Contemporary Reviews in Cardiovascular Medicine

Pathophysiology of Bleeding and Clotting in the Cardiac

Surgery Patient
From Vascular Endothelium to Circulatory Assist Device Surface
Hardean E. Achneck, MD; Bantayehu Sileshi, MD; Amar Parikh, BA; Carmelo A. Milano, MD;
Ian J. Welsby, MD; Jeffrey H. Lawson, MD, PhD

C linicians are faced with the challenge of navigating the

precarious balance between bleeding and clotting. Bleeding
disorders or failure to obtain adequate hemostasis during surgery
may lead to severe hemorrhage. However, if thrombotic com-
plications occur (eg, thromboembolic stroke), they may be far
more difficult to treat. To achieve a stable equilibrium between
bleeding and clotting, the treating physician should have a
fundamental understanding of coagulation biology.
In this article, we review the physiological role of the vascular
endothelium in maintaining an antithrombogenic environment at
baseline and a prothrombotic state after injury. Commonly used
hemostatic and anticoagulant drugs and their mechanism of
action are examined in this context. This is followed by a review
of the most common inherited and acquired bleeding and
clotting disorders, as well as the mechanism by which they lead
to defects in coagulation biology. The approach to a bleeding
patient is then discussed, including the interpretation of the most
frequently used coagulation tests. Finally, we analyze mechan-
ical assist device therapy as an extreme case of an acquired
bleeding and clotting diathesis.
Coagulation Cascade
The concept of blood coagulation dates back to the 1960s, when
Davie, Ratnoff, and Macfarlane published articles in Nature and
Science outlining the fundamental principle of a cascade of
proenzymes activated through proteolytic cleavage that in turn
activate downstream enzymes.1,2 Schematically, the coagula-
tion system is divided into the extrinsic and intrinsic pathways
(Figure 1 and Movie I in the online-only Data Supplement). The
extrinsic pathway is triggered in response to tissue trauma and is
initiated with exposure of tissue factor. The role of the intrinsic
pathway is less clear in vivo but becomes important when the
blood is activated via contact with artificial surfaces, such as a
cardiopulmonary bypass circuit or a mechanical circulatory
assist device (MCAD).3
These pathways are interconnected on many levels and
converge at the prothrombinase complex, which consists of
factors Xa and Va bound together by calcium ions on a
phospholipid membrane. The prothrombinase complex con-
verts prothrombin (factor II) to thrombin (factor IIa). Throm-
bin activates factor XIII to XIIIa, which stabilizes the fibrin
clot by covalently cross-linking fibrin.
Endothelium as Modulator of Anticoagulation
and Coagulation
Anticoagulation
The endothelium is in direct contact with blood and modu-
lates both anticoagulation and coagulation. In its healthy
state, it exhibits antiplatelet, anticoagulant, and fibrinolytic
properties (Figure 2 and Movie II in the online-only Data
Supplement).
Antiplatelet Properties of the Endothelium
There are 2 independent pathways of platelet activation. The
first is a tissue factor dependent pathway, in which consti-
tutively expressed tissue factor on the vessel wall is activated
by disulfide isomerases, subsequently leading to thrombin gen-
eration. Thrombin then cleaves the platelet thrombin receptor
Par4, activating platelets. This pathway does not require disrup-
tion of the endothelium. The second pathway is dependent on the
exposure of subendothelial matrix proteins after endothelial
disruption. The exposed collagen interacts with platelet glyco-
protein VI, von Willebrand factor (vWF), and glycoprotein
1b-V-IX, leading to platelet capture and activation.4,5
Moreover, adenosine diphosphate (ADP) activates platelets
through binding to the platelet surface receptors P2Y1 and
P2Y12. This enables platelet aggregation and adhesion to
subendothelial structures via fibrinogen, fibrin, vWF, and vitro-
nectin. ADP also triggers the release of the contents stored in
and dense granules. The endothelium expresses ectonucleotidase
enzymes that degrade ADP by dephosphorylation. Furthermore,
endothelial cells synthesize and release nitric oxide, which
inhibits platelet adhesion and acts synergistically with prostacy-
clin to inhibit platelet aggregation (Figure 2).6
Antiplatelet Drugs
Common antiplatelet agents can be grouped into 3 categories:
aspirin, glycoprotein IIb/IIIa inhibitors, and P2Y12 antago-

From the Departments of Surgery (H.E.A., B.S., A.P., J.H.L.), Cardiovascular and Thoracic Surgery (C.A.M.), Anesthesiology and Critical Care
(I.J.W.), and Pathology (J.H.L.), Duke University Medical Center, Durham, NC.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/122/20/2068/DC1.
Correspondence to Dr Hardean E. Achneck, Department of Surgery, Box 2622, Duke University Medical Center, Durham, NC 27710. E-mail
hardean.achneck@duke.edu
(Circulation. 2010;122:2068-2077.)
2010 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.110.936773

