A reduction of prothrombin conversion by cardiac surgery with cardiopulmonary bypass shifts the haemostatic balance towards bleeding

Summary

Cardiac surgery with cardiopulmonary bypass (CPB) is associated with blood loss and post-surgery thrombotic complications. The process of thrombin generation is disturbed during surgery with CPB because of haemodilution, coagulation factor consumption and heparin administration. We aimed to investigate the changes in thrombin generation during cardiac surgery and its underlying pro- and anticoagulant processes, and to explore the clinical consequences of these changes using in silico experimentation. Plasma was obtained from 29 patients undergoing surgery with CPB before heparinisation, after heparinisation, after haemodilution, and after protamine administration. Thrombin generation was measured and prothrombin conversion and thrombin inactivation were quantified. In silico experimentation was used to investigate the reaction of patients to the administration of procoagulant factors and/or anticoagulant factors. Surgery with CPB causes significant coagulation factor consumption and a reduction of thrombin generation. The total amount of prothrombin converted and the rate of prothrombin conversion decreased during surgery. As the surgery progressed, the relative contribution of α₂-macroglobulin-dependent thrombin inhibition increased, at the expense of antithrombin-dependent inhibition. In silico restoration of post-surgical prothrombin conversion to pre-surgical levels increased thrombin generation excessively, whereas co-administration of antithrombin resulted in the normalisation of post-surgical thrombin generation. Thrombin generation is reduced during surgery with cardiopulmonary bypass because of a balance shift between prothrombin conversion and thrombin inactivation. According to in silico predictions of thrombin generation, this new balance increases the risk of thrombotic complications with prothrombin complex concentrate administration, but not if antithrombin is co-administered.

Keywords

Cardiopulmonary bypass - thrombin generation - thrombin inactivation - prothrombin conversion - transfusion

