title: Monitoring incomplete heparin reversal and heparin rebound after cardiac surgery.
abstract: OBJECTIVE
  To assess the incidence of incomplete heparin reversal and heparin rebound after cardiac surgery with cardiopulmonary bypass (CPB) and the ability of the activated coagulation time (ACT) and thromboelastography (TEG) to detect these phenomena.
  
  
  METHODS
  Prospective single-center study.
  
  
  METHODS
  University hospital.
  
  
  METHODS
  Forty-one patients undergoing elective cardiac surgery with CPB and with normal preoperative TEG parameters.
  
  
  METHODS
  ACT, TEG, and plasma heparin levels were measured in all patients at 5 different times between 20 minutes and 3 hours after protamine administration. The variability of TEG reaction time (R) with and without heparinase (delta-R [DR]) was used to detect the presence of residual heparin.
  
  
  RESULTS
  Plasma heparin expressed as anti-FXa activity was detected in 180 (88%) samples. At univariate analysis, ACT, R-kaolin (R-k), and DR significantly correlated with plasma heparin concentration (respectively, p = 0.007, p = 0.006, and p = 0.002). At multivariate analysis, R-k and DR remained associated with plasma heparin concentration (respectively, p = 0.014 and p = 0.004). Greater quartiles of heparin were associated with higher values of R-k and DR. Combined procedures had significantly lower DR than isolated procedures (p = 0.017), and CPB time and heparinization time positively correlated with R-k (respectively, p = 0.044 and p = 0.022). No association was observed between heparin concentration, ACT, and TEG parameters with postoperative bleeding and need for blood and blood components transfusions.
  
  
  CONCLUSIONS
  Heparin rebound and incomplete heparin reversal are very common phenomena after cardiac surgery with CPB; ACT is not able to detect residual heparin activity, whereas TEG analysis with and without heparinase allows the diagnosis of heparin rebound.
authors.affiliation: Division of Cardiac Surgery, Department of Emergencies and Organ Transplantation (D.E.T.O.) University "Aldo Moro" of Bari, Italy; Department of Thoracic and Cardiovascular Surgery, La Pitié-Salpêtrière Hospital, Paris, France.
authors.forename: Antonella
authors.initials: A
authors.lastname: Galeone
authors.forename: Crescenzia
authors.initials: C
authors.lastname: Rotunno
authors.forename: Pietro
authors.initials: P
authors.lastname: Guida
authors.forename: Assunta
authors.initials: A
authors.lastname: Bisceglie
authors.forename: Giovanni
authors.initials: G
authors.lastname: Rubino
authors.forename: Luigi de Luca Tupputi
authors.initials: Lde L
authors.lastname: Schinosa
authors.forename: Domenico
authors.initials: D
authors.lastname: Paparella
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000639:trends*; D002315:Cardiopulmonary Bypass / Q000009:adverse effects / Q000639:trends*; D016903:Drug Monitoring / Q000379:methods*; D005260:Female; D006493:Heparin / Q000097:blood*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013916:Thrombelastography / Q000379:methods*; D014914:Whole Blood Coagulation Time / Q000379:methods
chemical_list: D006493:Heparin
keywords: activated coagulation time; cardiopulmonary bypass; heparin; heparin rebound; protamine; thromboelastography