-labelled activated haemostasis and fibrinolysis during cardiopulmo-
antithrombin protease complexes. Thromb Res 1983;30: nary bypass: comparison of plasma levels in arterial and
165–77 coronary venous blood. Thromb Res 2005;116:33–9
11. Knudsen L, Hasenkam JM, Kure HH, Hughes P, Bellaiche L, 29. Teufelsbauer H, Proidl S, Havel M, Vukovich T. Early activa-
Ahlburg P, Djurhuus C. Monitoring thrombin generation tion of hemostasis during cardiopulmonary bypass: evidence
with prothrombin fragment 1.2 assay during cardiopulmo- for thrombin mediated hyperfibrinolysis. Thromb Haemost
1992;68:250 –2
nary bypass surgery. Thromb Res 1996;84:45–54
30. Marx G, Pokar H, Reuter H, Doering V, Tilsner V. The effects
12. Eisses MJ, Velan T, Aldea GS, Chandler WL. Strategies to
of aprotinin on hemostatic function during cardiac surgery.
reduce hemostatic activation during cardiopulmonary by-
J Cardiothorac Vasc Anesth 1991;5:467–74
pass. Thromb Res 2006;117:689 –703
31. Raivio P, Kuitunen A, Suojaranta-Ylinen R, Lassila R, Petaja J.
13. Hampton WW, Townsend MC, Schirmer WJ, Haybron DM, Thrombin generation during reperfusion after coronary ar-
Fry DE. Effective hepatic blood flow during cardiopulmonary tery bypass surgery associates with postoperative myocardial
bypass. Arch Surg 1989;124:458 –9 damage. J Thromb Haemost 2006;4:1523–9
14. Hunt BJ, Parratt RN, Segal HC, Sheikh S, Kallis P, Yacoub M. 32. de Haan J, Boonstra PW, Tabuchi N, van Oeveren W, Ebels T.
Activation of coagulation and fibrinolysis during cardiotho- Retransfusion of thoracic wound blood during heart surgery
racic operations. Ann Thorac Surg 1998;65:712– 8 obscures biocompatibility of the extracorporeal circuit. J Tho-
15. Valen G, Eriksson E, Risberg B, Vaage J. Fibrinolysis during rac Cardiovasc Surg 1996;111:272–5
cardiac surgery: release of tissue plasminogen activator in 33. de Haan J, Boonstra PW, Monnink SH, Ebels T, van Oeveren
arterial and coronary sinus blood. Eur J Cardiothorac Surg W. Retransfusion of suctioned blood during cardiopulmonary
1994;8:324 –30 bypass impairs hemostasis. Ann Thorac Surg 1995;59:901–7
16. Harker LA, Malpass TW, Branson HE, Hessel EA II, Slichter 34. De Somer F, Van Belleghem Y, Caes F, Francois K, Van
SJ. Mechanism of abnormal bleeding in patients undergoing Overbeke H, Arnout J, Taeymans Y, Van Nooten G. Tissue
cardiopulmonary bypass: acquired transient platelet dysfunc- factor as the main activator of the coagulation system during
tion associated with selective alpha-granule release. Blood cardiopulmonary bypass. J Thorac Cardiovasc Surg 2002;123:
1980;56:824 –34 951– 8
17. Pickering NJ, Brody JI, Fink GB, Finnegan JO, Ablaza S. The 35. Eisses MJ, Seidel K, Aldea GS, Chandler WL. Reducing
behavior of antithrombin III, alpha 2 macroglobulin, and hemostatic activation during cardiopulmonary bypass: a
alpha 1 antitrypsin during cardiopulmonary bypass. Am J combined approach. Anesth Analg 2004;98:1208 –16
Clin Pathol 1983;80:459 – 64 36. Raivio P, Lassila R, Petaja J. Thrombin in myocardial ischemia-
18. Gelb AB, Roth RI, Levin J, London MJ, Noall RA, Hauck WW, reperfusion during cardiac surgery. Ann Thorac Surg 2009;88:
Cloutier M, Verrier E, Mangano DT. Changes in blood 318 –25
coagulation during and following cardiopulmonary bypass: 37. Hemker HC, Beguin S. Thrombin generation in plasma: its
lack of correlation with clinical bleeding. Am J Clin Pathol assessment via the endogenous thrombin potential. Thromb
1996;106:87–99 Haemost 1995;74:134 – 8
19. Mammen EF, Koets MH, Washington BC, Wolk LW, Brown 38. Hemker HC, Giesen P, Al Dieri R, Regnault V, de Smedt E,
JM, Burdick M, Selik NR, Wilson RF. Hemostasis changes Wagenvoord R, Lecompte T, Beguin S. Calibrated automated
during cardiopulmonary bypass surgery. Semin Thromb He- thrombin generation measurement in clotting plasma. Patho-
most 1985;11:281–92 physiol Haemost Thromb 2003;33:4 –15
20. Welters I, Menges T, Ballesteros M, Knothe C, Ruwoldt R, 39. Coakley M, Hall JE, Evans C, Duff E, Billing V, Yang L,
Gorlach G, Hempelmann G. Thrombin generation and acti- McPherson D, Stephens E, Macartney N, Wilkes AR, Collins
PW. Assessment of thrombin generation measured before and
vation of the thrombomodulin protein C system in open heart
after cardiopulmonary bypass surgery and its association
surgery depend on the underlying cardiac disease. Thromb
with post-operative bleeding. J Thromb Haemost 2010;9:
Res 1998;92:1–9
