title: Heparinless cardiopulmonary bypass with active-site blocked factor IXa: a preliminary study on the dog.
abstract: OBJECTIVE
  Cardiopulmonary bypass is a potent stimulus for activation of procoagulant pathways. Heparin, the traditional antithrombotic agent, however, is often associated with increased perioperative blood loss because of its multiple sites of action in the coagulation cascade and its antiplatelet and profibrinolytic effects. Furthermore, heparin-mediated immunologic reactions (that is, heparin-induced thrombocytopenia) may contraindicate its use. Cardiopulmonary bypass with a selective factor IXa inhibitor was tested to see whether it could effectively limit bypass circuit/intravascular space thrombosis while decreasing extravascular bleeding, thereby providing an alternative anticoagulant strategy when heparin may not be safely administered.
  
  
  METHODS
  Active site-blocked factor IXa, a competitive inhibitor of the assembly of factor IXa into the factor X activation complex, was prepared by modification of the enzyme's active site by the use of dansyl glutamic acid-glycine-arginine-chlormethylketone. Twenty mongrel dogs (five were given standard heparin/protamine; 15 were given activated site-blocked factor IXa doses ranging from 300 to 600 microg/kg) underwent 1 hour of hypothermic cardiopulmonary bypass, and blood loss was monitored for 3 hours after the procedure.
  
  
  RESULTS
  Use of activated site-blocked factor IXa as an anticoagulant in cardiopulmonary bypass limited fibrin deposition within the extracorporeal circuit as assessed by scanning electron microscopy, comparable with the antithrombotic effect seen with heparin. In contrast to heparin, effective antithrombotic doses of activated site-blocked factor IXa significantly diminished blood loss in the thoracic cavity and in an abdominal incisional bleeding model.
  
  
  CONCLUSIONS
  These initial studies on the dog suggest that administration of activated site-blocked factor IXa may be an effective alternative anticoagulant strategy in cardiopulmonary bypass when heparin is contraindicated, affording inhibition of intravascular/extracorporeal circuit thrombosis with enhanced hemostasis in the surgical wound.
authors.affiliation: Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
authors.forename: T B
authors.initials: TB
authors.lastname: Spanier
authors.forename: M C
authors.initials: MC
authors.lastname: Oz
authors.forename: O P
authors.initials: OP
authors.lastname: Minanov
authors.forename: R
authors.initials: R
authors.lastname: Simantov
authors.forename: W
authors.initials: W
authors.lastname: Kisiel
authors.forename: D M
authors.initials: DM
authors.lastname: Stern
authors.forename: E A
authors.initials: EA
authors.lastname: Rose
authors.forename: A M
authors.initials: AM
authors.lastname: Schmidt
mesh_terms: D000818:Animals; D000925:Anticoagulants / Q000008:administration & dosage*; D001665:Binding Sites; D001777:Blood Coagulation / Q000187:drug effects; D016063:Blood Loss, Surgical / Q000517:prevention & control; D002315:Cardiopulmonary Bypass; D004285:Dogs; D015949:Factor IXa / Q000037:antagonists & inhibitors*; D006490:Hemostatics / Q000008:administration & dosage*; D006493:Heparin / Q000008:administration & dosage*; D007036:Hypothermia, Induced; D010974:Platelet Aggregation / Q000187:drug effects; D011479:Protamines / Q000008:administration & dosage; D011517:Prothrombin Time; D013927:Thrombosis / Q000097:blood / Q000517:prevention & control
chemical_list: D000925:Anticoagulants; D006490:Hemostatics; D011479:Protamines; D006493:Heparin; D015949:Factor IXa