血栓弹力图应用价值的再探讨──在纤溶功能测定中的意义

本文采用在血样中加入一定量尿激酶，然后测定血栓弹力图（ＴＥＧ），并与常规方法进行了比较。本组共测定正常人３４例。各种临床疾病计５０例。结果表明本文介绍方法较常现方法更能敏感反应血块纤溶状况。同时还提出血块开始溶解时间（Ｔ０），最大溶解幅度（Ｐｍａｘ）和溶解速度（Ｖ）三种新的测定参数。并对其意义进行了分析。     

Coagulation status in coronary artery disease patients with type II diabetes mellitus compared with non-diabetic coronary artery disease patients using the PFA-100® and ROTEM®

Previous investigations in patients with coronary artery disease (CAD) revealed differences in thromboelastographic parameters indicating different states of coagulability. The aim of the present study was to investigate the coagulation status of patients with documented CAD and type II diabetes mellitus (DM) and non-diabetic patients with coronary artery disease with the PFA-100® and the ROTEM®. No differences were found in platelet function as measured with collagen/epinephrine (263.6 ± 70.6 s vs. 254.6 ± 65.3 s) and collagen/ADP cartridges (105.3 ± 63.2 s vs. 90.6 ± 47.3 s) in CAD patients with DM and CAD patients without DM. Measured with the EXTEM reagent of the ROTEM®, mean maximum clot elasticity (MCE) in patients with CAD and DM (233.6 ± 86.9) was significantly longer than in CAD patients without DM (186.7 ± 54.5), (p = 0.03). A similar result was seen using the INTEM reagent; patients with CAD and DM (234.4 ± 83.9) showed a higher value for MCE than CAD patients without DM (190.8 ± 57.8) which was of borderline significance (p = 0.053). Moreover, a weak trend for higher maximum clot firmness (MCF) was seen in CAD patients with DM compared with CAD patients without DM with the EXTEM reagent (68.1 ± 7.5 vs. 63.6 ± 8.6, p = 0.08) and the INTEM reagent (68.4 ± 7.2 vs. 64.1 ± 8.2, p = 0.09). The ROTEM® analysis indicates increased coagulability in patients with coronary artery disease and diabetes mellitus compared to non-diabetic CAD patients. Moreover, the ROTEM® device seems to be an appropriate and easy-to-use tool to describe the coagulation status in these patients groups.     

体外循环术后TEG监测值与胸腔引流量和输血量的相关性研究

目的 通过血栓弹力描记图（TEG）的监测和传统凝血功能监测了解体外循环后凝血功能的改变，比较两者与术后出血量（胸腔引流量）和输血量的相关性，评估TEG在体外循环手术中的监测意义。 方法 124例病人分别在术前、肝素中和后10min、肝素中和后的3h抽血监测TEG和凝血三项（凝血酶原时间：PT，活化全血凝固时间：aPTT；纤维蛋白原：Fb）。记录病人回ICU后不同时间点的引流量以及病人总的输血量。比较病人在体外循环后凝血功能的变化，并分别作肝素中和后10min时的监测结果与不同时间点引流量和总输血量的相关性分析。 结果 ①病人的凝血功能在体外循环后都受到了明显的损害（P〈0．01）；②病人的引流量、输血量和监测值有一定的相关性，而TEG的监测值比凝血三项相关性好。 结论 TEG和凝血三项都能反映出体外循环后病人凝血功能的损伤，而TEG与术后的出血量及输血量的相关性更好，能对临床治疗起到有效的监测和一定的指导作用。     

