The Study On The Coagulation Function Anomalies For Patients With Congenital Cyanotic Heart Diseases

Objectives:In clinical practice,we find a phenomenon that the patients with cyanotic congenital heart disease usually have more risks of blood loss and embolisms than that of acyanotic patients after open heart surgery with cardiopulmonary bapss,and the APTT and PT values of cyanotic patients are also usually higher than that of acyanotic patients in routine coagulation function test before operation.For these reasons,we have a hypothesis that the coagulation function of cyanotic patients may be abnormal for hypoxia and related organ dysfunction.To prove our hypothesis,we selected two groups of patients(cyanotic group and acyanotic group) for contrast study.The followings are what we will discuss.1,Discuss the differences of coagulation function,anti-coagulation function, fibrinolysis function,and blood platelet count between cyanotic and acyanotic patients.2,Making regression analysis for parameters of coagulation function, anti-coagulation function,fibrinolysis function,and blood platelet count with blood oxygen pressure for patients with cyanotic heart diseases.3,Discuss the changes of coagulation function,anti-coagulation function, fibrinolysis function,and blood platelet count during perioperative periods.4,Analyze the blood loss after open heart surgery with cardiopulmonary bypass for patients with Fallot of Tetralogy and the effects of modified ultrafiltration and oxygenator.Methods1,Cases collectionIn our study,we adopted 69 cases of patients with cyanotic congenital heart diseases hospitalized in Nan Fang hospital from June,2006 to October,2008 for study group,and we also adopted 24 cases of patients with acyanotic congenital heart diseases as contrast group.All patients' heart function gradeⅠ～Ⅱ(NYHA),without antiplatelet agents(aspirin,et al),anticoagulation agents and hormone therapy two weeks before hospitalization.Normal liver and kidney function,without any system diseases,no history of trauma and operation.All patients were diagnosed with echocardiography or cardioangiography and proved by operation.2,Parameters collected and analyzedGeneral parameters:every patients' name,sex,age,weight,ID number,dianosis, procedure,clamp time were recorded,and oxygenator,ultrafiltration,blood loss of first day postoperation and weight averaged blood loss were recorded for patients with Fallot of tetralogy.Blood gas parameters and blood cell counting:all patients were collected artery blood for blood gas analysis and peripheral blood for routine blood test,blood gas pressure,hemoglobulin,HCT,and platelet counting were recorded.The same parameters were recorded for patients with Fallot of tetralogy on the 4^th,7^th,and 10^th day postoperation.Parameters of coagulation,anticoagulation,and fibrinolysis function:all patients received routine coagulation function,coagulation factor activities,antithrombin activity,protein C activity,fibrinogen activity,FDP,D-dimer test and coagulationⅡactivity/ATⅢration was calculated.The same parameters were recorded for patients with Fallot of tetralogy on the 4^th,7^th,and 10^th day postoperation except parameters of fibrinolysis system.ResultsPartsⅠ1,APTT and PT values of patients with cyanotic congenital heart diseases are significantly higher than that of patients in contrast group;no significant differences of TT values between two groups are not showed;Fbg content of patients with cyanotic heart diseases showed significantly lower than that of patients in contrast group.2,Coagulation factorⅡ,Ⅶ,Ⅷ,Ⅸ,Ⅹactivities are significantly lower of patients with cyanotic heart diseases than that of patients in contrast group.3,ATⅢactivities of patients with cyanotic heart diseases are significantly higher than that of patients in contrast group,well protein C activities of patients with cyanotic heart diseases are lower than that of patients in contrast group without statistics difference,coagulationⅡactivity/ATⅢration are significantly lower of patients with cyanotic heart diseases than that of patients in contrast group.4,Fibrinogen activity and FDP,D-dimer content analysis showed no statistics differences with two groups.5,Hemoglobulin and HCT are significantly higher of patients with cyanotic heart diseases than that of patients in contrast group,well platelet counting and artery blood oxygen pressure are significantly lower of patients with cyanotic heart diseases than that of patients in contrast group.6,Hemoglobulin contents are related with blood oxygen pressure and platelet counting are related with hemoglobulin for patients with