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Double Blind Randomized Placebo-Controlled Trial Comparing the Effects of Anti-thrombin vs Placebo on the
Coagulation System in Infants with Anti-Thrombin Deficiency Undergoing Congenital Cardiac Surgery
Rebecca Scholl, MD1, Claudia Benkwitz, MD2, Manuel Fontes, MD3, Nirmish Shah, MD4, Robert Jaquiss, MD5, Andrew Lodge, MD5, Warwick Ames, MD1, Hercilia Homi, MD1, Kelly Machovec, MD1, Edmund Jooste, MD1
1Division of Pediatric Cardiac Anesthesia, 4Division of Hematology, 5Division of Congenital Cardiac Surgery, Duke University Medical Center, Durham, NC 27710, USA2Division of Pediatric Anesthesia, Department of Anesthesiology, Monroe Carell Jr. Children’s Hospital, Vanderbilt University, Nashville, TN 37232, USA
3Division of Cardiac Anesthesia, Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, USA
Extraordinary Care –
Through a Culture of innovation
Introduction
• Anti-thrombin III (ATIII) plays a critical role in achieving
adequate heparinization for cardiopulmonary bypass
(CPB) and preventing vascular thrombosis.
• It is recognized that neonates and infants, less than 7
months, have decreased ATIII.
• Insufficient ATIII levels in infants undergoing congenital
heart surgery may be responsible for the increased
frequency of heparin resistance, consumptive
coagulopathy from deficient anticoagulation, and
postoperative thrombotic events in this population.
Methods
• Randomized, double blinded, placebo
controlled study
• 2 academic centers
• Inclusion
• Infants < 7 months
• Cardiac surgery requiring CPB
• ATIII < 70%
• Exclusion
• < 2.5 kg
• Hereditary ATIII deficiency
• ECMO at time of surgery
• History of thrombosis
• Renal failure
• Prematurity < 37 weeks GA
• History intracranial hemorrhage
• Prior ATIII supplementation
• Prior therapeutic anticoagulant use
• Units required =
100% −𝑏𝑎𝑠𝑒𝑙𝑖𝑛𝑒 𝐴𝑇𝐼𝐼𝐼 𝑙𝑒𝑣𝑒𝑙 𝑥 % 𝑥 𝑏𝑜𝑑𝑦 𝑤𝑡
1.4
• Recorded
• Demographics
• Laboratory values
• Heparin and protamine doses
• Hemostatic agents
• Blood products administered
• Operating room times
• 24 hour chest tube output
• Occurrence of postoperative thrombosis
Table 1. Demographics and Perioperative Variables
AT Group
(n=20)
Placebo Group
(n=19)p Value
Age (days) 9.8 ± 19.7 17.2 ± 30.2 0.174
Gender (M:F) 14:06 13:06 0.915
Weight (kg) 3.4 ± 0.5 3.5 ± 0.6 0.792
Aristotle score level 0.304
Level 2 (includes Aristotle scores 6.0-7.9) 3 (15.0 %) 1 (5.3%)
Level 3 (includes Aristotle scores 8.0-9.9) 7 (35.0%) 4 (21.1%)
Level 4 (includes Aristotle scores 10.0-15.0) 10 (50.0%) 14 (61.5%)
ACT baseline (sec) 129 ± 22 120 ± 13 0.141
Pre CPB Heparin dose determined by HMS machine (U/kg) 532 ± 64 602 ± 154 0.106
ACT post heparin (sec) 740 ± 221 583 ± 127 0.041
Heparin dosing – Total on CPB (U) 4372 ± 1627 5520 ± 1924 0.055
Total CPB time (min) 185 ± 60 212 ± 66 0.186
Total Cross clamp time (min) 87.4 ± 54 101.4 ± 32 0.329
Protamine dose determined by HMS machine (mg/kg) 11 ± 7.6 9.3 ± 2.8 0.545
Protamine to chest closure time (min) 109.8 ± 56.5 105.1 ± 59 0.757
Chest Tube output (protamine time plus 24 hrs) (mls) 74.9 ± 50 138 ± 94 0.016
Exposure to any Blood products in 24h Postop (n) 6 11
Total 24h Postop Blood product unit exposures (n) 6 19 0.000003
24h Postop FFP Unit exposures (n) 1 3
24h Postop Platelet Unit exposures (n) 0 4
24h Postop Cryo-precipitate Unit exposures (n) 0 3
24 Postop Red Blood cell Unit exposures (n) 5 9
Major Adverse Events 8 8 0.894
Introduction: Anti-thrombin (AT) is crucial for heparin to be effective1
and for the prevention of thrombosis2 and levels are known to be low in
infants. We tested the hypothesis that pre cardiopulmonary bypass
(CPB) normalization of AT levels to 100% would improve anticoagulation
during CPB, attenuate activation of the coagulation cascade, as
measured by fibrin degradation products- D-Dimers, and mitigate micro-
thrombosis in the post-operative period.