282–92
21. Chandler WL, Patel MA, Gravelle L, Soltow LO, Lewis K,
40. Eichinger S, Hron G, Kollars M, Kyrle PA. Prediction of
Bishop PD, Spiess BD. Factor XIIIA and clot strength after recurrent venous thromboembolism by endogenous thrombin
cardiopulmonary bypass. Blood Coagul Fibrinolysis 2001;12: potential and D-dimer. Clin Chem 2008;54:2042– 8
101– 8 41. Campbell DJ. The kallikrein-kinin system in humans. Clin
22. Davidson SJ, Burman JF, Philips SM, Onis SJ, Kelleher AA, De Exp Pharmacol Physiol 2001;28:1060 –5
Souza AC, Pepper JR. Correlation between thrombin potential 42. Sharma JN. Role of tissue kallikrein-kininogen-kinin path-
and bleeding after cardiac surgery in adults. Blood Coagul ways in the cardiovascular system. Arch Med Res 2006;37:
Fibrinolysis 2003;14:175–9 299 –306
23. Chandler WL. Effects of hemodilution, blood loss, and con- 43. Sharma JN. Involvement of the kinin-forming system in the
sumption on hemostatic factor levels during cardiopulmo- physiopathology of rheumatoid inflammation. Agents Ac-
nary bypass. J Cardiothorac Vasc Anesth 2005;19:459 – 67 tions Suppl 1992;38:343– 61
24. Moor E, Hamsten A, Blomback M, Herzfeld I, Wiman B, 44. Schmaier AH, McCrae KR. The plasma kallikrein-kinin sys-
Ryden L. Haemostatic factors and inhibitors and coronary tem: its evolution from contact activation. J Thromb Haemost
artery bypass grafting: preoperative alterations and relations 2007;5:2323–9
to graft occlusion. Thromb Haemost 1994;72:335– 42 45. Fuhrer G, Gallimore MJ, Heller W, Hoffmeister HE. Studies
25. Yavari M, Becker RC. Coagulation and fibrinolytic protein on components of the plasma kallikrein-kinin system in
kinetics in cardiopulmonary bypass. J Thromb Thrombolysis patients undergoing cardiopulmonary bypass. Adv Exp Med
2009;27:95–104 Biol 1986;198:385–91
46. Campbell DJ, Dixon B, Kladis A, Kemme M, Santamaria JD. 67. de Haan J, van Oeveren W. Platelets and soluble fibrin
Activation of the kallikrein-kinin system by cardiopulmonary promote plasminogen activation causing downregulation of
bypass in humans. Am J Physiol Regul Integr Comp Physiol platelet glycoprotein Ib/IX complexes: protection by apro-
2001;281:R1059 –70 tinin. Thromb Res 1998;92:171–9
47. Gallimore MJ, Jones DW, Winter M, Wendel HP. Changes in 68. Michelson AD, Barnard MR. Plasmin-induced redistribution
high molecular weight kininogen levels during and after of platelet glycoprotein Ib. Blood 1990;76:2005–10
cardiopulmonary bypass surgery measured using a chromo- 69. Rinder CS, Bohnert J, Rinder HM, Mitchell J, Ault K, Hillman
genic peptide substrate assay. Blood Coagul Fibrinolysis R. Platelet activation and aggregation during cardiopulmo-
2002;13:561– 8 nary bypass. Anesthesiology 1991;75:388 –93
48. Cugno M, Nussberger J, Biglioli P, Alamanni F, Coppola R, 70. Slaughter TF, Sreeram G, Sharma AD, El-Moalem H, East CJ,
Agostoni A. Increase of bradykinin in plasma of patients Greenberg CS. Reversible shear-mediated platelet dysfunc-
undergoing cardiopulmonary bypass: the importance of lung tion during cardiac surgery as assessed by the PFA-100
exclusion. Chest 2001;120:1776 – 82 platelet function analyzer. Blood Coagul Fibrinolysis 2001;12:
49. Brown NJ, Gainer JV, Stein CM, Vaughan DE. Bradykinin 85–93
stimulates tissue plasminogen activator release in human 71. Velik-Salchner C, Maier S, Innerhofer P, Kolbitsch C, Streif W,
vasculature. Hypertension 1999;33:1431–5 Mittermayr M, Praxmarer M, Fries D. An assessment of
50. Brown NJ, Nadeau JH, Vaughan DE. Selective stimulation of cardiopulmonary bypass-induced changes in platelet func-
tissue-type plasminogen activator (t-PA) in vivo by infusion tion using whole blood and classical light transmission ag-
of bradykinin. Thromb Haemost 1997;77:522–5 gregometry: the results of a pilot study. Anesth Analg
51. Agostoni A, Cugno M. Influence of contact system deficiencies 2009;108:1747–54
during cardiopulmonary bypass. Thromb Haemost 2001;85: 72. Ray MJ, Marsh NA, Hawson GAT. Relationship of fibrinoly-
191–2 sis and platelet function to bleeding after cardiopulmonary
52. Stavrou E, Schmaier AH. Factor XII: what does it contribute to bypass. Blood Coagul Fibrinolysis 1994;5:679 – 85
our understanding of the physiology and pathophysiology of 73. Freyburger G, Janvier G, Dief S, Boisseau MR. Fibrinolytic
hemostasis & thrombosis? Thromb Res 2010;125:210 –5 and hemorheologic alterations during and after elective aortic