• References

• 1 Groenenberg I, Weerwind PW, Everts PA. et al. Dutch perfusion incident survey. Perfusion 2010; 25: 329-336.
• 2 Ranucci M.. Haemostatic and thrombotic issues in cardiac surgery. Semin Thromb Haemost 2015; 41: 84-90.
• 3 Bosch Y, Al Dieri R, ten Cate H. et al. Preoperative thrombin generation is predictive for the risk of blood loss after cardiac surgery: a research article. J Cardiothorac Surg 2013; 8: 154.
• 4 Bosch YP, Al Dieri R, ten Cate H. et al. Measurement of thrombin generation intra-operatively and its association with bleeding tendency after cardiac surgery. Thromb Res 2014; 133: 488-494.
• 5 Nilsson J, Scicluna S, Malmkvist G. et al. A randomized study of coronary artery bypass surgery performed with the Resting Heart System utilizing a low vs a standard dosage of heparin. Interact Cardiovasc Thorac Surg 2012; 15: 834-839.
• 6 Percy CL, Hartmann R, Jones RM. et al. Correcting thrombin generation ex vivo using different haemostatic agents following cardiac surgery requiring the use of cardiopulmonary bypass. Blood Coagul Fibrinolysis 2015; 26: 357-367.
• 7 Woodman RC, Harker LA.. Bleeding complications associated with cardiopulmonary bypass. Blood 1990; 76: 1680-1697.
• 8 De Somer F, Van Belleghem Y, Caes F. et al. Tissue factor as the main activator of the coagulation system during cardiopulmonary bypass. J Thoracic Cardiovasc Surg 2002; 123: 951-958.
• 9 Edmunds Jr. LH, Colman RW.. Thrombin during cardiopulmonary bypass. Ann Thorac Surg 2006; 82: 2315-2322.
• 10 Haidl H, Cimenti C, Leschnik B. et al. Age-dependency of thrombin generation measured by means of calibrated automated thrombography (CAT). Thromb Haemost 2006; 95: 772-775.
• 11 Koestenberger M, Cvirn G, Rosenkranz A. et al. Thrombin generation in paediatric patients with congenital heart disease. Determination by calibrated automated thrombography. Hamostaseologie 2008; 28 (Suppl. 01) S61-66.
• 12 Hemker HC, Giesen P, AlDieri R. et al. The calibrated automated thrombogram (CAT): a universal routine test for hyper- and hypocoagulability. Pathophysiol Haemost Thromb 2002; 32: 249-253.
• 13 Deutschmann A, Schlagenhauf A, Leschnik B. et al. Increased procoagulant function of microparticles in pediatric inflammatory bowel disease: role in increased thrombin generation. J Ped Gastroenterol Nutr 2013; 56: 401-407.
• 14 Lejhancova-Tousovska K, Zapletal O, Vytiskova S. et al. Profile of thrombin generation in children with acute lymphoblastic leukemia treated by Berlin-Frank-furt-Munster (BFM) protocols. Blood Coagul Fibrinolysis 2012; 23: 144-154.
• 15 Levy JH.. Pharmacologic preservation of the haemostatic system during cardiac surgery. Ann Thorac Surg 2001; 72: S1814-1820.
• 16 Levy JH, Montes F, Szlam F. et al. The in vitro effects of antithrombin III on the activated coagulation time in patients on heparin therapy. Anesth Analg 2000; 90: 1076-1079.
• 17 Levy JH, Sniecinski RM.. Activated clotting times, heparin responses, and antithrombin: have we been wrong all these years?. Anesth Analg 2010; 111: 833-835.
• 18 Sandset PM, Abildgaard U, Larsen ML.. Heparin induces release of extrinsic coagulation pathway inhibitor (EPI). Thromb Res 1988; 50: 803-813.
• 19 Kremers RM, Peters TC, Wagenvoord RJ. et al. The balance of pro- and anticoagulant processes underlying thrombin generation. J Thromb Haemost 2015; 13: 437-447.
• 20 Al Dieri R, de Laat B, Hemker HC. Thrombin generation: what have we learned?. Blood Rev 2012; 26: 197-203.
• 21 Kremers RM, Wagenvoord RJ, Hemker HC.. The effect of fibrin(ogen) on thrombin generation and decay. Thromb Haemost 2014; 112: 486-494.
• 22 Schols SE, Heemskerk JW, van Pampus EC.. Correction of coagulation in dilutional coagulopathy: use of kinetic and capacitive coagulation assays to improve haemostasis. Transfusion Med Rev 2010; 24: 44-52.
• 23 Sorensen B, Spahn DR, Innerhofer P. et al. Clinical review: Prothrombin complex concentrates--evaluation of safety and thrombogenicity. Crit Care 2011; 15: 201.
• 24 Rosing J, Tans G, Govers-Riemslag JW. et al. The role of phospholipids and factor Va in the prothrombinase complex. J Biol Chem 1980; 255: 274-283.
• 25 Church FC, Whinna HC.. Rapid sulfopropyl-disk chromatographic purification of bovine and human thrombin. Anal Biochem 1986; 157: 77-83.
• 26 Thaler E, Schmer G.. A simple two-step isolation procedure for human and bovine antithrombin II/III (heparin cofactor): a comparison of two methods. Br J Haematol 1975; 31: 233-243.
• 27 Hendrix H, Lindhout T, Mertens K. et al. Activation of human prothrombin by stoichiometric levels of staphylocoagulase. J Biol Chem 1983; 258: 3637-3644.
• 28 Clauss A. Rapid physiological coagulation method in determination of fibrinogen. Acta Haematol 1957; 17: 237-246.
• 29 Hemker HC, Kremers R.. Data management in thrombin generation. Thromb Res 2013; 131: 3-11.
• 30 Kremers RM, Mohamed AB, Pelkmans L. et al. Thrombin Generating Capacity and Phenotypic Association in ABO Blood Groups. PLoS One 2015; 10: e0141491.
• 31 Kremers RMW, Wagenvoord RJ, de Laat HB. et al. Low paediatric thrombin generation is caused by an attenuation of prothrombin conversion. Thromb Haemost. 2016 In press.
• 32 Mitrophanov AY, Rosendaal FR, Reifman J.. Therapeutic correction of thrombin generation in dilution-induced coagulopathy: computational analysis based on a data set of healthy subjects. The journal of trauma and acute care surgery 2012; 73 (02) (Suppl. 01) S95-S102.
• 33 Mitrophanov AY, Rosendaal FR, Reifman J.. Computational analysis of intersubject variability and thrombin generation in dilutional coagulopathy. Transfusion 2012; 52: 2475-2486.
• 34 Schols SE, Lance MD, Feijge MA. et al. Impaired thrombin generation and fibrin clot formation in patients with dilutional coagulopathy during major surgery. Thromb Haemost 2010; 103: 318-328.
• 35 Ninivaggi M, Feijge MA, Baaten CC. et al. Additive roles of platelets and fibrinogen in whole-blood fibrin clot formation upon dilution as assessed by thromboelastometry. Thromb Haemost 2014; 111: 447-457.
• 36 Hemker HC, De Smedt E, Chandler WL. et al. Thrombin generation and plasma dilution. Am J Clin Pathol 2010; 133: 163 author reply 164.
• 37 Tanaka KA, Key NS, Levy JH.. Blood coagulation: haemostasis and thrombin regulation. Anesth Analg 2009; 108: 1433-1446.
• 38 Dielis AW, Castoldi E, Spronk HM. et al. Coagulation factors and the protein C system as determinants of thrombin generation in a normal population. J Thromb Haemost 2008; 6: 125-131.
• 39 Morizumi S, Hiramatsu Y, Matsuzaki K. et al. Early heparin administration attenuates tissue factor-mediated thrombin generation during simulated cardiopulmonary bypass. J Cardiac Surg 2014; 29: 35-40.
• 40 Key NS, Negrier C.. Coagulation factor concentrates: past, present, and future. Lancet 2007; 370: 439-448.
• 41 Mitrophanov AY, Wolberg AS, Reifman J.. Kinetic model facilitates analysis of fibrin generation and its modulation by clotting factors: implications for haemostasis-enhancing therapies. Mol Bio Sys 2014; 10: 2347-2357.
• 42 Grottke O, Levy JH.. Prothrombin complex concentrates in trauma and perioperative bleeding. Anesthesiology 2015; 122: 923-931.
• 43 Kohler M.. Thrombogenicity of prothrombin complex concentrates. Thromb Res 1999; 95 (04) (Suppl. 01) S13-17.