2068
Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015
 Achneck et al
Figure 1. Coagulation cascade. The extrinsic and intrinsic path-
ways serve to activate factor X to Xa, a component of the pro-
thrombinase complex (factors Xa and Va also bound together
by Ca2 on phospholipid [PL]) that converts prothrombin (factor
II) to thrombin (factor IIa). Thrombin activates factor XIII to XIIIa,
which stabilizes the fibrin clot by covalently cross-linking fibrin.
The clotting cascade is balanced by the fibrinolytic system,
which culminates in the conversion of plasminogen to plasmin.
All coagulation factors evaluated through the partial thrombo-
plastin time are represented by transparent ovals, and all factors
assessed through the PT are represented by colored ovals.
Half-colored ovals indicate that partial thromboplastin time and
PT both measure the function of these specific coagulation fac-
tors. tPA indicates tissue plasminogen activator.
nists. Aspirin irreversibly acetylates the catalytic site of
cyclooxygenase-1, the enzyme necessary for the processing
of thromboxane A2. Because aspirin has not been associated
with increased bleeding after surgery and may improve
outcome after cardiac surgery, it should be continued
perioperatively.7
The glycoprotein IIb/IIIa inhibitors ReoPro (abciximab),
Integrilin (eptifibatide), and Aggrastat (tirofiban) are intrave-
nous agents that block aggregation of activated platelets.
They are commonly used in the setting of acute coronary
syndromes and percutaneous coronary intervention. In con-
trast, Plavix (clopidogrel), Ticlid (ticlopidine), and, more
recently, Effient (prasugrel), as well as the soon-to-be-
released drug Brilinta (ticagrelor), are oral agents that prevent
platelet thrombus formation by inhibiting the ADP receptor
P2Y12.8 Prasugrel appears to be more potent and is associ-
ated with more surgical bleeding than clopidogrel, whereas
ticagrelor is associated with less surgical bleeding.9,10 Abcix-
imab, clopidogrel, ticlopidine, and prasugrel bind irreversibly
to platelets, requiring de novo repopulation of the circulating
Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015
Pathophysiology of Bleeding and Clotting 2069
platelet pool by the bone marrow to recover effective platelet
function. The drug dose given, bone marrow turnover, and
size of the circulating platelet pool (itself related to patient
size and platelet count) may explain the interpatient variabil-
ity of the recovery of platelet function. Transfusion of
multiple platelet units may be required to achieve hemostasis
after cardiopulmonary bypass.
Reversible receptor binding is seen with the glycoprotein
IIb/IIIa inhibitors eptifibatide and tirofiban (both of their
half-life periods are 2 hours, with recovery of platelet
function occurring 4 to 8 hours after discontinuation) and the
P2Y12 receptor antagonist ticagrelor (half-life of 7 to 8 hours
and recovery of platelet function after 12 hours). The elimi-
nation half-life of these drugs is important to consider
because free drugs will bind to and inhibit transfused or
native platelets. All approved agents are cleared renally, and
renal impairment approximately doubles the time until plate-
let function recovery. Even though the not-yet-approved drug
ticagrelor is cleared mainly through the liver, it has been
associated with an increase in creatinine and should be
avoided in patients with renal dysfunction.10,11
Anticoagulant Properties of the Endothelium
The endothelial surface is coated with heparin-like glycos-
aminoglycans, which act as cofactors in stimulating anti-
thrombin to inactivate thrombin. Antithrombin also inhibits
factors VIIa, IXa, Xa, and XIa. The administration of heparin
(eg, during cardiopulmonary bypass) takes advantage of this
mechanism by augmenting the inhibitory action of antithrom-
bin. In patients who appear unresponsive to high doses of
heparin, antithrombin deficiency should be suspected.
Thrombomodulin and the recently characterized Z-dependent
protease inhibitor are part of 2 other important anticoagulant
systems of the endothelium described in more detail in Figure
2. In addition, tissue factor pathway inhibitor suppresses the
extrinsic pathway (see below) by directly inhibiting factor Xa
and the tissue factor/VIIa catalytic complex.12
Antifibrinolytic Properties of the Endothelium
Tissue plasminogen activator is constitutively synthesized
and released from endothelium. Tissue plasminogen activator
catalyzes the proteolytic cleavage of plasminogen to plasmin,
which then degrades fibrin.
Antifibrinolytic Drugs
Pharmacological agents used to inhibit conversion of plas-
minogen to plasmin include the lysine analogs Amicar
(-aminocaproic acid) and Cyklokapron (tranexamic acid).
Trasylol (aprotinin) acts by inhibiting plasmin and was used
extensively in cardiac surgery until its recent withdrawal
from the US market.13
Coagulation
Injured endothelial cells quickly become prothrombotic. Ac-
tivated platelets and damaged endothelial cells provide a
platform of negatively charged phospholipids, which bind
coagulation factors and convert inactive zymogens to their
active serine proteases. In addition, endothelial cells release
stored vWF, which promotes platelet adhesion to subendo-
thelial collagen via the platelet surface glycoprotein Ib. This
2070 Circulation November 16, 2010