Methods: This is a randomized, double blinded, placebo controlled study
in infants with AT levels less than 70% undergoing CPB at 2 academic
centers. Half were given AT (Thrombate®) to normalize to 100%
functional assay and the other half received placebo. We recorded
demographics, laboratory values, hemostatic agents, blood products
administered, operating room times, 24-hour chest tube output, and
occurrence of post-operative thrombosis. Summary statistics, pooled T-
test, Fisher exact test and Wilcoxon Rank-Sum test were performed-
Data are represented as percentage or mean +/- SD, with statistical
significance defined as p<0.05.
Results: Over a 24 month period, 223 patients were screened; 68 met
inclusion criteria, 40 were randomized, and 1 (in Placebo group) was
withdrawn during the study due to ECMO initiation in the operating room.
Thirty percent of screened patients had AT levels <70%. Table 1 shows
demographic and peri-operative variables. Notable differences were
observed between the two groups including higher first post-heparin
activated clotting time (ACT) and AT levels in the treatment group. Table
2 shows Laboratory results. No differences were noted between the 2
groups with CPB circuit red blood cell and FFP prime usage, or
intraoperative blood, platelet, cryoprecipitate, recombinant Factor VIIa
and Prothombin Complex Concentrate usage. Significantly, 24 hours
post-operative chest tube output, overall blood product transfusions and
D-Dimer production were all lower in the AT group. No difference in
major adverse events (significant bleeding, stroke, allergic reaction,
ECMO initiation, chest exploration or death) was noted.
Conclusion:
Replacement of AT improves anticoagulation during CPB without
increased rates of bleeding or adverse events. Furthermore our results
suggest extension of these beneficial effects into the postoperative
period, reflected by significantly less postoperative bleeding and
transfusions, and generation of D-Dimers. We conclude that treatment of
low AT levels with exogenous AT is helpful in infants undergoing cardiac
surgery on CPB.
Results
• 24 month period, screened 223 patients
• 30% patients had ATIII <70% (68 met inclusion criteria)
• 40 randomized (1 placebo group withdrawn due to
ECMO initiation in OR)
• Demographics and Perioperative Variables (Table 1)
• Treatment group demonstrated higher:
• First post-heparin activated clotting time (ACT)
• ATIII levels (persisted into early ICU stay)
• Measured sensitive biomarkers for ongoing coagulation and
fibrinolytic system activation (Table 2)
• No differences:
• CPB circuit RBC and FFP prime usage
• Intraoperative blood, platelet, cryoprecipitate,
recombinant Factor VIIa and Prothrombin
Complex Concentrate usage
• Significant differences: Treatment group showed lower:
• 24 hour postoperative chest tube output
• Overall blood product transfusion
• D-dimer production
• POD 4: reflecting attenuation of coagulation
cascade during CPB resulting in less
fibrinolysis
• No difference
• Major adverse events: Significant bleeding, stroke,
allergic reactions, ECMO initiation, chest
exploration or death.
Table 2. Study Lab Values
Time Point ATIII Group (n=20)Placebo Group
(n=19)p Value
ATIII functional assay (%) T1 (Baseline) 54 ± 12 54 ± 13 0.982
ATIII functional assay (%) T2 (30 min after study drug) 99 ± 19 49 ± 16 <0.0001
ATIII functional assay (%) T3 (30 min on CPB) 83 ± 20 55 ± 27 0.0007
ATIII functional assay (%) T4 (just prior to coming off CPB) 87 ± 34 63 ± 28 0.048
ATIII functional assay (%) T5 (Arrival in ICU) 82 ± 18 63 ± 19 0.003
ATIII functional assay (%) T6 (POD 2) 58 ± 15 57 ± 14 0.84
ATIII functional assay (%) T7 (POD 4) 70.7 ± 20 66 ± 17 0.475
D Dimer (mcg/ml) T1 (Baseline) 1.2 ± 0.8 1.3 ± 0.8 0.855
D Dimer (mcg/ml) T5 (Arrival in ICU) 1.0 ± 0.9 1.3 ± 1 0.225
D Dimer (mcg/ml) T6 (POD 2) 1.5 ± 1 2.3 ± 2 0.313
D Dimer (mcg/ml) T7 (POD 4) 3.6 ± 1.7 6.8 ± 4.2 0.008
Conclusion
• ATIII replacement to 100%
• Improved anticoagulation during CPB
• No increased rates of intraoperative bleeding or
adverse events
• Beneficial effects persisted in postoperative period
• Less bleeding
• Decreased blood product transfusion
• Reduced fibrinolysis (D-Dimers)
• Normalization of ATIII with exogenous AT is helpful in
infants undergoing cardiac surgery on CPB.
Results represented by Mean ± SD. HMS machine – Hemostasis Management System machine; CPB – cardiopulmonary bypass; AT – Anti-Thrombin; Postop -
Postoperative
Purpose
• Normalization of ATIII levels to 100% pre
cardiopulmonary bypass in infants undergoing
congenital cardiac surgery would result in:
• Improved anticoagulation for CPB
• Decreased total heparin and protamine
dose
• Less intraoperative bleeding due to
attenuation of coagulation cascade
• Decreased thrombosis in postoperative
period