53. Burman J, Chung H, Lane D, Philippou H, Adami A, Lincoln graft surgery: implications for postoperative management.
J. Role of factor XII in thrombin generation and fibrinolysis Anesth Analg 1993;76:504 –12
during cardiopulmonary bypass. Lancet 1994;344:1192–3 74. Lu H, Du Buit C, Soria J, Touchot B, Chollet B, Commin PL,
54. Chung HI, Burman JF, Balogun BA, Lincoln JCR, Pepper JR. Conseiller C, Echter E, Soria C. Postoperative hemostasis and
Elevated fibrinolysis in cardiopulmonary bypass is factor XII fibrinolysis in patients undergoing cardiopulmonary bypass
dependent. Fibrinolysis 1994;8:84 –5 with and without aprotinin therapy. Thromb Haemost 1994;72:
55. Braat EA, Dooijewaard G, Rijken DC. Fibrinolytic properties 438 – 43
of activated FXII. Eur J Biochem 1999;263:904 –11
75. Rifon J, Paramo JA, Panizo C, Montes R, Rocha E. The
56. Zhao X, Courtney JM, Yin HQ, West RH, Lowe GD. Blood
increase of plasminogen activator inhibitor activity is associ-
interactions with plasticised poly (vinyl chloride): influence of
ated with graft occlusion in patients undergoing aorto-
surface modification. J Mater Sci Mater Med 2008;19:713–9
coronary bypass surgery. Br J Haematol 1997;99:262–7
57. Chandler WL, Velan T. Secretion of tissue plasminogen
76. Levy JH, Tanaka KA. Inflammatory response to cardiopulmo-
activator and plasminogen activator inhibitor 1 during car-
nary bypass. Ann Thorac Surg 2003;75:S715–20
diopulmonary bypass. Thromb Res 2003;112:185–92
77. Warren OJ, Smith AJ, Alexiou C, Rogers PL, Jawad N, Vincent
58. Tanaka K, Takao M, Yada I, Yuasa H, Kusagawa M, Deguchi
C, Darzi AW, Athanasiou T. The inflammatory response to
K. Alterations in coagulation and fibrinolysis associated with
cardiopulmonary bypass. Part 1. Mechanisms of pathogene-
cardiopulmonary bypass during open heart surgery. J Car-
diothorac Anesth 1989;3:181– 8 sis. J Cardiothorac Vasc Anesth 2009;23:223–31
59. Chandler WL, Fitch JCK, Wall MH, Verrier ED, Cochran RP, 78. Warren OJ, Watret AL, de Wit KL, Alexiou C, Vincent C,
Soltow LO, Spiess BD. Individual variations in the fibrinolytic Darzi AW, Athanasiou T. The inflammatory response to
response during and after cardiopulmonary bypass. Thromb cardiopulmonary bypass. Part 2. Anti-inflammatory thera-
Haemost 1995;74:1293–7 peutic strategies. J Cardiothorac Vasc Anesth 2009;23:384 –93
60. Booyse FM, Bruce R, Dolenak D, Grover M, Casey LC. Rapid 79. Levy JH. Anti-inflammatory strategies and hemostatic agents:
release and deactivation of plasminogen activators in human old drugs, new ideas. Hematol Oncol Clin North Am 2007;21:
endothelial cell cultures in the presence of thrombin and 89 –101
ionophore A23187. Semin Thromb Hemost 1986;12:228 –30 80. Laffey JG, Boylan JF, Cheng DC. The systemic inflammatory
61. Pretorius M, Scholl FG, McFarlane JA, Murphey LJ, Brown response to cardiac surgery: implications for the anesthesiolo-
NJ. A pilot study indicating that bradykinin B2 receptor gist. Anesthesiology 2002;97:215–52
antagonism attenuates protamine-related hypotension after 81. Shibamiya A, Tabuchi N, Chung J, Sunamori M, Koyama T.
cardiopulmonary bypass. Clin Pharmacol Ther 2005;78: Formation of tissue factor-bearing leukocytes during and
477– 85 after cardiopulmonary bypass. Thromb Haemost 2004;92:
62. Fuhrer G, Gallimore MJ, Heller W, Hoffmeister HE. Aprotinin 124 –31
in cardiopulmonary bypass: effects on the Hageman factor 82. Chung J, Suzuki H, Tabuchi N, Sato K, Shibamiya A, Koyama
(FXII)– kallikrein system and blood loss. Blood Coagul Fibri- T. Identification of tissue factor and platelet-derived particles
nolysis 1992;3:99 –104 on leukocytes during cardiopulmonary bypass by flow cy-
63. Chandler WL, Alessi MC, Aillaud MF, Vague P, Juhan-Vague tometry and immunoelectron microscopy. Thromb Haemost
I. Formation, inhibition and clearance of plasmin in vivo. 2007;98:368 –74
Haemostasis 2000;30:204 –18 83. Johnell M, Elgue G, Thelin S, Larsson R, Siegbahn A. Cell
64. van den Goor JM, van Oeveren W, Rutten PM, Tijssen JG, adhesion and tissue factor upregulation in oxygenators used
Eijsman L. Adhesion of thrombotic components to the surface during coronary artery bypass grafting are modified by the
of a clinically used oxygenator is not affected by trillium Corline Heparin Surface. Scand Cardiovasc J 2002;36:351–7
coating. Perfusion 2006;21:165–72 84. Barstad RM, Ovrum E, Ringdal MA, Oystese R, Hamers MJ,
65. Nishida H, Aomi S, Tomizawa Y, Endo M, Koyanagi H, Nojiri Veiby OP, Rolfsen T, Stephens RW, Sakariassen KS. Induction
C, Oshiyama H, Kido T, Yokoyama K. Comparative study of of monocyte tissue factor procoagulant activity during coro-
biocompatibility between the open circuit and closed circuit nary artery bypass surgery is reduced with heparin-coated
in cardiopulmonary bypass. Artif Organs 1999;23:547–51 extracorporeal circuit. Br J Haematol 1996;94:517–25
66. Chandler WL, Velan T. Plasmin generation and D-dimer 85. Tabuchi N, Shibamiya A, Koyama T, Fukuda T, van Oeveren
formation during cardiopulmonary bypass. Blood Coagul W, Sunamori M. Activated leukocytes adsorbed on the sur-
Fibrinolysis 2004;15:583–91 face of an extracorporeal circuit. Artif Organs 2003;27:591– 4
86. el Habbal MH, Carter H, Smith LJ, Elliott MJ, Strobel S. 104. Shigeta O, Kojima H, Jikuya T, Terada Y, Atsumi N, Sakak-
Neutrophil activation in paediatric extracorporeal circuits: ibara Y, Nagasawa T, Mitsui T. Aprotinin inhibits plasmin-
effect of circulation and temperature variation. Cardiovasc induced platelet activation during cardiopulmonary bypass.