Figure 2. Anticoagulatory features of vascular endothelium. Left to right, Thrombomodulin (TM) binds thrombin (T) and prevents it from
cleaving fibrinogen. It simultaneously activates the zymogen protein C to its activated form (aC), and, together with protein S (S),
degrades the phospholipid membrane bound coagulation factors Va and VIIIa. The endothelial surface is also coated with heparin-like
glycosaminoglycans, which act as cofactors in stimulating antithrombin (AT) to inactivate thrombin (T). Similarly, heparin cofactor II (HC
II) inhibits thrombin (T). Ectonucleotidase enzymes (E) on the endothelial plasma membrane degrade ADP, thereby inhibiting platelet
aggregation and activation. The endothelium also releases prostacyclin (PGI2) and nitric oxide (NO), both of which act synergistically to
inhibit platelet aggregation. Annexins (eg, annexin 5 [annexin V]), are nonglycosylated proteins that bind to membrane phospholipids in
a Ca2-dependent fashion and displace coagulation factors in addition to reducing platelet adhesion. Tissue factor pathway inhibitor
(TFPI) inhibits tissue factor (TF) and factor VIIa in the presence of factor Xa. Z-dependent protease inhibitor (ZPI) is a recently described
glycoprotein, which, in the presence of protein Z and Ca2, inhibits factor Xa on the endothelial phospholipid surface. In the absence of
cofactors, ZPI can also inhibit factors IXa and XIa. Tissue plasminogen activator (tPA) is released and catalyzes the proteolytic cleavage
of plasminogen to plasmin, which in turn degrades fibrin.

mechanism is taken advantage of clinically when desmopres-
sin (1-deamino-8-D-arginine vasopressin), a synthetic analog
of arginine vasopressin, is administered to a bleeding cardiac
patient. It causes a rapid elevation of plasma levels of vWF by
stimulating its release from Weibel-Palade bodies in endo-
thelial cells and increases levels of factor VIII.14 After injury,
endothelial cells also cease expressing antithrombogenic
molecules, such as thrombomodulin, but secrete tissue factor
(thromboplastin). This activates the extrinsic clotting path-
way and plasminogen activator inhibitor type I, which indi-
rectly slows fibrin degradation.
Inherited and Acquired Bleeding and
Clotting Disorders
Inherited Bleeding Disorders
Von Willebrand Disease
Von Willebrand disease (vWD) is the most common inherited
bleeding disorder and affects up to 1% of the population. It
Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015
results from mutations that directly hinder the synthesis and
function of vWF. vWD may also be an acquired disorder and
has been associated with antibody formation, proteolysis,
increased factor clearance, and, most notably, decreased
synthesis or degradation, resulting from increased shear stress
in patients with aortic valve stenosis (see below).15
In addition to platelet adhesion and aggregation, vWF also
acts as a carrier protein for factor VIII, which would other-
wise have a greatly shortened half-life. vWF is synthesized by
megakaryocytes and endothelial cells and circulates as a
series of high-molecular-weight multimers. Patients with
vWD generally suffer from prolonged bleeding time, al-
though the severity and location of the bleeding varies with
the specific type of vWD.
Hemophilias
Hemophilia A and B are X-linked recessive inherited bleed-
ing disorders. Hemophilia A is marked by factor VIII defi-
ciency, whereas hemophilia B is characterized by a lack of
 Achneck et al
factor IX. In mild to moderate forms of the disease, patients
have 1% to 5% of normal factor activity, and in severe forms
patients have 1% of the normal factor concentration.16 The
combined incidence rate of both types is 1 in 5000 male
births.
Acquired Bleeding Disorders
Vitamin K Deficiency
Vitamin K is essential for the synthesis of factors II, VII, IX,
and X. Deficient states of vitamin K (eg, secondary to
malabsorption syndromes) therefore increase patients bleeding
tendencies. Coumadin (warfarin) inhibits vitamin K epoxide
reductase, which is necessary to recycle vitamin K to its
reduced state. Only in its reduced state can vitamin K participate
in the vital carboxylation of glutamic acid residues of the
coagulation factors II, VII, IX, and X in the liver.17
Liver Disease
Because the liver is responsible for synthesizing most coag-
ulation factors, hypoperfusion (shock liver) or advanced
liver disease decreases circulating procoagulant factors, re-
flected in a prolonged prothrombin time (PT).
Intraoperative Metabolic Abnormalities
Clinicians must also consider hypothermia, acidosis, anemia,
and hypocalcemia. Hypothermia has been shown to inhibit
coagulation enzymes, decrease platelet count and function,
