Patients with infective endocarditis undergoing cardiac surgery have distinct ROTEM profiles and more bleeding complications compared to patients without infective endocarditis

Abstract

Background: The coagulation system is crucial in the pathogenesis of infective endocarditis and undergoes significant changes during course of the disease. However, little is known about the implications of those changes in the perioperative period. Aim of the present study was to delineate the specific coagulation patterns and their clinical consequence in patients undergoing cardiac surgery due to infective endocarditis.

Methods: In this single-centre, exploratory, prospective observational study, we investigated the incidence and degree of coagulopathy in patients with (n = 31) and without infective endocarditis (n = 39) undergoing cardiac valve surgery. The primary outcome was the differences between these two groups in rotational thromboelastometry (ROTEM) results before, during and after surgery. The secondary outcomes were the differences between the groups in heparin sensitivity, bleeding complications, and transfusion requirements.

Results: Most ROTEM parameters in EXTEM, INTEM and FIBTEM assays were significantly altered in patients with infective endocarditis. Clotting time in the EXTEM assay was significantly prolonged in the endocarditis group at all time-points, while all clot firmness parameters (A5, A10 and MCF) were significantly increased. The heparin sensitivity index was significantly lower in the endocarditis group (median index 0.99 vs 1.17s. IU-1.kg-1, p = .008), indicating increased heparin resistance. Patients with infective endocarditis had more bleeding complications as assessed by the universal definition of perioperative bleeding score (OR 3.0, p = .018), and more patients with endocarditis underwent early re-exploration (p = .018).

Conclusions: The findings of this exploratory investigation show significantly altered coagulation profiles in patients with infective endocarditis, with concomitant hyper- and hypocoagulability. Furthermore, the incidence of bleeding complications and transfusion requirements were increased in patients with endocarditis. These results show the potential of ROTEM to detect coagulation abnormalities in patients with infective endocarditis. Existing point-of-care coagulation testing guided algorithms for optimizing perioperative coagulation management possibly need to be adjusted for these high-risk patients undergoing cardiac surgery.

Fig 1. Flowchart of screening and inclusion.

Fig 2. Exemplary TEMograms of ROTEM channels EXTEM and FIBTEM.

TEMograms shown from patients with and without infective endocarditis at three time points: 1. after induction of anesthesia, 2. directly after removal of the aortic cross-clamp before protamine administration, and 3. at the end of surgery.

Fig 3. Heparin sensitivity index (HSI), comparing patients with and without infective endocarditis.

The red line indicates the median HSI in patients without IE. Numbers indicate the median HIS of the respective group.

Fig 4. Number of patients receiving transfusion and coagulation factors in patients with and without infective endocarditis.

*Indicates statistical significance. Abbreviations: RBC = packed red cells, FFP = fresh frozen plasma, Tc = thrombocytes, Fib = fibrinogen concentrate, PCC = prothrombin complex concentrate.