The Effects of Cardiopulmonary Bypass on Platelet Aggregation and Fibrinolysis

Öz

In this study, platelet activity and fibrinolysis, which have an important role in hemostasis, were evaluated in patients undergoing off-pump and on-pump coronary bypass operation. Study was planned prospectively and a total of 22 patients who underwent coronary bypass operation were divided in two groups. 11 patients in off-pump group and 11 patients in the on-pump group were evaluated. Blood samples were taken from the patients preoperatively, 1 hour, 1 day and 4 days after surgery. t-PA, u-PA, PAI-1, t-PA/PAI-1 and D-Dimer were used to determine fibrinolytic activity, and platelet aggregation was measured to determine the degree of platelet activity. Postoperative fibrinolytic activity was higher in both groups, especially in on-pump group. Postoperative levels return to preoperative levels on the 4th day. There was no significant difference in the activity levels of platelets in both groups. It is generally considered that the risk of early postoperative thrombosis is low due to hemodilution and high-dose heparin used in on-pump surgeries. Accordingly, the use of early anticoagulants is not common. On the other hand, there is a habit of using anticoagulants in the early period in off-pump bypass surgeries. The results of our study show that the post-operative D-dimer elevation in patients using cardiopulmonary bypass shows that the risk of early thrombosis continues after the pump and, the use of anticoagulants immediately after surgery can be considered.

Anahtar Kelimeler

• Off-pump
• bypass
• platelet aggregation
• fibrinolysis
• open heart surgery.

Kardiyopulmoner Bypass’ın Trombosit Agregasyonu ve Fibrinoliz Üzerine Etkileri

Öz

Bu çalışmada, off-pump ve on-pump koroner bypass uygulanan hastalarda, prokoagülan aktivitede önemli rolü olan trombositlerin aktivite düzeyleri ve fibrinolitik aktivite değerlendirilmiştir. Çalışma, prospektif olarak planlanıp koroner bypass yapılan hastalar pompasız hasta grubunda 11 hasta, pompalı hasta grubunda 11 hasta olmak üzere, toplam 22 hasta değerlendirmeye alındı. Hastalardan ameliyat öncesi, ameliyat sonrası 1. saat, 1. gün ve 4. günde kan örnekleri alındı. Fibrinolitik aktiviteyi belirlemek için t-PA, u-PA, PAI-1, t-PA/PAI-1 ve D-Dimer, trombosit aktivitesini belirlemek için trombosit agregasyonu ölçüldü. On-pump grubunda daha fazla olmak üzere her iki grupta da ameliyat sonrasında fibrinolitik aktivite yüksek bulundu. Bu değerler ameliyat sonrası 4. günde ameliyat öncesi seviyelerine döndü. Trombosit agregasyonu her iki grupta da anlamlı bir fark göstermedi. Genellikle on-pump ameliyatlarda hemodilüsyon ve kullanılan yüksek doz heparin nedeni ile ameliyat sonrası erken tromboz riskinin düşük olduğu düşünülür. Buna bağlı olarak da erken dönem antikoagulan kullanımı yaygın değildir. Buna karşılık off-pump bypass ameliyatlarında erken dönemde antikoagulan kullanma alışkanlığı vardır. Yaptığımız bu çalışmanın gösterdiği sonuç kardiyopulmoner bypass kullanılan hastalarda ameliyat sonrası D-dimer yüksekliği erken tromboz riskinin pompa sonrası da devam ettiğini göstermektedir ve hemen ameliyat sonrası antikoagulan kullanımı düşünülebilir.

Anahtar Kelimeler

• Off-pump
• bypass
• trombosit agregasyonu
• fibrinoliz
• açık kalp ameliyatı.