and stimulate fibrinolysis, whereas acidosis impedes fibrin
polymerization. Anemia further aggravates bleeding diathesis
because red cells are thought to assist in platelet margination
against an injured vessel wall.18 Hypocalcemia from citrate
toxicity in massively transfused patients must be corrected to
permit enzymatic reactions of the coagulation cascade.
Disseminated Intravascular Coagulation
Initiated by massive tissue destruction and endothelial injury,
disseminated intravascular coagulation leads to the release of
tissue factor, which triggers widespread thrombus formation
in the microcirculation. This further exacerbates endothelial
injury by depleting coagulation factors and platelets while
also activating the fibrinolytic system, resulting in a con-
sumptive coagulopathy. Fragmentation of erythrocytes gen-
erates schistocytes and hemolysis. Elevated D-dimers, throm-
bocytopenia, a prolonged PT, partial thromboplastin time,
and thrombin time, and decreased fibrinogen levels are
typically noted.
Inherited Clotting Disorders
The most common inherited thrombophilias are mutations in
the factor V gene, also know as factor V Leiden, and a
G20210A mutation in the prothrombin gene. Predominantly
found in whites with a prevalence of 5% to 8% in most
European studies, factor V Leiden renders factor V resistant
to degradation by activated protein C and is associated with
20% to 40% of all venous thromboses.19,20 Found in 2% of
the white population, the prothrombin 20210A variant in-
creases plasma prothrombin concentration, thereby increasing
the risk of thromboembolic events.
Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015
Pathophysiology of Bleeding and Clotting 2071
Hyperhomocysteinemia
Hyperhomocysteinemia constitutes a risk factor for athero-
sclerosis and possibly thrombotic events. The enzyme meth-
ylenetetrahydrofolate reductase reduces 5,10-methylenetetra-
hydrofolate to 5-methyltetrahydrofolate, which is used to
convert homocysteine to methionine. The C677T mutation of
methylenetetrahydrofolate reductase causes a mild enzymatic
dysfunction, and a coinheritance of MTHRF mutation with
factor V Leiden is associated with an increased incidence of
venous thromboembolism.21
Protein C and Protein S Deficiency
Other less common inherited causes of thrombosis include
deficiencies in protein C and protein S and, rarely, antithrombin.
Acquired Clotting Disorders
Most cases of thromboembolism occur when a patient with 1
or more predispositions to clotting suffers a precipitating
event. Such events include surgery, trauma, immobilization
after surgery, pregnancy and the puerperium, neoplasia,
myeloproliferative disorders, and use of contraceptives or
hormone replacement therapy.
Antiphospholipid Syndrome
Second to smoking, the most common acquired thrombo-
philia is antiphospholipid syndrome, in which autoantibodies
(anticardiolipin antibodies or lupus anticoagulant) that recog-
nize anionic phospholipids can inhibit protein C and protein
S, as well as activate prothrombin.22 This acquired disorder
predisposes affected patients to venous as well as arterial
thromboses and often manifests as repeated miscarriages.
Paradoxically, it is noted by an abnormally elevated partial
thromboplastin time in conjunction with a normal PT due to
a selective in vitro effect of the antibodies. The diagnosis of
antiphospholipid syndrome can be confirmed with special-
ized lupus anticoagulant panels.
Heparin-Induced Thrombocytopenia
Heparin-induced thrombocytopenia type II is mediated by
antibodies to a combined heparin/platelet factor 4 antigen
capable of activating platelets. In contrast to heparin-induced
thrombocytopenia type I, which causes a transient mild
thrombocytopenia, heparin-induced thrombocytopenia type II
may also lead to thrombosis; it is then referred to as
heparin-induced thrombotic thrombocytopenia. The treatment
of heparin-induced thrombotic thrombocytopenia requires
cessation of all heparin exposure and initiation of an alterna-
tive anticoagulant; the direct thrombin inhibitors argatroban
and bivalirudin are typically used.
Practical Considerations of Antithrombotic Therapy
Many patients who present for cardiac surgery are likely to
have received anticoagulation therapy for prophylaxis or
treatment of venous thromboembolism, atrial fibrillation,
prosthetic valves, acute coronary syndrome, or heparin-
induced thrombocytopenia.
Before choosing a specific agent for anticoagulation, the
physician must answer 4 crucial questions: (1) How can this
particular drug be reversed? (2) If no effective reversal agent
exists (as is the case for most of these drugs), should surgery
be delayed until the effect has cleared? (3) If no antidote
2072 Circulation November 16, 2010

