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Semin Thromb Hemost
DOI: 10.1055/s-0045-1802573
Review Article

Monitoring Hemostatic Function during Cardiac Surgery with Point-of-Care Viscoelastic Assays: A Narrative Review

Brandon Jin An Ong   *
1   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
,
Hui Xin See Tow   *
1   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
,
Alyssa Tze Wei Fong
1   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
,
Ryan Ruiyang Ling
1   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
2   Australia and New Zealand Intensive Care Research Centre, School of Preventive Medicine and Public Health, Monash University, Melbourne, Victoria, Australia
3   Department of Anaesthesia, National University Hospital, National University Health System, Singapore
,
Kiran Shekar
4   Intensive Care Unit, Caboolture Hospital, Brisbane, Queensland, Australia
5   Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
6   Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Queensland, Australia
7   Faculty of Health, Queensland University of Technology, University of Queensland, Brisbane, Queensland, Australia
,
Kristine Teoh
1   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
9   Division of Adult Cardiac Surgery, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
,
Lian Kah Ti
1   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
3   Department of Anaesthesia, National University Hospital, National University Health System, Singapore
,
Graeme MacLaren
1   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
10   Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
,
Bingwen Eugene Fan
1   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
11   Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
12   Department of Hematology, Tan Tock Seng Hospital, Singapore
,
Kollengode Ramanathan
1   Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
10   Cardiothoracic Intensive Care Unit, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
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Abstract

Bleeding is a well-known and severe complication of cardiac surgery. Cardiopulmonary bypass, along with heparinization and hemodilution, is thought to affect all pathways of the hemostatic process, leading to excessive bleeding and worsened morbidity and mortality. The traditionally used standard laboratory tests (SLTs) were not designed for the surgical setting, have long turnaround times, and are poor predictors of bleeding. This review aims to give an overview of viscoelastic assays (VEAs), compare VEAs to conventional testing methods, and summarize the evidence for VEAs in cardiac surgery. A search of Medline via Pubmed, Scopus, and Embase yielded 2,868 papers, which we reviewed and summarized the key findings. VEAs such as rotational thromboelastometry and thromboelastography provide a quick turnaround, graphical, global impression of hemostasis in whole blood. VEAs allow for the analysis of specific contributors to the coagulation process and may facilitate cause-oriented hemostatic treatment and the development of treatment algorithms. VEAs have been found to have a high specificity and high negative predictive value for coagulopathic bleeding. Patients treated with VEA-based algorithms have been shown to have lower rates of bleeding, transfusion requirements, and exposure to allogeneic blood products. However, VEA-based algorithms have not demonstrated a mortality benefit and evidence for outcomes such as surgical re-exploration and hospital length of stay remains equivocal. In conclusion, VEAs have been shown to be comparable if not superior to SLTs in cardiac surgery. Further large-scale studies are needed to better evaluate the impact of VEAs on clinical outcomes.

Keywords

viscoelastic assays - cardiac surgery - hemostasis - rotational thromboelastometry - thromboelastography

Authors' Contributions

K.R. and B.E.F. contributed to the study conception, with K.R. designing the study. The search strategy was developed by B.J.A.O. and R.R.L., while B.J.A.O., H.X.S.T., and A.T.W.F. conducted the literature review and narrative synthesis. The initial manuscript draft was prepared by B.J.A.O., H.X.S.T., A.T.W.F., and R.R.L., with all authors contributing to revisions for intellectually important content. All authors have read and approved the final draft, and B.J.A.O. and K.R. held the final responsibility for the manuscript submission.


* Contributed equally as joint first authors.




Publication History

Article published online:
12 February 2025

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