血脂对非ST段抬高型急性冠脉综合征患者经皮冠状动脉介入术后双联抗血小板治疗残余血小板反应性的影响

目的 探讨植入药物洗脱支架的非ST段抬高型急性冠脉综合征（non-ST elevation acute coronary syndrome,NSTE-ACS）患者接受阿司匹林+氯吡格雷双抗治疗后，血脂水平对残余血小板反应性影响。方法 前瞻性招募复旦大学附属中山医院心内科2017年2月至2017年12月诊治的NSTE-ACS患者335例。所有患者行冠脉造影及支架植入术，术前给予负荷剂量氯吡格雷300 mg、阿司匹林300 mg，术后维持剂量为氯吡格雷75 mg、阿司匹林100 mg。术后第3天进行血栓弹力图检测，二磷酸腺苷诱导的血小板-纤维蛋白凝块强度（adenosine diphosphate-induced platelet-fibrin clot strength,MAADP）大于47 mm提示高残余血小板反应（high-residual platelet reactivity, HRPR）。HRPR组患者71例，non-HRPR组264例。比较两组患者间人口学特征及实验室检查指标。采用Pearson相关分析、逐步回归模型分析血脂水平对患者残余血小板反应性的影响。Kaplan-Me...     

Tailoring haemostatic treatment to patient requirements – an update on monitoring haemostatic response using thrombelastography

Summary.  Currently, there is no single haemostasis laboratory test that has the capacity to accurately illustrate the clinical effects of procoagulant or anticoagulant interventions. Although the time course of thrombin generation in plasma and the endogenous thrombin potential (ETP) may be useful coagulation parameters, clotting involves components other than thrombin (e.g. platelets, fibrinogen). The continuous coagulation profiles of thrombelastography may provide a more accurate reflection of in vivo biology, covering initiation, development and final clot strength during whole blood clot formation. This method has helped to clarify the mechanism of action of whole blood clot formation, demonstrating the differences from clotting in plasma, and the importance of platelets and tissue factor titrations. It has also been used to investigate hypocoagulation (in haemophilia A, rare coagulation disorders, anticoagulant therapy and dilutional coagulopathy), hypercoagulation and the ex vivo testing of haemostatic interventions. Thrombelastography has been shown to reflect the clinical efficacy of activated prothrombin complex concentrate (aPCC) and recombinant activated factor VII (rFVIIa) in patients with haemophilia A with inhibitors and in patients with acquired haemophilia. Overall, tailoring laboratory assays to illustrate and correlate with clinical phenotypes is essential for effective coagulation monitoring. Applying an algorithm of preoperative, perioperative and postoperative tests, including thrombelastography, may enable physicians to achieve this.     

CYP2C19基因多态性与介入治疗后氯吡格雷药物疗效的相关性研究

目的探讨PCI术后CYP2C19基因多态性与不同剂量氯吡格雷药物效果的相关性。方法通过基因芯片检测技术,筛选PCI术后CYP2C19基因突变为CYP2C19*2/*2、CYP2C19*2/*3或CYP2C19*3/*3的患者67例,随机分为常规组22例、2倍组22例和3倍组23例。常规组75 mg氯吡格雷、2倍组150 mg氯吡格雷、3倍组225 mg氯吡格雷,1次/d。分别于PCI术后1、3、6个月通过血栓弹力图检测各组氯吡格雷药物抑制率及再发心血管缺血事件发生率。结果 PCI术后6个月内,2倍组和3倍组患者心血管缺血事件发生率较常规组明显降低(81.8%vs 31.8%vs 21.7%,P<0.01),2倍组与3倍组比较差异无统计学意义(P>0.05)。术后1、3、6个月2倍组和3倍组氯吡格雷药物抑制率较常规组显著升高(P<0.01),2倍组与3倍组比较差异无统计学意义(P>0.05)。3组出血风险比较差异无统计学意义(P>0.05)。结论 CYP2C19基因变异患者增加氯吡格雷药物服用剂量,可在一定程度上提高血小板的抑制,降低心血管缺血事件发生率,且不增加出血事件的发生率。     

Low molecular weight heparin once versus twice for thromboprophylaxis following esophagectomy: a randomised,double-blind and placebo-controlled trial

Background

Venous thromboembolism (VTE) remained common complication following surgical resection of esophageal cancer. In this prospective randomized double-blind placebo-controlled trial ({"type":"clinical-trial","attrs":{"text":"NCT01267305","term_id":"NCT01267305"}}NCT01267305), we aim to compare the safety and efficacy between low molecular weight heparin (LMWH) once-daily (QD) and twice-daily (BID) for the prophylaxis of VTE following esophagectomy.