Kaynakça

1. 1. Melly L, Torregrossa G, Lee T, Jansens JL, Puskas JD. Fifty years of coronary artery bypass grafting. J Thorac Dis 2018; 10(3): 1960-7.
2. 2. Sabik JF, Gillinov AM, Blackstone EH, et al. Does off-pump coronary surgery reduce morbidity and mortality? J Thorac Cardiovasc Surg 2002; 124(4): 698–707.
3. 3. Parolari A, Alamanni F, Cannata A, et al. OPCAB versus CABG: meta-analysis of currently available randomized trials. Ann Thorac Surg 2003; 76(1): 37–40.
4. 4. Plicner D, Stoliński J, Wąsowicz M, et al. Preoperative values of inflammatory markers predict clinical outcomes in patients after CABG, regardless of the use of cardiopulmonary bypass. Indian Heart J 2016; 68(3): 10-5.
5. 5. Moor E, Hamsten A, Blombäck M, Herzfeld I, Wiman B, Rydén L. Hemostatic factors and inhibitors and coronary artery bypass grafting: preoperative alterations and relation to graft occlusion. Thromb Haemost 1994; 72(3): 335–42.
6. 6. Mannucci L, Gerometta PS, Mussoni L, et al. One month follow-up of haemostatic variables in patients undergoing aortocoronary bypass surgery: effect of aprotinin. Thromb Haemost 1995; 73(3): 356-61.
7. 7. Parolari A, Colli S, Mussoni L, et al. Coagulation and fibrinolytic markers in a two-month follow-up of coronary bypass surgery. J Thorac Cardiovasc Surg 2003; 125(2): 336-43.
8. 8. Li N, Astudillo R, Ivert T, Hjemdahl P. Biphasic pro-thrombotic and inflammatory responses after coronary artery bypass surgery. J Thromb Haemost 2003; 1(3): 470-6.

9. 9. Biglioli P, Cannata A, Alamanni F, et al. Biological effects of off-pump versus on-pump coronary artery surgery: focus on inflammation, hemostasis, and oxidative stress. Eur J Cardiothorac Surg 2003; 24(2): 260-9.
10. 10. Edmunds LH Jr. Managing fibrinolysis without aprotinin. Ann Thorac Surg. 2010; 89(1): 324-31.
11. 11. Bonk R, Trowbridge C, Stammers A, et al. Soluble fibrin monomer complex and cardiopulmonary bypass. J Extra Corpor Technol 2009;41(3): 157-60.
12. 12. Hoshino K, Muranishi K, Kawano Y, et al. Soluble fibrin is a useful marker for predicting extracorporeal membrane oxygenation circuit exchange because of circuit clots. J Artif Organs 2018; 21(2): 196-200.
13. 13. Chandler WL, Velan T. Plasmin generation and D-dimer formation during cardiopulmonary bypass. Blood Coagul Fibrinolysis 2004; 15(7): 583-91.
14. 14. Chandler WL, Velan T. Secretion of tissue plasminogen activator and plasminogen activator inhibitor 1 during cardiopulmonary bypass. Thromb Res 2003; 112(3): 185-92.
15. 15. Chandler WL, Velan T. Estimating the rate of thrombin and fibrin generation in vivo during cardiopulmonary bypass. Blood 2003; 101(11): 4355-62.
16. 16. Vallely MP, Bannon PG, Bayfield MS, Hughes CF, Kritharides L. Quantitative and temporal differences in coagulation, fibrinolysis, and platelet activation after on-pump and off-pump coronary artery bypass surgery. Heart Lung Circ 2009; 18(2):123-30.
17. 17. Casati V, Gerli C, Franco A, et al. Activation of coagulation and fibrinolysis during coronary surgery: on-pump versus off-pump techniques. Anesthesiology. 2001; 95(5): 1103-9.
18. 18. Roy S, Saha K, Mukherjee K, et al. Activation of coagulation and fibrinolysis during coronary artery bypass grafting: a comparison between on-pump and off-pump techniques. Indian J Hematol Blood Transfus 2014; 30(4): 333-41.
19. 19. Hertfelder HJ, Bös M, Weber D, Winkler K, Hanfland P, Preusse CJ. Perioperative monitoring of primary and secondary hemostasis in coronary artery bypass grafting. Semin Thromb Hemost 2005; 31(4) :426-40.