Res 1995;29:102–7 Circulation 1997;96:569 –74
87. Gillinov AM, Bator JM, Zehr KJ, Redmond JM, Burch RM, Ko 105. Diago MC, Garcia-Unzueta MT, Marcano G, Merino J, Salas E,
C, Winkelstein JA, Stuart RS, Baumgartner WA, Cameron DE. Amado JA. Serum soluble selectins in patients undergoing
Neutrophil adhesion molecule expression during cardiopul- cardiopulmonary bypass: relationship with circulating blood
monary bypass with bubble and membrane oxygenators. Ann cells and inflammation-related cytokines. Acta Anaesthesiol
Thorac Surg 1993;56:847–53 Scand 1997;41:725–30
88. Shen M, Horbett TA. The effects of surface chemistry and 106. Vallely MP, Bannon PG, Bayfield MS, Hughes CF, Kritharides
adsorbed proteins on monocyte/macrophage adhesion to L. Quantitative and temporal differences in coagulation,
chemically modified polystyrene surfaces. J Biomed Mater fibrinolysis and platelet activation after on-pump and off-
Res 2001;57:336 – 45 pump coronary artery bypass surgery. Heart Lung Circ
89. Parratt R, Hunt BJ. Direct activation of factor X by monocytes 2009;18:123–30
occurs during cardiopulmonary bypass. Br J Haematol 107. Lo B, Fijnheer R, Castigliego D, Borst C, Kalkman CJ, Nierich
1998;101:40 – 6 AP. Activation of hemostasis after coronary artery bypass
90. Hattori T, Khan MM, Colman RW, Edmunds LH Jr. Plasma grafting with or without cardiopulmonary bypass. Anesth
Analg 2004;99:634 – 40
tissue factor plus activated peripheral mononuclear cells
108. Johnell M, Elgue G, Larsson R, Larsson A, Thelin S, Siegbahn
activate factors VII and X in cardiac surgical wounds. J Am
A. Coagulation, fibrinolysis, and cell activation in patients
Coll Cardiol 2005;46:707–13
and shed mediastinal blood during coronary artery bypass
91. Sturk-Maquelin KN, Nieuwland R, Romijn FP, Eijsman L,
grafting with a new heparin-coated surface. J Thorac Cardio-
Hack CE, Sturk A. Pro- and non-coagulant forms of non-cell- vasc Surg 2002;124:321–32
bound tissue factor in vivo. J Thromb Haemost 2003;1:1920 – 6 109. Kongsgaard UE, Hovig T, Brosstad F, Geiran O. Platelets in
92. Philippou H, Adami A, Davidson SJ, Pepper JR, Burman JF, shed mediastinal blood used for postoperative autotransfu-
Lane DA. Tissue factor is rapidly elevated in plasma collected sion. Acta Anaesthesiol Scand 1993;37:265– 8
from the pericardial cavity during cardiopulmonary bypass. 110. Fabre O, Vincentelli A, Corseaux D, Juthier F, Susen S, Bauters
Thromb Haemost 2000;84:124 – 8 A, Van Belle E, Mouquet F, Le Tourneau T, Decoene C, Crepin
93. Weiler H. Regulation of inflammation by the protein C F, Prat A, Jude B. Comparison of blood activation in the
system. Crit Care Med 2010;38:S18 –25 wound, active vent, and cardiopulmonary bypass circuit. Ann
94. Danese S, Vetrano S, Zhang L, Poplis VA, Castellino FJ. The Thorac Surg 2008;86:537– 41
protein C pathway in tissue inflammation and injury: patho- 111. Koster A, Bottcher W, Merkel F, Hetzer R, Kuppe H. The more
genic role and therapeutic implications. Blood 2010;115: closed the bypass system the better: a pilot study on the
1121–30 effects of reduction of cardiotomy suction and passive vent-
95. Musial J, Niewiarowski S, Rucinski B, Stewart GJ, Cook JJ, ing on hemostatic activation during on-pump coronary artery
Williams JA, Edmunds LH Jr. Inhibition of platelet adhesion bypass grafting. Perfusion 2005;20:285– 8
to surfaces of extracorporeal circuits by disintegrins: RGD- 112. Skrabal CA, Khosravi A, Choi YH, Kaminski A, Westphal B,
containing peptides from viper venoms. Circulation 1990;82: Steinhoff G, Liebold A. Pericardial suction blood separation
261–73 attenuates inflammatory response and hemolysis after cardio-
96. Tsai WB, Grunkemeier JM, McFarland CD, Horbett TA. pulmonary bypass. Scand Cardiovasc J 2006;40:219 –23
Platelet adhesion to polystyrene-based surfaces preadsorbed 113. Takayama H, Soltow LO, Chandler WL, Vocelka CR, Aldea
with plasmas selectively depleted in fibrinogen, fibronectin, GS. Does the type of surgery effect systemic response follow-
vitronectin, or von Willebrand’s factor. J Biomed Mater Res ing cardiopulmonary bypass? J Card Surg 2007;22:307–13
2002;60:348 –59 114. Ferraris VA, Ferraris SP, Singh A, Fuhr W, Koppel D, McKenna
97. Niimi Y, Ichinose F, Ishiguro Y, Terui K, Uezono S, Morita S, D, Rodriguez E, Reich H. The platelet thrombin receptor and
Yamane S. The effects of heparin coating of oxygenator fibers postoperative bleeding. Ann Thorac Surg 1998;65:352– 8
on platelet adhesion and protein adsorption. Anesth Analg 115. Day JR, Punjabi PP, Randi AM, Haskard DO, Landis RC,
1999;89:573–9 Taylor KM. Clinical inhibition of the seven-transmembrane
98. Gorbet MB, Sefton MV. Biomaterial-associated thrombosis: thrombin receptor (PAR1) by intravenous aprotinin during
roles of coagulation factors, complement, platelets and leuko- cardiothoracic surgery. Circulation 2004;110:2597– 600
cytes. Biomaterials 2004;25:5681–703 116. Niewiarowski S, Senyi AF, Gillies P. Plasmin-induced platelet
99. Gemmell CH, Ramirez SM, Yeo EL, Sefton MV. Platelet aggregation and platelet release reaction: effects on hemosta-
sis. J Clin Invest 1973;52:1647–59
activation in whole blood by artificial surfaces: identification
117. de Haan J, Schonberger J, Haan J, van Oeveren W, Eijgelaar A.
of platelet-derived microparticles and activated platelet bind-
Tissue-type plasminogen activator and fibrin monomers syn-
ing to leukocytes as material-induced activation events. J Lab
ergistically cause platelet dysfunction during retransfusion of
Clin Med 1995;125:276 – 87
shed blood after cardiopulmonary bypass. J Thorac Cardio-
100. Grunkemeier JM, Tsai WB, Horbett TA. Hemocompatibility vasc Surg 1993;106:1017–23
of treated polystyrene substrates: contact activation, platelet 118. Mao Y, Jin J, Daniel JL, Kunapuli SP. Regulation of plasmin-
adhesion, and procoagulant activity of adherent platelets. induced protease-activated receptor 4 activation in platelets.