Methods

During August 2012 to July 2013, patients underwent esophagectomy were randomly assigned to nadroparin calcium QD (4,100 AxaIU qd + placebo qd, group QD), or nadroparin calcium BID (4,100 AxaIU q12h, group BID) in the prophylaxis of VTE. All patients received thrombelastography (TEG) before and 0/24/48/72 hours after operation. Daily vascular ultrasound of lower extremities was followed during the first 7 postoperative days to confirm the suspected deep venous thrombosis (DVT). Cumulatively postoperative chest drainage at 72 hours after the surgery was collected to identify the difference in volume and red blood cell (RBC) counts between the two groups. Any bleeding events and thromboembolic events were also documented.

Results

A total of 117 patients were enrolled in this study, and 111 eligible patients were randomly assigned (group QD: 55 patients; group BID: 56 patients). Patients’ clinical features were close between the two groups. TEG analysis [R time, K time, alpha angel and maximum amplitude (MA)] before and instantly after operation showed nearly identical results. However, compared with group QD, all TEG measurements of 24/48/72 hours postoperatively showed significantly prolonged R time and K time, and decreased alpha angel in group BID. In ultrasound follow-ups, a total of four cases of DVT (four cases in group QD and no case in group BID) were found in this cohort (7.27% versus 0%, P=0.046), and one case of pulmonary embolism (PE) (in group QD) was observed. The incidence of VTE was lower in group BID (9.09% versus 0%, P=0.032). At 72 hours after surgery, the cumulative volume of chest drainage were close between these two groups (1,001.39±424.58 versus 1,133.61±513.93 mL, P=0.406). RBC counts in chest drainage were also identical between two groups [(2.56±1.98)×10⁵ versus (2.71±4.67)×10⁵, P=0.61]. No patient died due to VTE or bleeding events.

Conclusions

For the prophylaxis of VTE, BID LMWH provided more potent efficacy and equal safety when compared to QD LMWH in patients undergoing selective esophagectomy. Further study based on larger population is required to confirm these findings.     

Comparison of the efficacy of two human fibrinogen concentrates to treat dilutional coagulopathy in vitro

Both congenital and acquired fibrinogen deficiency can be safely treated with administration of fibrinogen concentrate.

The aim of this study was to test the efficacy of a new fibrinogen product (Fibryga) compared to a licensed product (Haemocomplettan) in an in vitro model of dilutional coagulopathy.

Ten blood specimens from healthy volunteers were diluted 1:1 with balanced crystalloid solution and subsequently supplemented with each fibrinogen concentrate at a dose replicating in vivo supplementation (50?mg kg^?1). Changes in clot firmness (FIBTEM and EXTEM assay), as well as changes in the fibrinogen antigen level, fibrinogen activity, factor XIII level and fibronectin levels were assessed at baseline, after dilution and after adding fibrinogen concentrate.

There was no significant difference between the drugs in their in vitro ability to improve clot firmness in the FIBTEM assay (Fibryga: mean MCF 14.4?mm (SD 3.4?mm) vs. Haemocomplettan: MCF 14.1?mm (2.4); p?=?.584). Fibryga led to significantly higher clot firmness in EXTEM MCF: 56.7?mm (3.8) vs. 53.7?mm (3.7); p?p??1 (SD 0.002?g L^?1) vs. 0.002?g L^?1 (SD 0.002?g L^?1; p?This is the first study to demonstrate that Fibryga and Haemocomplettan have similar efficacy in improving clot firmness in a dilutional hypofibrinogenemia model in vitro.