Employing rotation thromboelastometry to analyse coagulation disturbances in congenital heart surgery

  • Dr Andreas Straub, Dept. of Thoracic, Cardiac and Vascular Surgery, University Hospital of Tübingen, Germany
  • Daniela Schiebold, Dept. of Thoracic, Cardiac and Vascular Surgery, University Hospital of Tübingen, Germany
  • Dr Hans Peter Wendel, Dept. of Thoracic, Cardiac and Vascular Surgery, University Hospital of Tübingen, Germany
  • Carole Hamilton, Dept. of Thoracic, Cardiac and Vascular Surgery, University Hospital of Tübingen, Germany
  • Dr Thomas Wagner, Dept. of Anesthesiology and Intensive Care Medicine, University Hospital of Tübingen, Germany
  • Dr Eckhard Schmid, Dept. of Anesthesiology and Intensive Care Medicine, University Hospital of Tübingen, Germany
  • Prof Gerhard Ziemer, Germany

    • Objective: Cardiac surgery employing cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) can induce a coagulopathy, which may be especially severe in infants. Patient management may be improved by quickly finding causes for coagulation disturbances peri-operatively. This study aimed to monitor coagulation defects during congenital heart surgery using rotation thromboelastometry (ROTEM®).
    Methods: Ten infants underwent surgery for congenital heart disease using CPB and DHCA. Blood was sampled at skin incision (baseline), during, and after CPB. In ROTEM® the clot amplitude at 10 minutes (A10) and clotting time (CT) were analysed with heparin-sensitive in-TEM®, heparinase-containing hep-TEM®, tissue factor-activated ex-TEM®, and fib-TEM®, which analyses the fibrin component of coagulation. Standard coagulation tests (including fibrinogen levels and platelet counts) were also performed.
    Results: The following changes occurred after CPB compared to baseline:
    In-TEM®-A10 and hep-TEM®-A10 decreased by mean±SEM 38±5% (p<0.0001) and 34±3% (p<0.0001) respectively, ex-TEM®-a10 by 27±4% (p<0.0001), and fib-TEM®-a10 by 22±11% (p=0.034). In-TEM®-CT and hep-TEM®-CT were prolonged by 214±54 sec (p=0.002) and 206±77 sec (p=0.013) respectively. These findings indicate clotting factor depletion, platelet dysfunction and exclude excessive heparin. After targeted blood product administration coagulation was satisfactory.
    Significant correlations of in-TEM®-a10 with platelet counts (r=0.63/p=0.049) and A10 changes with fibrinogen levels (r≥0.69/p≤0.026) were observed.
    Conclusions: During congenital heart surgery ROTEM® detects causes of CPB- and DHCA-associated coagulopathy. ROTEM® results are quickly available and reflect changes in plasmatic and cellular components of haemostasis. ROTEM® can thereby contribute to specific blood product treatment and may decrease bleeding complications.