J Biomed Mater Res 1998;41:657–70 Platelets 2009;20:191– 8
101. Gemmell CH. Assessment of material-induced procoagulant 119. Quinton TM, Kim S, Derian CK, Jin J, Kunapuli SP. Plasmin-
activity by a modified Russell viper venom coagulation time mediated activation of platelets occurs by cleavage of
test. J Biomed Mater Res 1998;42:611– 6 protease-activated receptor 4. J Biol Chem 2004;279:18434 –9
102. Zillmann A, Luther T, Muller I, Kotzsch M, Spannagl M, 120. van Oeveren W, Harder MP, Roozendaal KJ, Eijsman L,
Kauke T, Oelschlagel U, Zahler S, Engelmann B. Platelet- Wildevuur CR. Aprotinin protects platelets against the initial
associated tissue factor contributes to the collagen-triggered effect of cardiopulmonary bypass. J Thorac Cardiovasc Surg
activation of blood coagulation. Biochem Biophys Res Com- 1990;99:788 –96
mun 2001;281:603–9 121. Huang H, Ding W, Su Z, Zhang W. Mechanism of the
103. Khuri S, Wolfe J, Josa M, Axford TC, Szymanski I, Assousa S, preserving effect of aprotinin on platelet function and its use
Ragno G, Patel M, Silverman A, Park M, Valeri CR. Hemato- in cardiac surgery. J Thorac Cardiovasc Surg 1993;106:11– 8
logic changes during and after cardiopulmonary bypass and 122. Soslau G, Horrow J, Brodsky I. Effect of tranexamic acid on
their relationship to the bleeding time and nonsurgical blood platelet ADP during extracorporeal circulation. Am J Hematol
loss. J Thorac Cardiovasc Surg 1992;104:94 –107 1991;38:113–9
123. Khan MM, Hattori T, Niewiarowski S, Edmunds LH Jr, 140. Rahe-Meyer N, Solomon C, Tokuno ML, Winterhalter M,
Colman RW. Truncated and microparticle-free soluble tissue Shrestha M, Hahn A, Tanaka K. Comparative assessment of
factor bound to peripheral monocytes preferentially activate coagulation changes induced by two different types of heart-
factor VII. Thromb Haemost 2006;95:462– 8 lung machine. Artif Organs 2010;34:3–12
124. Weerwind PW, Lindhout T, Caberg NE, De Jong DS. Throm- 141. Biancari F, Rimpilainen R. Meta-analysis of randomised trials
bin generation during cardiopulmonary bypass: the possible comparing the effectiveness of miniaturised versus conven-
role of retransfusion of blood aspirated from the surgical tional cardiopulmonary bypass in adult cardiac surgery.
field. Thromb J 2003;1:3 Heart 2009;95:964 –9
125. Chung JH, Gikakis N, Rao AK, Drake TA, Colman RW, 142. Zangrillo A, Garozzo FA, Biondi-Zoccai G, Pappalardo F,
Edmunds LH. Pericardial blood activates the extrinsic coagu- Monaco F, Crivellari M, Bignami E, Nuzzi M, Landoni G.
lation pathway during clinical cardiopulmonary bypass. Cir- Miniaturized cardiopulmonary bypass improves short-term
culation 1996;93:2014 – 8 outcome in cardiac surgery: a meta-analysis of randomized
126. Aldea GS, Soltow LO, Chandler WL, Triggs CM, Vocelka CR, controlled studies. J Thorac Cardiovasc Surg 2010;139:1162–9
Crockett GI, Shin YT, Curtis WE, Verrier ED. Limitation of 143. Halkos ME, Puskas JD. Off-pump coronary surgery: where do
thrombin generation, platelet activation, and inflammation by we stand in 2010? Curr Opin Cardiol 2010;25:583– 8
elimination of cardiotomy suction in patients undergoing 144. Casati V, Gerli C, Franco A, Della Valle P, Benussi S, Alfieri O,
coronary artery bypass grafting treated with heparin-bonded Torri G, D’Angelo A. Activation of coagulation and fibrino-
circuits. J Thorac Cardiovasc Surg 2002;123:742–55 lysis during coronary surgery: on-pump versus off-pump
127. Westerberg M, Bengtsson A, Jeppsson A. Coronary surgery techniques. Anesthesiology 2001;95:1103–9
without cardiotomy suction and autotransfusion reduces the 145. Untch BR, Jeske WP, Schwartz J, Botkin S, Prechel M, Wa-
postoperative systemic inflammatory response. Ann Thorac lenga JM, Bakhos M. Inflammatory and hemostatic activation
Surg 2004;78:54 –9 in patients undergoing off-pump coronary artery bypass
128. Nakahira A, Sasaki Y, Hirai H, Matsuo M, Morisaki A, grafting. Clin Appl Thromb Hemost 2008;14:141– 8
Suehiro S, Shibata T. Cardiotomy suction, but not open 146. Ballotta A, Saleh HZ, El Baghdady HW, Gomaa M, Belloli F,
venous reservoirs, activates coagulofibrinolysis in coronary Kandil H, Balbaa Y, Bettini F, Bossone E, Menicanti L, Frigiola A,
artery surgery. J Thorac Cardiovasc Surg 2011;141:1289 –97 Bellucci C, Mehta RH. Comparison of early platelet activation in
129. Wang G, Bainbridge D, Martin J, Cheng D. The efficacy of patients undergoing on-pump versus off-pump coronary artery
an intraoperative cell saver during cardiac surgery: a bypass surgery. J Thorac Cardiovasc Surg 2007;134:132– 8
meta-analysis of randomized trials. Anesth Analg 2009;109: 147. Puskas JD, Williams WH, Mahoney EM, Huber PR, Block PC,
320 –30 Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach ME,
130. Belway D, Rubens FD. Currently available biomaterials for McCall SA, Petersen RJ, Bailey DE, Weintraub WS, Guyton
use in cardiopulmonary bypass. Expert Rev Med Devices RA. Off-pump vs conventional coronary artery bypass graft-
2006;3:345–55 ing: early and 1-year graft patency, cost, and quality-of-life
131. Ranucci M, Mazzucco A, Pessotto R, Grillone G, Casati V, outcomes—a randomized trial. JAMA 2004;291:1841–9
Porreca L, Maugeri R, Meli M, Magagna P, Cirri S, Giomarelli 148. Garvin S, Fitzgerald D, Muehlschlegel JD, Perry TE, Fox AA,
P, Lorusso R, de Jong A. Heparin-coated circuits for high-risk Shernan SK, Collard CD, Aranki S, Body SC. Heparin dose
patients: a multicenter, prospective, randomized trial. Ann response is independent of preoperative antithrombin activity in
Thorac Surg 1999;67:994 –1000 patients undergoing coronary artery bypass graft surgery using
132. Mangoush O, Purkayastha S, Haj-Yahia S, Kinross J, Hayward low heparin concentrations. Anesth Analg 2010;111:856 – 61
M, Bartolozzi F, Darzi A, Athanasiou T. Heparin-bonded 149. Hirsh J. Current anticoagulant therapy: unmet clinical needs.
