title: Individualized heparin and protamine management improves rotational thromboelastometric parameters and postoperative hemostasis in valve surgery.
abstract: OBJECTIVE
  This study investigated whether a tailored approach to heparin and protamine management improved thromboelastometric parameters after cardiopulmonary bypass and reduced postoperative blood loss compared with activated coagulation time (ACT)-based fixed target heparin and protamine management.
  
  
  METHODS
  Randomized controlled study.
  
  
  METHODS
  Tertiary university hospital.
  
  
  METHODS
  Patients undergoing elective valve surgery (n = 38).
  
  
  METHODS
  Heparin and protamine management were based either on the ACT (n = 19) or hemostasis management system (HMS) measurements (n = 19; HMS Plus; Medtronic, Minneapolis, MN).
  
  
  RESULTS
  The target ACT for initiation of cardiopulmonary bypass was 480 seconds. Study variables included rotational thromboelastometry EXTEM (extrinsic coagulation), HEPTEM (intrinsic coagulation with heparinase), and FIBTEM (fibrin part of clot formation) tests and 24-hour blood loss. The use of HMS reduced the median protamine-to-heparin ratio from 1.00 (1.00-1.00) to 0.62 (0.56-0.66; p<0.001). The ACT group showed a prolonged postbypass clotting time for both EXTEM (86 ± 13 seconds v 78 ± 10 seconds; p = 0.05) and HEPTEM (217 ± 58 seconds v 183 ± 24 seconds; p = 0.03) tests. There was a moderate correlation between protamine dosing with the EXTEM and HEPTEM clotting time (r = 0.42; p = 0.009 and r = 0.38; p = 0.02, respectively). The number of patients with more than 450 mL/24 hours was higher in the ACT than in the HMS group (42% v 12%; p = 0.04).
  
  
  CONCLUSIONS
  Individualized heparin and protamine management decreased the protamine-to-heparin ratio, improved postbypass thromboelastometric hemostatic parameters, and reduced the incidence of severe blood loss compared with an ACT-based strategy, supporting the added value of this approach for hemostatic optimization during cardiac surgery.
authors.affiliation: Department of Cardio-thoracic Surgery, Institute for Cardio-vascular Research, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Alexander B A
authors.initials: AB
authors.lastname: Vonk
authors.affiliation: Department of Cardio-thoracic Surgery, Institute for Cardio-vascular Research, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Dennis
authors.initials: D
authors.lastname: Veerhoek
authors.affiliation: Department of Anesthesiology, Institute for Cardio-vascular Research, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Charissa E
authors.initials: CE
authors.lastname: van den Brom
authors.affiliation: Department of Cardio-thoracic Surgery, Institute for Cardio-vascular Research, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Laurentius J M
authors.initials: LJ
authors.lastname: van Barneveld
authors.affiliation: Department of Anesthesiology, Institute for Cardio-vascular Research, VU University Medical Center, Amsterdam, The Netherlands. Electronic address: c.boer@vumc.nl.
authors.forename: Christa
authors.initials: C
authors.lastname: Boer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D006348:Cardiac Surgical Procedures / Q000379:methods*; D002315:Cardiopulmonary Bypass; D005260:Female; D005337:Fibrin / Q000032:analysis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods; D006351:Heart Valves / Q000601:surgery*; D006487:Hemostasis; D006493:Heparin / Q000008:administration & dosage / Q000627:therapeutic use*; D006494:Heparin Antagonists / Q000008:administration & dosage / Q000627:therapeutic use*; D019763:Heparin Lyase; D006801:Humans; D008297:Male; D008875:Middle Aged; D010314:Partial Thromboplastin Time; D057285:Precision Medicine / Q000379:methods*; D011479:Protamines / Q000008:administration & dosage / Q000627:therapeutic use*; D013916:Thrombelastography / Q000379:methods*; D014914:Whole Blood Coagulation Time; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D006494:Heparin Antagonists; D011479:Protamines; D005337:Fibrin; D006493:Heparin; D019763:Heparin Lyase
keywords: anticoagulation; cardiopulmonary bypass; coagulation; extracorporeal circulation; heparin; protamine; surgical blood loss; thromboelastography