Table. Characteristics of Important Anticoagulants

Mechanism Elimination Current FDA
of Action Route Half-Life Clearance Approval Cautions Reversal Agent
Enoxaparin Low-molecular- Subcutaneous 4.57 h; FXa Liver, 10% VTE prophylaxis, Hepatic impairment Protamine 1 mg,
weight heparin activity persists renal treatment of DVT partial reversal,
anti-FXa, anti-FIIa for 12 h after a and PE, treatment of not cleared by
prophylactic dose NSTEMI hemodialysis
Fondaparinux Anti-FXa synthetic Subcutaneous 1721 h Renal VTE prophylaxis, Hepatic impairment, Probably
oligosaccharide treatment of DVT renal impairment, removed by
and PE advanced age, hemodialysis
small size
Bivalirudin Direct thrombin Intravenous 25 min; 57 min if Enzymatic 80%, Anticoagulation for Renal impairment, Probably
inhibitor CrCl 30 mL/h renal 20% PCI with or without hypothermia removed by
and 3.5 h if HIT hemodialysis
ESRD
Argatroban Direct thrombin Intravenous 3951 min; 118 Liver Prophylaxis or Hepatic impairment 20% cleared by
inhibitor min with hepatic treatment of hemodialysis
impairment thrombosis or PCI
in patients at risk
of HIT
Dabigatran Direct thrombin Oral 1214 h after 80% excreted Approved in Europe Not recommended Probably
inhibitor multiple doses renally and Canada for VTE if CrCl 30 mL/min removed by
prophylaxis hemodialysis
Rivaroxaban Direct FXa Oral 59 h 36% excreted Approved in Europe Not recommended Unlikely to be
inhibitor renally and Canada for VTE if CrCl 30 mL/min removed by
prophylaxis hemodialysis
Apixaban Direct FXa Oral 815 h 25% excreted Not yet approved for Currently under Unlikely to be
inhibitor renally commercial use investigation removed by
hemodialysis
FXa indicates factor Xa; FIIa, factor IIa; VTE, venous thromboembolism; DVT, deep venous thrombosis; PE, pulmonary embolism; NSTEMI, nonST-segment elevation
myocardial infarction; CrCl, creatinine clearance; ESRD, end-stage renal disease; PCI, percutaneous coronary intervention; and HIT, heparin-induced thrombocytopenia.

