The effectiveness of different functional fibrinogen polymerization assays in eliminating platelet contribution to clot strength in thromboelastometry.
BACKGROUND
Viscoelastic tests such as functional fibrinogen polymerization assays (FFPAs) in thrombelastography (TEG®) or thromboelastometry (ROTEM®) measure clot elasticity under platelet inhibition. Incomplete platelet inhibition influences maximum clot firmness (MCF) of FFPAs. We compared the ability of existing and newly developed FFPAs to eliminate the platelet contribution to clot strength.


METHODS
MCF of whole blood (WB), platelet-rich plasma (PRP), and platelet-poor plasma samples was recorded using a ROTEM device with different FFPAs, including the TEG functional fibrinogen test (FFTEG) and different ROTEM-based assays: the standard fib-tem reagent (FIBTEM), a lyophilized single-portion reagent fib-tem S (FIBTEM-S), a newly developed reagent FIBTEM PLUS, as well as FIBTEM or the standard extrinsic activation reagent ex-tem® (EXTEM) combined with 10-μg abciximab (FIBTEM-ABC/EXTEM-ABC).


RESULTS
In WB (platelet count [mean ± SD], 183 ± 37 × 10/μL; plasma fibrinogen concentration, 2.49 ± 0.58 g/L), FFTEG and EXTEM-ABC showed higher MCF (15.7 ± 2.8 mm) than FIBTEM or FIBTEM-S (11.4 ± 3.3 mm, P < 0.001), whereas FIBTEM-ABC and FIBTEM PLUS resulted in lower MCF (9.3 ± 2.8 mm, P < 0.001). In 2 different PRP samples, with platelet counts of 407 ± 80 × 10/μL and 609 ± 127 × 10/μL, FIBTEM-ABC and FIBTEM PLUS reduced platelet contribution to clot strength within 95% confidence interval limits of -1.4 to 0.1 mm and -1.2 to 0.4 mm, respectively. Using all FFPAs it was observed that the Pearson correlation coefficient between plasma fibrinogen concentration and WB MCF was high (range, 0.75-0.93) and significant, regardless of the underlying platelet inhibiting component. Evaluating differences in the interception of regression lines by using analysis of covariance, we compared platelet-poor plasma and both PRP samples within the same assays and found that in contrast to the FIBTEM-ABC and FIBTEM PLUS assays, the FFTEG, EXTEM-ABC, FIBTEM, and FIBTEM-S methods still detected residual platelet activity and grossly overestimated fibrin clot strength in samples with high platelet counts.


CONCLUSIONS
FFPAs based solely on glycoprotein-IIb/IIIa inhibition, such as FFTEG or EXTEM-ABC, are less effective than cytochalasin D-based assays, such as FIBTEM or FIBTEM-S, at inhibiting the platelet component of clot strength. The FIBTEM PLUS assay, and the combination of FIBTEM and abciximab, sufficiently inhibits platelet contribution to clot elasticity. The combination of a glycoprotein-IIb/IIIa receptor blocker and cytochalasin D allows evaluation of functional fibrinogen polymerization without platelet "noise." In a clinical setting, the significance of potent platelet inhibition ensures a more accurate assessment of MCF and therefore the need for fibrinogen supplementation therapy. Further studies are necessary to investigate the application and impact of these tests in a clinical situation.
From the Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna; Department of Anesthesiology and Intensive Care, Salzburger Landeskliniken SALK, Salzburg, Austria; CSL Behring, Marburg, Germany; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy; and Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital of Salzburg, Salzburg, Austria.
Christoph J
CJ
Schlimp
Cristina
C
Solomon
Marco
M
Ranucci
Gerald
G
Hochleitner
Heinz
H
Redl
Herbert
H
Schöchl
D000077284:Abciximab; D000328:Adult; D000911:Antibodies, Monoclonal / Q000737:chemistry; D001777:Blood Coagulation / Q000502:physiology; D001792:Blood Platelets / Q000166:cytology*; D015638:Cytochalasin D / Q000737:chemistry; D004548:Elasticity; D005337:Fibrin / Q000737:chemistry; D005340:Fibrinogen / Q000737:chemistry* / Q000627:therapeutic use; D006023:Glycoproteins / Q000737:chemistry; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000737:chemistry; D008297:Male; D010976:Platelet Count; D058105:Polymerization; D012044:Regression Analysis; D012815:Signal Processing, Computer-Assisted; D013916:Thrombelastography / Q000379:methods*; D014783:Viscosity
D000911:Antibodies, Monoclonal; D006023:Glycoproteins; D007140:Immunoglobulin Fab Fragments; D015638:Cytochalasin D; D005337:Fibrin; D005340:Fibrinogen; D000077284:Abciximab