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

by Selleckchem | May 24 2023

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.

Comments：

In this single-centre, exploratory, prospective observational study, researchers aimed to investigate the incidence and degree of coagulopathy in patients undergoing cardiac valve surgery with and without infective endocarditis. The study included 31 patients with infective endocarditis and 39 patients without endocarditis. The primary outcome of the study was to compare the differences between the two groups in rotational thromboelastometry (ROTEM) results before, during, and after surgery. The secondary outcomes included the differences between the groups in heparin sensitivity, bleeding complications, and transfusion requirements.

The study found that 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, indicating increased heparin resistance. Patients with infective endocarditis had more bleeding complications, as assessed by the universal definition of perioperative bleeding score, and more patients with endocarditis underwent early re-exploration.

The study's findings suggest that patients with infective endocarditis have significantly altered coagulation profiles, with both hyper- and hypocoagulability, which may lead to increased bleeding complications and transfusion requirements. The study also highlights the potential of ROTEM to detect coagulation abnormalities in patients with infective endocarditis, which may require adjustments to existing point-of-care coagulation testing-guided algorithms for optimizing perioperative coagulation management in these high-risk patients undergoing cardiac surgery.