exists and surgery is delayed, what is the drugs half-life of
elimination? (4) How is the particular agent cleared? Cardio-
genic shock, for instance, reduces renal clearance, thus
prolonging the effect of drugs that are cleared renally. For
emergent cases and in the setting of intractable bleeding,
increasing clearance of particular drugs with hemofiltration,
hemodialysis, or plasmapheresis and increasing thrombin
generation with recombinant activated factor VII or pro-
thrombin complex concentrates should be considered for
rescue therapy.23 The individual features of antithrombotic
agents are detailed in the Table.
Intravenous unfractionated heparin therapy is familiar to
most clinicians and is rapidly reversible with protamine
sulfate. Low-molecular-weight heparin is much less likely to
induce heparin-induced thrombocytopenia than unfraction-
ated heparin and is dosed subcutaneously as a fixed dose by
body weight, but its clearance is dependent on renal function,
and it is only partially reversed by protamine. Low-
molecular-weight heparin therapy can lead to perioperative
hemorrhage and ideally should be discontinued 24 hours
before cardiac surgery.24 Bivalirudin and argatroban are
direct thrombin inhibitors used for the treatment of heparin-
induced thrombocytopenia; bivalirudin is approved by the US
Food and Drug Administration for use during percutaneous
coronary intervention. Recent data suggest that fondaparinux
is also safe for venous thromboprophylaxis and the treatment
of heparin-induced thrombocytopenia, but a prolonged half-
life and dependence on renal elimination warrant caution for
Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015
perioperative use.25 Newly developed oral agents such as
apixaban and rivaroxaban are nearing approval in the United
States and are also included in the Table.
Approach to the Patient With a
Bleeding Diathesis
The fundamental causes of abnormal bleeding are failures in
primary hemostasis (platelet inhibition/dysfunction, thrombo-
cytopenia, and vWD), failure to generate thrombin (proco-
agulant factor deficiency), and failure to form a stable fibrin
clot (hypofibrinogenemia or dysfibrinogenemia and exces-
sive fibrinolysis). We will briefly discuss the PT, activated
partial thromboplastin time (aPTT), mixing studies, and
platelet function testing such as thromboelastography as some
of the most important diagnostic tests available to the cardiac
surgeon and anesthesiologist.
PT and aPTT
The PT indicates the relative functionality of the extrinsic and
common pathways by timing how long it takes plasma to clot
after the addition of tissue factor. It is markedly prolonged in
the absence of vitamin K and is dependent on factors II, V,
VII, and X. On the other hand, aPTT measures the effective-
ness of the intrinsic and common pathways. The test is
partial because of the absence of tissue factor from the
method of testing. In the following section, we will discuss a
systematic approach to the interpretation of these coagulation
tests (Figure 3).
 Achneck et al Pathophysiology of Bleeding and Clotting 2073

Figure 3. Systematic diagnostic approach to bleeding diathesis. To diagnose the cause of a bleeding diathesis, we recommend a sys-
tematic approach, initiated with the evaluation of platelet (PLT) count and PT/aPTT, before proceeding to further tests, such as fibrino-
gen levels, mixing studies, platelet function analysis (PFA), and/or platelet aggregation tests. DIC indicates disseminated intravascular
coagulation.

