Review Article

Heparin resistance management during cardiac surgery: a literature review and future directions

¹ Perfusion Services, Heart Vascular and Thoracic Institute, Cleveland Clinic, PO BOX 112412, Abu Dhabi, United Arab Emirates
² Critical Care Institute, Cleveland Clinic, PO BOX 112412, Abu Dhabi, United Arab Emirates
³ Cleveland Clinic Lerner College of Medicine, Western Reserve University, 44195 Ohio, USA
⁴ Anesthesiology Institute, Cleveland Clinic, PO BOX 112412, Abu Dhabi, United Arab Emirates
⁵ Cardiothoracic Surgery Department Heart and Vascular Institute, Cleveland Clinic, PO BOX 112412, Abu Dhabi, United Arab Emirates
⁶ All India Institute of Medical Sciences, 110029 New Delhi, India
⁷ Department of Cardiac Perfusion Technology, Khyber Medical University, 25100 Peshawar, Pakistan
⁸ ECMO Task Force, Department of Health, PO BOX 5674, 20224 Abu Dhabi, United Arab Emirates

^* Corresponding author: buttsab9@hotmail.com

Received: 9 April 2024
Accepted: 18 June 2024

Abstract

Introduction: Heparin, a commonly used anticoagulant in cardiac surgery, binds to antithrombin III (ATIII) to prevent clot formation. However, heparin resistance (HR) can complicate surgical procedures, leading to increased thromboembolic risks and bleeding complications. Proper diagnosis and management of HR are essential for optimizing surgical outcomes. Methodology: Diagnosis of HR involves assessing activated clotting time (ACT) and HR assays. Management strategies were identified through a comprehensive review of the literature, including studies exploring heparin dosage adjustments, antithrombin supplementation, and alternative anticoagulants in cardiac surgery patients with HR. A thorough search of relevant studies on HR was conducted using multiple scholarly databases and relevant keywords, resulting in 59 studies that met the inclusion criteria. Discussion: HR occurs when patients do not respond adequately to heparin therapy, requiring higher doses or alternative anticoagulants. Mechanisms of HR include AT III deficiency, PF4 interference, and accelerated heparin clearance. Diagnosis involves assessing ACT and HR assays. HR in cardiac surgery can lead to thromboembolic events, increased bleeding, prolonged hospital stays, and elevated healthcare costs. Management strategies include adjusting heparin dosage, supplementing antithrombin levels, and considering alternative anticoagulants. Multidisciplinary management of HR involves collaboration among various specialities. Strategies include additional heparin doses, fresh frozen plasma (FFP) administration, and antithrombin concentrate supplementation. Emerging alternatives to heparin, such as direct thrombin inhibitors and nafamostat mesilate, are also being explored. Conclusion: Optimizing the management of HR is crucial for improving surgical outcomes and reducing complications in cardiac surgery patients. Multidisciplinary approaches and emerging anticoagulation strategies hold promise for addressing this challenge effectively.