Objectives
To determine the onset of heparin anticoagulation, using 2 different measures of activated
clotting times (ACT), thromboelastography (TEG; R-time), and anti-Xa levels, after
administering low- (100 U/kg) and high- (300 U/kg) dose intravenous (IV) heparin to
patients undergoing transcatheter aortic valve replacement (TAVR) and cardiac surgery,
respectively.
Design
Prospective study.
Setting
Single academic institution.
Participants
Patients with normal baseline coagulation presenting for TAVR or cardiac valve surgery.
Interventions
Coagulation studies were performed at baseline, 30 seconds, 90 seconds, and 180 seconds
after IV heparin administration. The tests included iSTAT (iACT) and Hemochron ACT
(hACT), TEG R-Time, and anti-Xa levels. At the authors’ institution, anti-Xa is the
preferred measure of heparin anticoagulation when time permits. ACT, a rapid point-
of-care test, is used to assess intraprocedural anticoagulation.
Measurements and Main Results: After both low- and high-dose heparin, there are peak increases in ACT and anti-Xa
at 30 seconds, followed by a decline at 90 seconds and plateau at 180 seconds. The
TEG R-time remained elevated (>80 minutes) throughout. For TAVR cases, all anti-Xa
was >1.5 IU/mL, and was associated with an iACT >180 seconds and an hACT >200 seconds.
For cardiac valve surgery cases, all anti-Xa was >2.4 and associated with an iACT
>420 seconds and and hACT >340 seconds. Compared with hACT, iACTs were significantly
lower at all time points after low-dose heparin, but not after high-dose heparin.
Conclusions
In this pilot study, heparin anticoagulation was detected as early as 30 seconds after
IV administration, based on ACT, anti-Xa levels, and TEG R-time.
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References
- Point-of-care coagulation testing in cardiac surgery.Semin Thromb Hemost. 2017; 43: 386-396
- Anticoagulation monitoring part 2: Unfractionated heparin and low-molecular-weight heparin.Ann Pharmacother. 2005; 39: 1275-1285
- Heparin therapy during extracorporeal circulation.J Thorac Cardiovasc Surg. 1975; 69: 674-684
- Early anticoagulation peak and rapid distribution after intravenous heparin.Anesthesiology. 1988; 68: 126-129
- Is the ACT two minutes after heparin injection reliable?.Perfusion. 2011; 26: 322-326
- STS/SCA/AmSECT clinical practice guidelines: Anticoagulation during cardiopulmonary bypass.J Extra Corpor Technol. 2018; 50: 5-18
- The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical practice guidelines-anticoagulation during cardiopulmonary bypass.Ann Thorac Surg. 2018; 105: 650-662
- The clinical onset of heparin is rapid.Anesthesia Analg. 2001; 92: 1391-1395
- The truth about activated clotting time measurements.Catheter Cardiovasc Interv. 2005; 65: 338-339
- Clinical evaluation of the i-STAT kaolin activated clotting time (ACT) test in different clinical settings in a large academic urban medical center: Comparison with the Medtronic ACT Plus.Am J Clin Pathol. 2011; 135: 741-748
- Assessment of heparin anticoagulation measured using i-STAT and hemochron activated clotting time.J Cardiothorac Vasc Anesth. 2018; 32: 1603-1608
- Evaluation of a new point-of-care Celite-activated clotting time analyzer in different clinical settings: The i-STAT Celite-activated clotting time test.Anesthesiology. 2003; 99: 54-59
- Heparin and low-molecular-weight heparin: Mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy, and safety.Chest. 2001; 119 (64s-94)
- Heparin overview and issues.Pharmacotherapy. 2004; 24 (103s-7)
- Pharmacokinetics of heparin and low molecular weight heparin.Baillieres Clin Haematol. 1990; 3: 531-544
- Heparin pharmacokinetics and pharmacodynamics.Clin Pharmacokinet. 1992; 22: 359-374
- 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement.J Am Coll Cardiol. 2012; 59: 1200-1254
- Heparin administration during extracorporeal circulation. Heparin rebound and postoperative bleeding.J Thorac Cardiovasc Surg. 1979; 78: 95-102
- Point-of-care measurement of activated clotting time for cardiac surgery as measured by the Hemochron signature elite and the Abbott i-STAT: Agreement, concordance, and clinical reliability.BMC Anesthesiol. 2019; 19: 174
- Evaluation of point-of-care ACT coagulometers and anti-Xa activity during cardiopulmonary bypass.J Cardiothorac Vasc Anesth. 2020; 34: 2921-2927
- Anticoagulation management during cross-clamping and bypass.Best Pract Res Clin Anaesthesiol. 2016; 30: 359-370