Bleeding With Normal PT and aPTT
If PT, aPTT, and platelet count are normal in a patient with a
history of mucocutaneous bleeding, then primary hemostasis
should be investigated (eg, with the platelet function analyzer
PFA-100 [Dade Behring, Inc, Deerfield, Ill], which can also
screen for vWD).26 Specifically, testing platelet aggregation/
function and analyzing platelet morphology are necessary to
single out rare cases of inherited disorders of platelet func-
tion, including Bernard-Soulier syndrome, Glanzmann
thrombasthenia, and the various storage pool diseases, in
addition to antiplatelet drug effects.
Bleeding With Abnormal PT or aPTT
A normal PT and prolonged aPTT are indicative of a problem
with the intrinsic pathway (factors XI, XII, VIII, IX), whereas
a prolonged PT and normal aPTT indicate a disorder of the
extrinsic pathway, most likely a result of reduced factor VII
from Coumadin therapy, vitamin K deficiency, and liver
disease. It should be noted that vitamin K deficiency and liver
disease can present with elevation of both PT and aPTT.
When a patient presents with prolonged PT and aPTT but
normal platelet count and function, the physician should rule
out a fibrinogen abnormality by measuring the thrombin time
or testing for D-dimers and other fibrin degradation prod-
ucts.27 Fibrinogen levels need to be 80 mg/dL in order to be
the sole cause of a prolonged PT and aPTT. Generalized
Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015
reduction in procoagulant factor concentration with a mixed
PT/aPTT pattern can be the result of a long cardiopulmonary
bypass run.
Mixing Studies
Diagnosis of Coagulation Factor Deficiency
To perform a mixing study, the patients blood sample is
mixed with pooled normal plasma in vitro, and the coagula-
tion screen is repeated. If the assay is normal after mixing,
then a coagulation factor deficiency can be diagnosed. For
preoperative diagnostic purposes, the specific factor defi-
ciency can be sought by serially adding patient plasma to
factor-deficient plasma. The plasma deficient in the same
factor as the patient will be the only one not to correct the
clotting time. Liver disease and vitamin K deficiency lead to
a marked decrease in the synthesis of prothrombin (factor II)
and factors VII, IX, and X. Factor V production, however, is
independent of vitamin K, and therefore a deficiency of this
factor indicates a hepatic synthetic dysfunction. The exact
biosynthetic origin of factor VIII is still a matter of debate,
and the extent to which factor VIII is generated in hepatocytes
versus endothelium is not clear.28 Factor VIII is elevated in
hepatic necrosis and reduced in disseminated intravascular
coagulation (secondary to thrombin-induced proteolysis by
activated protein C). An isolated factor VIII deficiency rules
out vitamin K deficiency and liver disease.
2074 Circulation November 16, 2010
Diagnosis of Coagulation Factor Inhibitor
If the assay remains abnormal after mixing, then an inhibitor
of coagulation is present. Immediate acting inhibitors include
lupus anticoagulants that recognize phospholipid-protein co-
factors. A longer incubation of up to 2 hours may be
necessary for slower binding inhibiting antibodies to recog-
nize coagulation factor proteins. Therefore, laboratory reports
of this test include both an immediately obtained and an
incubated value.
Inhibitors are rare but can develop after repeated exposure
to factor concentrates used to treat preexisting deficiencies,
such as hemophilia A (factor VIII) or B (factor IX), or they
can develop de novo (acquired inhibitors). The most common
is a spontaneous, acquired factor VIII inhibitor that is
associated with liver disease, pregnancy, autoimmune dis-
ease, and malignancy.29 However, pertinent to cardiac sur-
gery is the development of antibodies after exposure to
bovine thrombin used as a topical hemostatic agent. These
antibodies cross-react with human thrombin and factor V,
leading to a prolonged thrombin time and a significant
bleeding diathesis during subsequent surgeries.30 Platelet
transfusions can specifically treat isolated factor V inhibitors
because platelet degranulation delivers factor Va to a site of
injury, but achieving hemostasis in the presence of inhibitors
requires the use of a bypassing agent.31 Prothrombin complex
concentrates or recombinant factor VIIa can generate throm-
bin despite the upstream inhibition.32 Longer-term treatment
of inhibitors requires plasmapheresis or long-term immuno-
suppression until the autoantibody does not recur.
Thromboelastography
Thromboelastography determines clot formation and lysis
within a given blood sample by measuring the shear elastic
modulus of whole blood samples during clot formation
(Figure 4).33 However, it does not measure the effect of
aspirin, thienopyridines (P2Y12 platelet receptor inhibitors),
or low-molecular-weight heparin. Thromboelastography pro-
vides a global assessment of hemostatic function in whole
blood, preserving the interplay between erythrocytes, plate-
lets, coagulation factors, and fibrinogen. Thromboelastogra-
phy has been demonstrated to be remarkably accurate when
used to predict postoperative hemorrhage, with a success rate
of 87%, whereas the activated clotting time and coagulation
profile posted accuracy rates of 30% and 51%, respectively.34
Addition of a heparinase reagent allows diagnosis of abnor-
mal coagulation potential during heparinization.
The Implantable MCAD: An Extreme Case of
Acquired Bleeding and Clotting
The implantation of vascular grafts or devices, such as
MCADs, introduces a foreign body into the patient that is in
constant contact with the blood. Because the endothelium is
missing on artificial surfaces, it cannot exert its antithrom-
botic actions, increasing the risk for occlusive thrombosis or
thromboembolic events. Because of the relative lack of
organs available for heart transplant, MCADs, such as the left
ventricular assist device, will become a much more com-
monly employed therapy for patients with end-stage heart
failure and may benefit 30 000 to 60 000 patients per year in
Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015
Figure 4. Thromboelastography. A thromboelastogram mea-
sures 4 key values: the R value represents the clotting time,
which measures the time it takes for the first signs of a clot to
appear. The k value is the time period from the end of R until
the clot reaches a certain strength, generally expressed as an
amplitude of 20 mm. The angle is the angle between the line
in the middle of the thromboelastography tracing and the line
tangent to the developing body of the graph. It represents the
kinetics of fibrin cross-linking. The MA value is the maximum
amplitude of the graph, and it reflects the final strength of the
clot. Adapted from Srinivasa et al33 with permission of the pub-
lisher. Copyright 2001, Lippincott Williams & Wilkins, Inc.
the future.35 However, among the major complications of
implantable MCADs are bleeding and thrombosis.
Bleeding Complications With MCAD Therapy
In the immediate postoperative period, the risk of bleeding
predominates over thrombosis and is compounded by con-
comitant renal and hepatic dysfunction and possible technical
difficulties of a redo sternotomy (Figure 5 and Movies IV and
V in the online-only Data Supplement). In the later postop-
erative period, bleeding continues to predominate. It is
hypothesized that because of the high shear stress generated
by left ventricular assist devices, the vWF multimers are
elongated, and thus cleavage sites become exposed to metal-
loproteinase ADAMTS13, which then cleaves the hemostatic
high-molecular-weight vWF multimers.36 Similar to Heydes
syndrome, this leads to acquired vWD.36
Thromboembolic Complications With
MCAD Therapy
Whereas bleeding is much more common with current left
ventricular assist device technology, thrombosis and embolic
strokes are potentially more catastrophic and difficult to treat.
In a recent prospective multicenter study of 281 patients
treated with a second-generation continuous-flow device,
50% of patients suffered from bleeding complications, but
only 1% of patients died of bleeding.37 In contrast, 1% of
patients died because of device thrombosis, and 5% suffered
ischemic strokes, half of those with fatal outcomes.37 Of note,
end-stage heart disease itself predisposes to bleeding and
thromboembolism, although patients treated with MCADs
have been significantly more likely to suffer from these
adverse events than those on optimal medical management.38
Therefore, most patients receive some form of long-term
 Achneck et al Pathophysiology of Bleeding and Clotting 2075

