title: A novel protamine variant reversal of heparin anticoagulation in human blood in vitro.
abstract: OBJECTIVE
  Protamine reversal of heparin anticoagulation during cardiovascular surgery may cause severe hypotension and pulmonary hypertension. A novel protamine variant, [+18RGD], has been developed that effectively reverses heparin anticoagulation without toxicity in canine experiments. Heretofore, human studies have not been undertaken. This investigation hypothesized that [+18RGD] would effectively reverse heparin anticoagulation of human blood in vitro.
  
  
  METHODS
  Fifty patients who underwent anticoagulation therapy during vascular surgery had blood sampled at baseline and 30 minutes after receiving heparin (150 IU/kg). Activated clotting times were used to define specific quantities of [+18RGD] or protamine necessary to completely reverse heparin anticoagulation in the blood sample of each patient. These defined amounts of [+18RGD] or protamine were then administered to the heparinized blood samples, and percent reversals of activated partial thromboplastin time, thrombin clotting time, and antifactor Xa/IIa levels were determined. In addition, platelet aggregation assays, as well as platelet and white blood cell counts were performed.
  
  
  RESULTS
  [+18RGD] and protamine were equivalent in reversing heparin as assessed by thrombin clotting time, antifactor Xa, antifactor IIa levels, and white blood cell changes. [+18RGD], when compared with protamine, was superior in this regard, as assessed by activated partial thromboplastin time (94.5 +/- 1.0 vs 86.5 +/- 1.3% delta, respectively; p < 0.001) and platelet declines (-3.9 +/- 2.9 vs -12.8 +/- 3.4 per mm3, respectively; p = 0.048). Platelet aggregation was also decreased for [+18RGD] compared with protamine (23.6 +/- 1.5 vs 28.5 +/- 1.9%, respectively; p = 0.048).
  
  
  CONCLUSIONS
  [+18RGD] was as effective as protamine for in vitro reversal of heparin anticoagulation by most coagulation assays, was statistically more effective at reversal than protamine by aPTT assay, and was associated with lesser platelet reductions than protamine. [+18RGD], if less toxic than protamine in human beings, would allow for effective clinical reversal of heparin anticoagulation.
authors.affiliation: Unit for Laboratory Animal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0329, USA.
authors.forename: M S
authors.initials: MS
authors.lastname: Hulin
authors.forename: T W
authors.initials: TW
authors.lastname: Wakefield
authors.forename: P C
authors.initials: PC
authors.lastname: Andrews
authors.forename: S K
authors.initials: SK
authors.lastname: Wrobleski
authors.forename: M D
authors.initials: MD
authors.lastname: Stoneham
authors.forename: A R
authors.initials: AR
authors.lastname: Doyle
authors.forename: G B
authors.initials: GB
authors.lastname: Zelenock
authors.forename: L A
authors.initials: LA
authors.lastname: Jacobs
authors.forename: C J
authors.initials: CJ
authors.lastname: Shanley
authors.forename: V M
authors.initials: VM
authors.lastname: TenCate
authors.forename: J C
authors.initials: JC
authors.lastname: Stanley
mesh_terms: D000368:Aged; D001777:Blood Coagulation / Q000187:drug effects*; D001779:Blood Coagulation Factors / Q000187:drug effects; D005260:Female; D006494:Heparin Antagonists / Q000627:therapeutic use*; D006801:Humans; D066298:In Vitro Techniques; D007958:Leukocyte Count / Q000187:drug effects; D008297:Male; D008875:Middle Aged; D010974:Platelet Aggregation / Q000187:drug effects; D010976:Platelet Count / Q000187:drug effects; D011479:Protamines / Q000627:therapeutic use*; D014656:Vascular Surgical Procedures / Q000379:methods*
chemical_list: D001779:Blood Coagulation Factors; D006494:Heparin Antagonists; D011479:Protamines; C109762:protamine +18RGD