Finding a common definition of heparin resistance in adult cardiac surgery: communication from the ISTH SSC subcommittee on perioperative and critical care thrombosis and hemostasis

J Thromb Haemost. 2024 Apr;22(4):1249-1257. doi: 10.1016/j.jtha.2024.01.001. Epub 2024 Jan 11.

Abstract

Ensuring adequate anticoagulation for patients requiring cardiac surgery and cardiopulmonary bypass (CPB) is important due to the adverse consequences of inadequate anticoagulation with respect to bleeding and thrombosis. When target anticoagulation is not achieved with typical doses, the term heparin resistance is routinely used despite the lack of uniform diagnostic criteria. Prior reports and guidance documents that define heparin resistance in patients requiring CPB and guidance documents remain variable based on the lack of standardized criteria. As a result, we conducted a review of clinical trials and reports to evaluate the various heparin resistance definitions employed in this clinical setting and to identify potential standards for future clinical trials and clinical management. In addition, we also aimed to characterize the differences in the reported incidence of heparin resistance in the adult cardiac surgical literature based on the variability of both target-activated clotting (ACT) values and unfractionated heparin doses. Our findings suggest that the most extensively reported ACT target for CPB is 480 seconds or higher. Although most publications define heparin resistance as a failure to achieve this target after a weight-based dose of either 400 U/kg or 500 U/kg of heparin, a standardized definition would be useful to guide future clinical trials and help improve clinical management. We propose the inability to obtain an ACT target for CPB of 480 seconds or more after 500 U/kg as a standardized definition for heparin resistance in this setting.

Keywords: anticoagulation; cardiac surgery; cardiopulmonary bypass; heparin; resistance; sensitivity.

Publication types

  • Review
  • Practice Guideline

MeSH terms

  • Adult
  • Anticoagulants / adverse effects
  • Blood Coagulation
  • Cardiac Surgical Procedures* / adverse effects
  • Cardiopulmonary Bypass / adverse effects
  • Communication
  • Critical Care
  • Heparin / adverse effects
  • Humans
  • Thrombosis* / drug therapy
  • Thrombosis* / etiology
  • Thrombosis* / prevention & control
  • Whole Blood Coagulation Time

Substances

  • Heparin
  • Anticoagulants