Cardiopulmonary support and physiology
Fatal pulmonary microthrombi during surgical therapy for end-stage heart failure: Possible association with antifibrinolytic therapy

https://doi.org/10.1016/j.jtcvs.2006.01.005Get rights and content
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Background

Maintaining hemostasis in patients with end-stage heart failure undergoing cardiac surgery is always challenging. These patients have chronic hepatic insufficiency, resulting in derangement of coagulation. In addition, they are commonly receiving both systemic anticoagulation (warfarin or heparin) and antiplatelet therapy. The introduction of antifibrinolytics has had a significant effect on postoperative coagulopathy. We report fatal pulmonary microthrombi in patients receiving antifibrinolytics who developed suprasystemic pulmonary artery pressures and right heart failure that was impossible to overcome despite insertion of a right ventricular assist device.

Methods

We reviewed the surgical procedure and autopsy reports to identify patients with high pulmonary artery pressures caused by pulmonary microthrombi after a cardiac surgical procedure for end-stage heart failure. Patient demographics and preoperative, intraoperative, and postoperative variables were collected from a retrospective review of the patients’ medical records.

Results

We identified 9 patients (7 men and 2 women; mean age, 45 ± 16 years) who died of pulmonary microthrombi after cardiac surgery between January 1997 and January 2004. Surgical procedures included 5 left ventricular assist device implantations, 2 heart transplantations, and 2 left ventricular reconstructions with mitral valve repair or replacement. Eight patients received aprotinin, and 1 patient received ε-aminocaproic acid immediately before and during cardiopulmonary bypass. All patients had severe suprasystemic pulmonary artery pressures after protamine administration for heparin reversal, a complication that proved fatal in all cases. Intraoperative wedge biopsy of the lungs revealed multiple microthrombi within capillaries and in the small- and medium-sized pulmonary arterioles.

Conclusion

We report 9 cases for which fatal pulmonary microthrombi might be associated with the use of prophylactic antifibrinolytic therapy. Mortally ill patients with multiorgan failure who are receiving systemic anticoagulation and undergoing surgical procedures require careful perioperative monitoring to identify potential hazards. Anticoagulation and antifibrinolytic therapy protocols may require adjustment in such patients.

CTSNet classification

11
16
27

Abbreviations and Acronyms

ACT
activated clotting time
ATIII
antithrombin III
CPB
cardiopulmonary bypass
DIC
disseminated intravascular coagulopathy
EACA
ε-aminocaproic acid
FFP
fresh frozen plasma
IABP
intra-aortic balloon pump
kACT
kaolin-activated clotting time
KIU
kallikrein inactivation unit
LVAD
left ventricular assist device
RVAD
right ventricular assist device

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