circuits versus nonheparin-bonded circuits: an evaluation of Thromb Res 2003;109:S1– 8
their effect on clinical outcomes. Eur J Cardiothorac Surg 150. Lobato RL, Despotis GJ, Levy JH, Shore-Lesserson LJ, Carlson
2007;31:1058 – 69 MO, Bennett-Guerrero E. Anticoagulation management dur-
133. Gunaydin S. Emerging technologies in biocompatible surface ing cardiopulmonary bypass: a survey of 54 North American
modifying additives: quest for physiologic cardiopulmonary institutions. J Thorac Cardiovasc Surg 2010;139:1665– 6
bypass. Curr Med Chem Cardiovasc Hematol Agents 2004;2: 151. Fitzgerald DJ, Patel A, Body SC, Garvin S. The relationship
295–302 between heparin level and activated clotting time in the adult
134. De Somer F, Francois K, van Oeveren W, Poelaert J, De Wolf cardiac surgery population. Perfusion 2009;24:93– 6
D, Ebels T, Van Nooten G. Phosphorylcholine coating of 152. Brister SJ, Ofosu FA, Buchanan MR. Thrombin generation
extracorporeal circuits provides natural protection against during cardiac surgery: is heparin the ideal anticoagulant?
blood activation by the material surface. Eur J Cardiothorac Thromb Haemost 1993;70:259 – 62
Surg 2000;18:602– 6 153. Koster A, Fischer T, Praus M, Haberzettl H, Kuebler WM,
135. Ereth MH, Nuttall GA. Biocompatibility of Trillium Biopas- Hetzer R, Kuppe H. Hemostatic activation and inflammatory
sive Surface-coated oxygenator versus uncoated oxygenator response during cardiopulmonary bypass: impact of heparin
during cardiopulmonary bypass. J Cardiothorac Vasc Anesth management. Anesthesiology 2002;97:837– 41
2001;15:545–50 154. Despotis GJ, Joist JH, Hogue CWJ, Alsoufiev A, Kater K,
136. Pappalardo F, Della Valle P, Crescenzi G, Corno C, Franco A, Goodnough LT, Santoro SA, Spitznagel E, Rosenblum M,
Torracca L, Alfieri O, Galli L, Zangrillo A, D’Angelo A. Lappas DG. The impact of heparin concentration and acti-
Phosphorylcholine coating may limit thrombin formation vated clotting time monitoring on blood conservation: a
during high-risk cardiac surgery: a randomized controlled prospective, randomized evaluation in patients undergoing
trial. Ann Thorac Surg 2006;81:886 –91 cardiac operation. J Thorac Cardiovasc Surg 1995;110:46 –54
137. Zimmermann AK, Weber N, Aebert H, Ziemer G, Wendel 155. Slight RD, Buell R, Nzewi OC, McClelland DB, Mankad PS. A
HP. Effect of biopassive and bioactive surface-coatings on the comparison of activated coagulation time-based techniques
hemocompatibility of membrane oxygenators. J Biomed Ma- for anticoagulation during cardiac surgery with cardiopulmo-
ter Res B Appl Biomater 2007;80:433–9 nary bypass. J Cardiothorac Vasc Anesth 2008;22:47–52
138. Ranucci M, Balduini A, Ditta A, Boncilli A, Brozzi S. A system- 156. Khuri SF, Valeri CR, Loscalzo J, Weinstein MJ, Birjiniuk V,
atic review of biocompatible cardiopulmonary bypass circuits Healey NA, MacGregor H, Doursounian M, Zolkewitz MA.
and clinical outcome. Ann Thorac Surg 2009;87:1311–9 Heparin causes platelet dysfunction and induces fibrinolysis
139. Fromes Y, Gaillard D, Ponzio O, Chauffert M, Gerhardt before cardiopulmonary bypass. Ann Thorac Surg 1995;60:
MF, Deleuze P, Bical OM. Reduction of the inflammatory 1008 –14
response following coronary bypass grafting with total 157. Kemme MJ, Burggraaf J, Schoemaker RC, Kluft C, Cohen AF.