- Can we rely on the activated clotting time to measure heparin anticoagulation? A clinical evaluation of two ACT monitors.J Extra Corpor Technol. 2020; 52: 212-217
- Reproducibility and variability of activated clotting time measurements in the cardiac catheterization laboratory.Catheter Cardiovasc Interv. 2005; 65: 330-337
- Activated clotting times, heparin responses, and antithrombin: Have we been wrong all these years?.Anesth Analg. 2010; 111: 833-835
- Adequate anticoagulation during cardiopulmonary bypass determined by activated clotting time and the appearance of fibrin monomer.Ann Thorac Surg. 1978; 26: 231-240
- Activated clotting time and outcomes during percutaneous coronary intervention for non-ST-segment-elevation myocardial infarction: Insights from the FUTURA/OASIS-8 Trial.Circ Cardiovasc Interv. 2015; 8e002044
- Association between maximal activated clotting time and major bleeding complications during transradial and transfemoral percutaneous coronary intervention.JACC Cardiovasc Interv. 2018; 11: 1036-1045
- A review of antithrombotic therapy for transcatheter aortic valve replacement.Postgrad Med. 2013; 125: 59-72
- Heparin detection by the activated coagulation time: A comparison of the sensitivity of coagulation tests and heparin assays.J Cardiothorac Vasc Anesth. 1997; 11: 24-28
- Quantitative measurement of heparin in comparison with conventional anticoagulation monitoring and the risk of thrombotic events in adults on extracorporeal membrane oxygenation.Intensive Care Med. 2015; 41: 369-370
- Comparison between activated clotting time and anti-activated factor X activity for the monitoring of unfractionated heparin therapy in patients with aortic aneurysm undergoing an endovascular procedure.J Vasc Surg. 2018; 68: 400-407
- Anti-Xa activity relates to survival and efficacy in unselected acute coronary syndrome patients treated with enoxaparin.Circulation. 2004; 110: 392-398
- Impact of anticoagulation levels on outcomes in patients undergoing elective percutaneous coronary intervention: Insights from the STEEPLE trial.Eur Heart J. 2008; 29: 462-471
- Usefulness of baseline activated clotting time-guided heparin administration in reducing bleeding events during transfemoral transcatheter aortic valve implantation.JACC Cardiovasc Interv. 2014; 7: 140-151
- Comparison of activated coagulation time and whole blood heparin measurements with laboratory plasma anti-Xa heparin concentration in patients having cardiac operations.J Thorac Cardiovasc Surg. 1994; 108: 1076-1082
- Low activated coagulation time during cardiopulmonary bypass does not increase postoperative bleeding.Ann Thorac Surg. 1990; 49: 440-444
- Monitoring heparin anticoagulation and its neutralization.Ann Thorac Surg. 1981; 31: 161-166
- Heparin dosing and monitoring for cardiopulmonary bypass. A comparison of techniques with measurement of subclinical plasma coagulation.J Thorac Cardiovasc Surg. 1990; 99: 518-527
- Anticoagulation monitoring during vascular surgery: Accuracy of the Hemochron low range activated clotting time (ACT-LR).Br J Anaesth. 2006; 97: 453-459
- The activated clotting time in cardiac surgery: Should Celite or Kaolin be used?.Interact Cardiovasc Thorac Surg. 2017; 24: 549-554
- Celite and kaolin produce differing activated clotting times during cardiopulmonary bypass under aprotinin therapy.Thorac Cardiovasc Surg. 1994; 42: 218-221
- Is the Kaolin or Celite activated clotting time affected by tranexamic acid?.Ann Thorac Surg. 2002; 74: 390-393
- Variability of the activated coagulation time.Anesth Analg. 1988; 67: 469-472
- Thromboelastography for the monitoring of the antithrombotic effect of low-molecular-weight heparin after major orthopedic surgery.Anatol J Cardiol. 2015; 15: 932-937
- Evaluation of a heparin monitoring protocol for extracorporeal membrane oxygenation and review of the literature.J Thorac Dis. 2019; 11: 3325-3335
- Coagulation monitoring correlation with heparin dose in pediatric extracorporeal life support.Perfusion. 2017; 32: 675-685
- Thromboelastography-based anticoagulation management during extracorporeal membrane oxygenation: A safety and feasibility pilot study.Ann Intensive Care. 2018; 8: 7
- Cartridge-based thromboelastography can be used to monitor and quantify the activity of unfractionated and low-molecular-weight heparins.TH Open. 2019; 3: e295-e305
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Published online: August 04, 2022
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