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. 2023 Apr-Jun;39(2):285-291.
doi: 10.4103/joacp.joacp_521_21. Epub 2022 Jun 15.

Detection and quantification of perioperative heparin-like effects by rotational thromboelastometry in living-donor liver transplant recipients: A prospective observational study

Khaled A Yassen  1   2 , Emad K Refaat  1 , Safaa M Helal  3 , Ahmed A Metwally  3 , Sherin D Youssef  4 , Klaus Görlinger  5
Affiliations

Detection and quantification of perioperative heparin-like effects by rotational thromboelastometry in living-donor liver transplant recipients: A prospective observational study

Khaled A Yassen et al. J Anaesthesiol Clin Pharmacol. 2023 Apr-Jun.

Abstract

Background and aims: Heparin-like effects (HLEs) can affect hemostasis during liver transplantation. The aim of this study was to assess the perioperative incidence and severity of HLE with rotational thromboelastometry (ROTEM) and activated partial thromboplastin time (aPTT).

Material and methods: ROTEM and aPTT were measured intraoperatively and on postoperative days (POD) 1, 3, and 7. HLE was identified if ROTEM INTEM/HEPTEM CT-ratio was >1.25 and severe forms of HLE when ratio was ≥2. Based on aPTT, HLE was defined when aPTT ratio was >1.25 (patient aPTT/control aPTT).

Results: Thirty-eight recipients were included. Variable degrees of HLE were detected by aPTT-ratio and INTEM/HEPTEM CT ratio. No significant correlation existed between both ratios. Based on INTEM/HEPTEM CT ratio, HLE was detected in 7/38 during anhepatic phase, 19/38 post-reperfusion, 10/38 on POD1, 4/38 on POD3, and 0/38 on POD7. Four cases of severe HLE were identified by INTEM/HEPTEM CT ratio only in the anhepatic phase. Postoperative infusion of unfractionated heparin led to mild-moderate HLE on POD1 and 3 as evident by both tests. Red blood cell and plasma transfusion were higher with severe HLE (1350 ± 191 ml and 3558 ± 1407 ml). Composite adverse outcome of any complication or death within 3 months for patients without HLE, mild-moderate HLE, and severe HLE as detected by ROTEM was 27.8%, 42.9%, and 66.7%, respectively.

Conclusion: INTEM/HEPTEM CT ratio was able to detect and quantify HLE as aPTT ratio. The ability of the INTEM/HEPTEM CT ratio to identify severe HLE earlier in the anhepatic phase needs to be studied in a larger population. HLE is self-limiting, but when identified in a severe form, it is associated with worse outcome.

Keywords: Blood coagulation; heparin-like effect; liver transplantation; thromboelastometry.

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Conflict of interest statement

KG works as the Medical Director of Tem Innovations GmbH, Munich, Germany since July 2012. All other authors reported no potential conflict of interest relevant to this article.

Figures

Figure 1
Figure 1
a) Incidence (%) and severity of HLE as detected by INTEM/HEPTEM CT ratio during and after liver transplantation. b) Incidence (%) and severity of HLE as detected by aPTT ratio during and after liver transplantation. aPTT = activated partial thromboplastin time; CT = coagulation time; HLE = heparin-like effect
Figure 2
Figure 2
Individual course of the INTEM/HEPTEM CT ratio during the perioperative period in all 38 patients included in the study. Notably, there is a misleading visual impression that the number of cases with severe HLE is only five instead of effectively six since the values for case number 9 and 23 are very similar. CT = coagulation time; HLE = heparin-like effect
See this image and copyright information in PMC

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