minimal extracorporeal circulation. Eur J Cardiothorac Quantification of heparin-induced TFPI release: a maximum
Surg 2002;22:527–33 release at low heparin dose. Br J Clin Pharmacol 2002;54:627–34
158. Sandset PM, Bendz B, Hansen JB. Physiological function of 177. Ranucci M, Frigiola A, Menicanti L, Ditta A, Boncilli A, Brozzi
tissue factor pathway inhibitor and interaction with heparins. S. Postoperative antithrombin levels and outcome in cardiac
Haemostasis 2000;30:48 –56 operations. Crit Care Med 2005;33:355– 60
159. Levy JH, Tanaka KA, Hursting MJ. Reducing thrombotic 178. Garvin S, Muehlschlegel JD, Perry TE, Chen J, Liu KY, Fox
complications in the perioperative setting: an update on AA, Collard CD, Aranki SF, Shernan SK, Body SC. Postop-
heparin-induced thrombocytopenia. Anesth Analg 2007;105: erative activity, but not preoperative activity, of antithrom-
570 – 82 bin is associated with major adverse cardiac events after
160. Levy JH, Winkler AM. Heparin-induced thrombocytopenia coronary artery bypass graft surgery. Anesth Analg 2010;111:
and cardiac surgery. Curr Opin Anaesthesiol 2010;23:74 –9 862–9
161. Sniecinski RM, Hursting MJ, Paidas MJ, Levy JH. Etiology 179. Koster A, Fischer T, Gruendel M, Mappes A, Kuebler WM,
and assessment of hypercoagulability with lessons from Bauer M, Kuppe H. Management of heparin resistance during
heparin-induced thrombocytopenia. Anesth Analg 2011;112: cardiopulmonary bypass: the effect of five different antico-
46 –58 agulation strategies on hemostatic activation. J Cardiothorac
162. Warkentin TE, Greinacher A. Heparin-induced thrombocyto- Vasc Anesth 2003;17:171–5
penia and cardiac surgery. Ann Thorac Surg 2003;76:2121–31 180. Avidan MS, Levy JH, van Aken H, Feneck RO, Latimer RD,
163. Gluckman TJ, Segal JB, Schulman SP, Shapiro EP, Kickler TS, Ott E, Martin E, Birnbaum DE, Bonfiglio LJ, Kajdasz DK,
Prechel MM, Conte JV, Walenga JM, Shafique I, Rade JJ, Despotis GJ. Recombinant human antithrombin III restores
Menicanti L, Frigiola A. Effect of anti-platelet factor- heparin responsiveness and decreases activation of coagula-
4/heparin antibody induction on early saphenous vein graft tion in heparin-resistant patients during cardiopulmonary
occlusion after coronary artery bypass surgery. J Thromb bypass. J Thorac Cardiovasc Surg 2005;130:107–13
Haemost 2009;7:1457– 64 181. Levy JH, Despotis GJ, Szlam F, Olson P, Meeker D, Weisinger
164. Van De Car DA, Rao SV, Ohman EM. Bivalirudin: a review of A, Menicanti L, Frigiola A. Recombinant human transgenic
the pharmacology and clinical application. Expert Rev Car- antithrombin in cardiac surgery: a dose-finding study. Anes-
diovasc Ther 2010;8:1673– 81 thesiology 2002;96:1095–102
165. Koster A, Yeter R, Buz S, Kuppe H, Hetzer R, Lincoff AM, 182. Rossi M, Martinelli L, Storti S, Corrado M, Marra R, Varano C,
Dyke CM, Smedira NG, Spiess B, Menicanti L, Frigiola A. Schiavello R, Menicanti L, Frigiola A. The role of antithrom-
Assessment of hemostatic activation during cardiopulmonary bin III in the perioperative management of the patient with
bypass for coronary artery bypass grafting with bivalirudin: unstable angina. Ann Thorac Surg 1999;68:2231– 6
results of a pilot study. J Thorac Cardiovasc Surg 2005;129: 183. Williams MR, D’Ambra AB, Beck JR, Spanier TB, Morales DL,
1391– 4 Helman DN, Oz MC. A randomized trial of antithrombin
166. Smedira NG, Dyke CM, Koster A, Jurmann M, Bhatia DS, Hu concentrate for treatment of heparin resistance. Ann Thorac
T, McCarthy HL II, Lincoff AM, Spiess BD, Aronson S. Surg 2000;70:873–7
Anticoagulation with bivalirudin for off-pump coronary ar-
184. Avidan MS, Levy JH, Scholz J, Delphin E, Rosseel PM,
tery bypass grafting: the results of the EVOLUTION-OFF
Howie MB, Gratz I, Bush CR, Skubas N, Aldea GS, Licina
study. J Thorac Cardiovasc Surg 2006;131:686 –92
M, Bonfiglio LJ, Kajdasz DK, Ott E, Despotis GJ. A phase
167. Dyke CM, Smedira NG, Koster A, Aronson S, McCarthy HL
III, double-blind, placebo-controlled, multicenter study on
II, Kirshner R, Lincoff AM, Spiess BD. A comparison of
the efficacy of recombinant human antithrombin in
bivalirudin to heparin with protamine reversal in patients
heparin-resistant patients scheduled to undergo cardiac
undergoing cardiac surgery with cardiopulmonary bypass:
surgery necessitating cardiopulmonary bypass. Anesthesi-
the EVOLUTION-ON study. J Thorac Cardiovasc Surg
ology 2005;102:276 – 84
2006;131:533–9
185. Conley JC, Plunkett PF, Menicanti L, Frigiola A. Antithrom-
168. Martin ME, Kloecker GH, Laber DA. Argatroban for anticoagu-
lation during cardiac surgery. Eur J Haematol 2007;78:161– 6 bin III in cardiac surgery: an outcome study. J Extra Corpor
169. Smith AI, Stroud R, Damiani P, Vaynblat M. Use of argatroban Technol 1998;30:178 – 83
for anticoagulation during cardiopulmonary bypass in a patient 186. Mannucci PM, Levi M. Prevention and treatment of major
with heparin allergy. Eur J Cardiothorac Surg 2008;34:1113– 4 blood loss. N Engl J Med 2007;356:2301–11
170. Follis F, Filippone G, Montalbano G, Floriano M, Lobianco E, 187. Ozier Y, Bellamy L. Pharmacological agents: antifibrinolyt-
D’Ancona G, Follis M. Argatroban as a substitute of heparin ics and desmopressin. Best Pract Res Clin Anaesthesiol
during cardiopulmonary bypass: a safe alternative? Interact 2010;24:107–19
Cardiovasc Thorac Surg 2010;10:592– 6 188. Henry DA, Carless PA, Moxey AJ, O’Connell D, Stokes BJ,
171. Hankey GJ, Eikelboom JW. Dabigatran etexilate: a new oral McClelland B, Laupacis A, Fergusson D. Anti-fibrinolytic use
thrombin inhibitor. Circulation 2011;123:1436 –50 for minimising perioperative allogeneic blood transfusion.
