J. L. Cornibe and A. H. Katz: J Extra Corpor Technol 2025, 57, 174--177 175
and pulmonary hypertension. He reported shortness of breath, and the patient had no known drug allergies. The patient also has a history of multiple ablations, bone marrow biopsy( JAK2 V6 17F mutation, 7q and 20q deletion), use of Jakafi Ò( ruxolitinib)( Incyte, Wilmington, DE, USA) for which he became intolerant, and cardiomyopathy ejection fraction( EF) of 20 %. Inpatient oncological and hematological workups occurred over several weeks preoperatively. The decision to place the patient on CPB versus an off-pump procedure was due to the need for a modified Cox-maze IV in addition to the coronary bypass grafts for multi-vessel disease.
A discussion was held with the entire operating team regarding the care plan for the patient. Coagadex Ò( Coagulation Factor X, Human)( Bio Products Laboratory Limited, a Kendrion Company, Elstree, Borehamwood, UK) was preordered and held in the pharmacy. Antithrombin III( ATIII) was prophylactically brought to the operating room for standby. An entire CPB machine and disposable set were primed and ready in the sub-sterile. Pre-operative baseline labs were white blood cell count( WBC) 25.4 10 3 / mcL, Anti-Xa < = 0.10, and PLT 582 10 3 / mcL. One unit of blood, consisting of 400 mL autologous harvest, was removed prior to the chest incision. The starting in-room baseline HCT was 36.6 %. The baseline heparin concentration( Hepcon) was 3.1 mg / kg utilizing the Medtronic Ò HMS Plus Hemostasis Management System( HMS)( Medtronic, Inc., Minneapolis, MN, USA), which was increased to a prophylactic 4.0 mg / kg. The baseline ACT was 138 s. Although an ACT > 500 s was desired, achieving the Hepcon of 4.0 mg / kg was thought to be of greater value in determining adequate anticoagulation for this patient. Additionally, a decreased dose of 5.0 g of aminocaproic acid was administered in the pump prime, down from the usual 10 g dose. A femoral arterial pressure line was also placed due to compromised left ventricle function, which was the mean arterial pressure( MAP) treated and charted for this case.
A loading dose of 34,000 units( U) heparin was given, with 10,000 U added to the CPB prime. Due to a resulting 2.5 mg / kg Hepcon, while awaiting an ACT result, an additional 10,000 U of heparin was given systemically. Pre-CPB results were HCT of 37.8 % and ACT of 503 s. CPB was initiated at a 2.2 L / min / m 2 index utilizing bicaval venous cannulae and a central aortic cannula. Terumo TM Advanced Perfusion System 1 with Xcoating TM-lined disposables( circuit, Capiox Ò iCP Centrifugal Pump, and Capiox Ò FX25 reservoir / oxygenator with integrated arterial filter)( Terumo Cardiovascular Systems Corporation, Ann Arbor, MI, USA) were utilized. Venous antegrade prime( VAP) was not completed with the intent to dilute blood volume. In addition, once on CPB, acute normovolemic hemodilution( ANH) with one liter of autologous blood was separated off the circuit via the quick prime line and replaced with PlasmalyteA. Arterial blood gases and ACTs were performed more frequently than standard protocol at 20-minute intervals. The next resulting ACT was 653 s with a Hepcon of 2.5 mg / kg, an additional 15,000 U of heparin was given. TheHCTwas31.2 %, and300mLofPlasmalyteAwasadded to decrease the HCT below 30 %. Subsequent labs showed the ACT was 983 s and Hepcon was 3.5 mg / kg, an additional 15,000 U of heparin was given. HCT was 30.6 %. Flow was increased to a 2.4 L / min / m 2 index, and the patient was maintained normothermic. Standard protocol coagulation samples were drawn to be taken to the laboratory. The command was given to cool to 34 ° C. Current lab values were ACT 900 s, Hepcon 3.5 mg / kg, and HCT 29.4 %. An additional 5000 U of heparin were given. The aortic cross-clamp was applied. Modified Del Nido cardioplegia at a ratio of 4:1, cold 5 ° C, was given with 1800 mL antegrade followed by 200 mL retrograde to achieve arrest. The previous PLT count returned at 841 10 3 / mcL. Repeat labs were drawn for confirmation and resulted in 828 10 3 / mcL. The point-of-care labs at this point revealed an ACT > 999 s, Hepcon at 2.5 mg / kg, and HCT of 27.3 %. An additional 15,000 U of heparin were given due to the low Hepcon result and lack of consistent ACTs. A subsequent dose of 300 mL cold retrograde cardioplegia was delivered 30 min after the previous dose completion. The command was given to rewarm the patient to 36 ° C. Current point of care results were ACT > 999 s, Hepcon at 4.5 mg / kg, and HCT at 27.6 %. The aortic cross-clamp was removed.
At this point, PLT aggregation was seen around the pump suction lines. Due to this occurrence, in two separate increments, the initial separated-off pump blood volume was sent to the cell saver, washed, and returned to the pump to decrease the non-RBC components. Each occurrence yielded 500 mL washed RBCs( total of 1000 mL). A dose of 5000 U heparin was given in addition to this cell saver volume. When washing the cell saver volume, an 1 = 4 inch white band of PLT aggregation was also seen at the top of the wash bowl. Additional saline wash volume and leukocyte reduction filters were utilized before returning to the CPB circuit. Cerebral saturation and the aortic line pressure( pump) stayed consistent throughout the entire case. The patient was uneventfully weaned from CPB with a CPB time of 154 min and cross-clamp time of 49 min; receiving a CABG 2, modified Cox-Maze IV, and left atrial clip. Post-CPB, the patient was slowly reversed with protamine and the resulting labs were ACT 122 s, Hepcon of 0.0 mg / kg, and HCT of 32.1 %. Coagulopathies were not observed while closing. The stable patient was transferred post-operatively to the cardiac intensive care unit on 0.06 mcg / kg / min of epinephrine, 40 ng / kg / min of Giapreza Ò( angiotensin II)( Innoviva Specialty Therapeutics Inc., in partnership with La Jolla Pharmaceutical Company, Waltham, MA, USA), and 0.02 mcg / kg / min of norepinephrine. He received one unit of cryoprecipitate several hours later due to the resulting labs of Prothrombin Time( PT) 16.8 s, Partial Thromboplastin Time( PTT) 39.2 s, and INR 1.4.
The patient developed hypotension overnight. During the early morning of post-operative day( POD) 1, a stat echocardiogram was performed, revealing a hematoma and clot on the right ventricle. Lab results were WBC 72.9 10 3 / mcL, HCT 28 %, and PLT 823 10 3 / mcL. Return to the operating room was required for emergent evacuation of hematoma and mediastinal exploration. Post-reoperative lab results were WBC 43.1 10 3 / mcL, HCT 25.7 %, and PLT 557 10 3 / mcL. Coagadex Ò was not administered in either operating room encounter. The patient was uneventfully extubated on POD2 and discharged POD11, on Jakafi Ò and Eliquis Ò( apixaban)( Bristol-Myers Squibb Company, Princeton, NJ, USA & Pfizer, Inc., New York, NY, USA).