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J Thorac Cardiovasc Surg 1994;107:562-0568
© 1994 Mosby, Inc.

Cardiopulmonary Bypass, Myocardial Management, and Support Techniques

Thrombin regulation in congenital heart disease after cardiopulmonary bypass operations

Hamilton and Toronto, Ontario, Canada

Supported by a grant from the Hospital for Sick Children Foundation No. XG91-003.

Received for publication Jan. 21, 1993. Accepted for publication July 7, 1993. Address for reprints: S. Turner-Gomes, MB, ChB, Department of Pediatrics, McMaster University Medical Centre, 1200 Main St. West, Hamilton, Ontario, Canada L8N 3Z5.

Abstract

Children with cyanotic congenital heart disease who undergo operation with cardiopulmonary bypass are at increased risk of thromboembolic or hemorrhagic complications, or both. Regulation of thrombin, a key enzyme in coagulation, is essential in preventing these complications. We therefore examined the in vitro capacity of plasma from 15 children with cyanotic congenital heart disease to generate thrombin and to inhibit ¹²⁵I-thrombin before and after cardiopulmonary bypass. We also assessed whether thrombin had been generated in vivo by assaying levels of fibrinogen, thrombin-antithrombin III complexes, and D-dimer. Plasma levels of the thrombin inhibitors, antithrombin III, -2-macroglobulin, and heparin cofactor II were also measured. Thrombin regulation was normal before operation. After cardiopulmonary bypass, the in vitro capacity to generate thrombin decreased by 50%, and this was primarily a result of hemodilution (31%). Similar postoperative decreases were noted in the levels of antithrombin III, heparin cofactor II, and -2-macroglobulin (26% to 45%). However, the total in vitro plasma thrombin inhibitory capacity decreased by only 13%. Levels of thrombin-antithrombin III and D-dimer increased after operation, indicating that thrombin had been generated and inhibited in vivo. Clinically, there were no thromboembolic complications although six patients required replacement therapy for excessive small-vessel bleeding. In conclusion, thrombin regulation is significantly altered after cardiopulmonary bypass. Although thrombin is generated in vivo, the total residual capacity to do so is impaired because of hemodilution. Despite a concomitant decrease in thrombin inhibitor levels, the total residual in vitro capacity of plasma to inhibit thrombin is relatively spared. This suggests that after cardiopulmonary bypass the risk of hemorrhagic complications after an additional hemostatic challenge is relatively greater than the risk of thrombotic complications. This might be reflected in the predominance of hemorrhagic complications in our patients. (J THORAC CARDIOVASC SURG 1994;107:562-8)

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