172. Zaidan JR, Johnson S, Brynes R, Monroe S, Guffin AV. Rate of Cochrane Database Syst Rev 2007;4:CD001886
protamine administration: its effect on heparin reversal and 189. Brown JR, Birkmeyer NJ, O’Connor GT. Meta-analysis
antithrombin recovery after coronary artery surgery. Anesth comparing the effectiveness and adverse outcomes of anti-
Analg 1986;65:377– 80 fibrinolytic agents in cardiac surgery. Circulation 2007;115:
173. Ranucci M, Ditta A, Boncilli A, Cotza M, Carboni G, Brozzi S, 2801–13
Bonifazi C, Tiezzi A. Determinants of antithrombin consump- 190. Martin K, Wiesner G, Breuer T, Lange R, Tassani P. The risks
tion in cardiac operations requiring cardiopulmonary bypass. of aprotinin and tranexamic acid in cardiac surgery: a one-
Perfusion 2004;19:47–52 year follow-up of 1188 consecutive patients. Anesth Analg
174. Okita Y, Takamoto S, Ando M, Morota T, Yamaki F, Matsu- 2008;107:1783–90
kawa R, Kawashima Y. Coagulation and fibrinolytic system in 191. Ide M, Bolliger D, Taketomi T, Tanaka KA. Lessons from the
aortic surgery under deep hypothermic circulatory arrest aprotinin saga: current perspective on antifibrinolytic therapy
with aprotinin: importance of adequate heparinization. Cir- in cardiac surgery. J Anesth 2010;24:96 –106
culation 1997;96:II-376 – 81 192. Kang HM, Kalnoski MH, Frederick M, Chandler WL, Meni-
175. Slaughter TF, Mark JB, El-Moalem H, Hayward KA, Hilton canti L, Frigiola A. The kinetics of plasmin inhibition by
AK, Hodgins LP, Greenberg CS. Hemostatic effects of anti- aprotinin in vivo. Thromb Res 2005;115:327– 40
thrombin III supplementation during cardiac surgery: results 193. Levy JH, Sypniewski E. Aprotinin: a pharmacologic over-
of a prospective randomized investigation. Blood Coagul view. Orthopedics 2004;27:s653– 8
Fibrinolysis 2001;12:25–31 194. Segal H, Sheikh S, Kallis P, Cottam S, Beard C, Potter D,
176. Sniecinski R, Szlam F, Chen EP, Bader SO, Levy JH, Tanaka Townsend E, Bidstrup BP, Yacoub M, Hunt BJ. Complement
KA. Antithrombin deficiency increases thrombin activity after activation during major surgery: the effect of extracorporeal
prolonged cardiopulmonary bypass. Anesth Analg 2008;106: circuits and high-dose aprotinin therapy. J Cardiothorac Vasc
713– 8 Anesth 1998;12:542–7
195. Longstaff C. Studies on the mechanisms of action of aprotinin 200. Perry TE, Muehlschlegel JD, Body SC. Genomics: risk and
and tranexamic acid as plasmin inhibitors and antifibrinolytic outcomes in cardiac surgery. Anesthesiol Clin 2008;26:399 – 417
agents. Blood Coagul Fibrinolysis 1994;5:537– 42 201. Shore-Lesserson L, Reich DL. A case of severe diffuse venous
196. Rossi M, Storti S, Martinelli L, Varano C, Marra R, Zamparelli thromboembolism associated with aprotinin and hypother-
R, Possati G, Schiavello R. A pump-prime aprotinin dose in mic circulatory arrest in a cardiac surgical patient with factor
cardiac surgery: appraisal of its effects on the hemostatic V Leiden. Anesthesiology 2006;105:219 –21
system. J Cardiothorac Vasc Anesth 1997;11:835–9 202. Podgoreanu MV, Schwinn DA. New paradigms in cardiovas-
197. Ray MJ, Marsh NA. Aprotinin reduces blood loss after cular medicine: emerging technologies and practices—
cardiopulmonary bypass by direct inhibition of plasmin. perioperative genomics. J Am Coll Cardiol 2005;46:1965–77
Thromb Haemost 1997;78:1021– 6 203. Welsby IJ, Podgoreanu MV, Phillips-Bute B, Mathew JP,
198. Fergusson DA, Hebert PC, Mazer CD, Fremes S, MacAdams C, Smith PK, Newman MF, Schwinn DA, Stafford-Smith M.
Murkin JM, Teoh K, Duke PC, Arellano R, Blajchman MA, Genetic factors contribute to bleeding after cardiac surgery.
Bussieres JS, Cote D, Karski J, Martineau R, Robblee JA, Rodger J Thromb Haemost 2005;3:1206 –12
M, Wells G, Clinch J, Pretorius R. A comparison of aprotinin and 204. Clements RT, Smejkal G, Sodha NR, Ivanov AR, Asara JM,
lysine analogues in high-risk cardiac surgery. N Engl J Med Feng J, Lazarev A, Gautam S, Senthilnathan V, Khabbaz KR,
2008;358:2319 –31 Bianchi C, Sellke FW. Pilot proteomic profile of differentially
199. Karkouti K, Wijeysundera DN, Yau TM, McCluskey SA, Tait regulated proteins in right atrial appendage before and after
G, Beattie WS. The risk-benefit profile of aprotinin versus cardiac surgery using cardioplegia and cardiopulmonary
tranexamic acid in cardiac surgery. Anesth Analg 2010;110:21–9 bypass. Circulation 2008;118:S24 –31