title: Activation of hemostasis after coronary artery bypass grafting with or without cardiopulmonary bypass.
abstract: Activation of coagulation, fibrinolysis, and the vascular endothelium occurs after heart surgery with cardiopulmonary bypass (CPB), but the effects of eliminating CPB in patients undergoing coronary artery bypass grafting (CABG) are unknown. Therefore, we compared the hemostatic profiles of off-pump and on-pump CABG patients. Two groups of consecutive patients participating in a larger trial (the Octopus Trial) were randomly allocated to undergo CABG with (n = 20) or without (n = 20) CPB. Platelet numbers and plasma concentrations of P-selectin, prothrombin fragment 1.2 (F1.2), soluble fibrin, d-dimers, and von Willebrand factor (as a marker of endothelial cell activation) were measured and corrected for hemodilution. Compared with the on-pump CABG group, F1.2 and d-dimer levels were significantly lower (P = 0.004 and P = 0.03, respectively) in patients having CABG surgery performed off-pump. In the CPB group, F1.2 (median [interquartile range], 450% of baseline [233%-847%]) and d-dimer (538% [318%-1192%]) peaked in the immediate postoperative period and remained increased until Day 4, whereas in the off-pump group, F1.2 and d-dimer levels increased more gradually and peaked on Day 4 (342% [248%-515%] and 555% [387%-882%], respectively). In both groups, von Willebrand factor concentrations were increased until Day 4 (CPB, 308% [228%-405%]; off-pump, 288% [167%-334%]). Despite heparinization, CABG surgery with CPB was associated with excessive thrombin generation and fibrinolytic activity immediately after surgery. The off-pump group demonstrated a delayed postoperative response that became equal in magnitude to the CPB in the later (20-96 h) postoperative period.
authors.affiliation: *Department of Anesthesiology, †Department of Hematology, and ‡Heart-Lung Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands; and §Department of Thoracic Anesthesiology and Intensive Care, Isala Clinics, Zwolle, The Netherlands.
authors.forename: Bernard
authors.initials: B
authors.lastname: Lo
authors.forename: Rob
authors.initials: R
authors.lastname: Fijnheer
authors.forename: Domenico
authors.initials: D
authors.lastname: Castigliego
authors.forename: Cornelius
authors.initials: C
authors.lastname: Borst
authors.forename: Cor J
authors.initials: CJ
authors.lastname: Kalkman
authors.forename: Arno P
authors.initials: AP
authors.lastname: Nierich
mesh_terms: D000328:Adult; D000368:Aged; D002315:Cardiopulmonary Bypass; D001026:Coronary Artery Bypass; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006487:Hemostasis; D006801:Humans; D008297:Male; D008875:Middle Aged; D019007:P-Selectin / Q000097:blood; D011446:Prospective Studies; D014914:Whole Blood Coagulation Time
chemical_list: D005338:Fibrin Fibrinogen Degradation Products; D019007:P-Selectin; C036309:fibrin fragment D