cyanotic heart diseases,but platelet counting are not related with blood oxygen pressure.7,APTT values and coagulation factorⅡ,Ⅶ,Ⅷ,Ⅸ,Ⅹactivities are related with blood oxygen pressure for patients with cyanotic heart diseases,but protein C activities and fibrinogen activities are not related with blood oxygen pressure.PartⅡ1,The PT and APTT values of patients with Fallot of Tetralogy are significantly lower during postoperative periods than that before operation;the TT values are significantly lower during early postoperative periods than that before operation,well higher after 10^th day postoperation.2,The coagulation factorⅡ,Ⅶ,Ⅷ,Ⅸ,Ⅹactivities of patients with Fallot of Tetralogy are significantly higher during early postoperative periods than that before operation and decreased after one week postoperation,but still remained significantly higher than that before operation.3,The ATⅢactivities of patients with Fallot of Tetralogy are significantly higher during early postoperative periods than that before operation and decreased after 10^th day postoperation without statistics differences.Protein C activities changed similarly to that of ATⅢ.CoagulationⅡactivity/ATⅢration increased after operation and was significantly higher than that before operation.4,The platelet counting of patients with Fallot of Tetralogy decreased early after operation and increased one week later after operation;hemoglobulin and HCT are significantly lower after operation than that before operation.5,The blood losses during 1^st day after operation of patients with Fallot of Tetralogy are less than that of contrast group,but the weight averaged blood losses are significantly more than that of contrast group.6,The type of oxygenator for CPB are related with blood losses after operation, the blood losses during 1^st day and weight averaged blood losses after operation showed no significantly differences for patients using domestic membrane oxygenators and imported membrane oxygenators.For patients using bubble oxygenators,the blood losses during 1^st day after operation are significantly more than that of the patients using imported membrane oxygenators,but weight averaged blood losses after operation increase without significantly differences for patients of the contrast group.7,The blood losses during 1^st day after operation for patients with Fallot of Tetralogy are related wih ultrafiltration.For the patients accepted ultrafiltration,the blood losses are more than that of patients without ultrafiltration,but weight blood losses increased without no significant differences.Conclusions1,For patients with cyanotic congenital heart diseases,there are some coagulation function anomalies mainly about the intrinsic coagulation pathway. Usually the PT and APTT values increase significantly,but the APTT values increased more significantly.For there are no evidences of hyper fibrinlysis activities and the coagulation factors activities decreased significantly related to hypoxia,we conclude that the coagulation function anomalies are related to less coagulation factor synthesis due to hypoxia well not related to consumption of coagulation factors.2,The balance between coagulation and anticoagulation system moved to hyper anticoagulation activities for patients with cyanotic heart diseases.ATⅢis a broad-spectrum circulationary factors,whose function is to compensate the local hyper coagulation activity due to hypoxia and thicker blood.Protein C activities mainly acts as a local anticoagulation factor,whose function is to enhance the local hyper coagulation activities to ensure the complete of blood vessels.3,For patients with Fallot of Tetralogy,the coagulation function recovered after operation due to the enhanced blood oxygen pressure.During early postoperation periods,the coagulation function play more important roles than anticoagulation function does to ensure normal hemostasis procedure.But during late postopration periods,the hyper coagulation activities may cause embolisms and the patients man accept anticoagulation therapy.4,For patients with Fallot of Tetralogy,the platelet counting are less due to the higher HCT and hemoglobulin,and increased significantly higher late postoperation.This may also increase the risk of embolisms and may need some antiplatelet agents.5,The blood losses for patients with Fallot of Tetralogy are more than that of the contrast group due to coagulation function anomalies,and the selection of membrane oxygenators and modified ultrafiltration can reduce the consumption of coagulation factors,enhance the coagulation function and reduce the blood losses after operation.