Figure 5. Molecular pathways of bleeding and clotting on the blood-contacting surface of a MCAD. Left to right, High-molecular-weight
kininogen (HMWK) adsorbs to the titanium surface and initiates the intrinsic coagulation pathway (contact activation). The surface is
also populated with blood-derived monocytes and macrophages, which express tissue factor (TF) and activate the extrinsic coagulation
pathway. At the same time, platelets adhere and become activated (AP), releasing granules containing coagulation factor V, which
further contributes to thrombus formation. Top to bottom, The fibrinolytic system is also activated through the cleavage of prekallikrein
to kallikrein via factor XIIa (FXIIa). Kallikrein in turn converts plasminogen to plasmin, which cleaves fibrin. Fibrin degradation products
cause platelet dysfunction through their inhibitory effect on platelet receptors, compounding the bleeding risk. Center, Moreover, the
high shear stress may elongate vWF multimers, thus exposing vulnerable cleavage sites that lead to defunctionalized vWF molecules.
FXII indicates factor XII; FV, factor V; and GP, glycoprotein.

Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015

2076 Circulation November 16, 2010
anticoagulation during left ventricular assist device support,
although concurrent coagulopathies require careful dosing of
anticoagulants and antiplatelet drugs.
Spanier et al39 found significant thrombin generation and
fibrinolysis in patients with textured-surface MCADs that
caused a phenomenon of compensated coagulopathy. Fur-
thermore, they demonstrated progressive population of the
MCAD surface by activated macrophages and monocytes
expressing tissue factor and proinflammatory cytokines, as
well as persistently elevated levels of tissue factor in the
circulation (Figure 5 and Movie III in the online-only Data
Supplement).39
Because of these risks, MCAD design has focused on
engineering a device with higher flow, such as the current
HeartMate II (Thoratec, Pleasanton, Calif). However, as
described above, high flow within the HeartMate II device
causes bleeding complications, possibly as a result of ac-
quired vWD. Furthermore, the artificial titanium surface of
MCADs, which is thought to sequester platelets, may also
play a role in the observed postimplantation thrombocytope-
nia requiring transfusion or contributing to reoperation. Be-
cause it has become feasible to isolate endothelial progenitor
cells from peripheral blood, it may be possible to engineer
biogenic MCADs in the future, which are lined with the
patients own, blood-derived endothelial progenitor cells.40
Such a lining may prevent platelet adhesion and thrombus
formation in areas of low flow and stasis and possibly
ameliorate the dreaded side effects of infection and bleeding.
Conclusion
The vascular endothelium has a variety of innate mechanisms
that steer the coagulation system toward either the prevention
of clot formation or thrombosis. As such, it plays a crucial
role in maintaining normal blood flow. On the other hand, the
lack of a functioning endothelium contributes both directly and
indirectly to bleeding and clotting disorders. In addition, im-
plantable artificial devices, which lack an endothelial lining
entirely, are prone to cause coagulation abnormalities through
contact activation. In the future, it may be possible to bioengi-
neer a confluent lining of the patients own endothelial cells to
cover the blood contacting surface of such devices.
Acknowledgments
We thank Stanley Coffman from Medmedia Solutions (http://www.
medmediasolutions.com/about.shtml) for his expertise in generating
the video animations for this article.
Sources of Funding
This work was supported through National Institutes of Health grant
RC1HL099863-01, entitled Autologous EPC Lining to Improve
Biocompatibility of Circulatory Assist Devices, as well as the
Mid-Atlantic Postdoctoral Fellowship Award from the American
Heart Association, entitled Cell Seeding Endothelial Progenitor
Cells Onto Ventricular Assist Device Surface.
Disclosures
Dr Milano has served as a consultant to Thoratec Corp, Pleasanton,
Calif. The other authors report no conflicts.
Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015
References
1. Davie EW, Ratnoff OD. Waterfall sequence for intrinsic blood clotting.
Science. 1964;145:1310 1312.
2. Macfarlane RG. An enzyme cascade in the blood clotting mechanism, and
its function as a biochemical amplifier. Nature. 1964;202:498 499.
3. Spanier TB, Chen JM, Oz MC, Edwards NM, Kisiel W, Stern DM, Rose
EA, Schmidt AM. Selective anticoagulation with active site-blocked
factor IXA suggests separate roles for intrinsic and extrinsic coagulation
pathways in cardiopulmonary bypass. J Thorac Cardiovasc Surg. 1998;
116:860 869.
4. Dubois C, Panicot-Dubois L, Gainor JF, Furie BC, Furie B. Thrombin-
initiated platelet activation in vivo is vWF independent during thrombus
formation in a laser injury model. J Clin Invest. 2007;117:953960.
5. Furie B, Furie BC. Mechanisms of thrombus formation. N Engl J Med.
2008;359:938 949.
6. Radomski MW, Palmer RM, Moncada S. Comparative pharmacology of
endothelium-derived relaxing factor, nitric oxide and prostacyclin in
platelets. Br J Pharmacol. 1987;92:181187.
7. Mangano DT. Aspirin and mortality from coronary bypass surgery.
N Engl J Med. 2002;347:1309 1317.
8. Dobesh PP. Pharmacokinetics and pharmacodynamics of prasugrel, a
thienopyridine P2Y12 inhibitor. Pharmacotherapy. 2009;29:1089 1102.
9. Mahoney EM, Wang K, Arnold SV, Proskorovsky I, Wiviott S, Antman
E, Braunwald E, Cohen DJ. Cost-effectiveness of prasugrel versus clo-
pidogrel in patients with acute coronary syndromes and planned percu-
taneous coronary intervention: results from the trial to assess
improvement in therapeutic outcomes by optimizing platelet inhibition
with Prasugrel: Thrombolysis in Myocardial Infarction TRITON-TIMI
38. Circulation. 2010;121:7179.
10. Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C,
Horrow J, Husted S, James S, Katus H, Mahaffey KW, Scirica BM, Skene
A, Steg PG, Storey RF, Harrington RA, Freij A, Thorsen M. Ticagrelor
versus clopidogrel in patients with acute coronary syndromes. N Engl
J Med. 2009;361:10451057.
11. Teng R, Butler K. Pharmacokinetics, pharmacodynamics, tolerability and
safety of single ascending doses of ticagrelor, a reversibly binding oral
P2Y(12) receptor antagonist, in healthy subjects. Eur J Clin Pharmacol.
2010;66:487 496.
12. Corral J, Gonzalez-Conejero R, Hernandez-Espinosa D, Vicente V.
Protein Z/Z-dependent protease inhibitor (PZ/ZPI) anticoagulant system
and thrombosis. Br J Haematol. 2007;137:99 108.
13. Fergusson DA, Hebert PC, Mazer CD, Fremes S, Macadams C, Murkin
JM, Teoh K, Duke PC, Arellano R, Blajchman MA, Bussieres JS, Cote D,
Karski J, Martineau R, Robblee JA, Rodger M, Wells G, Clinch J,
Pretorius R. A comparison of aprotinin and lysine analogues in high-risk
cardiac surgery. N Engl J Med. 2008;358:2319 2331.
14. Rosenberg JB, Foster PA, Kaufman RJ, Vokac EA, Moussalli M, Kroner
PA, Montgomery RR. Intracellular trafficking of factor VIII to von
Willebrand factor storage granules. J Clin Invest. 1998;101:613 624.
15. Vincentelli A, Susen S, Le Tourneau T, Six I, Fabre O, Juthier F, Bauters
A, Decoene C, Goudemand J, Prat A, Jude B. Acquired von Willebrand
syndrome in aortic stenosis. N Engl J Med. 2003;349:343349.
16. White GC II, Rosendaal F, Aledort LM, Lusher JM, Rothschild C,
Ingerslev J. Definitions in hemophilia: recommendation of the scientific
subcommittee on factor VIII and factor IX of the scientific and standard-
ization committee of the International Society on Thrombosis and Hae-
mostasis. Thromb Haemost. 2001;85:560.
17. Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The phar-
macology and management of the vitamin K antagonists: the Seventh
ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest.
2004;126:04S233S.
18. Quaknine-Orlando B, Samama CM, Riou B, Bonnin P, Guillosson JJ,
Beaumont JL, Coriat P. Role of the hematocrit in a rabbit model of
arterial thrombosis and bleeding. Anesthesiology. 1999;90:1454 1461.
19. Rees DC, Cox M, Clegg JB. World distribution of factor V Leiden.
Lancet. 1995;346:11331134.
20. Svensson PJ, Dahlback B. Resistance to activated protein C as a basis for
venous thrombosis. N Engl J Med. 1994;330:517522.
21. Eldibany MM, Caprini JA. Hyperhomocysteinemia and thrombosis: an
overview. Arch Pathol Lab Med. 2007;131:872 884.
22. Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R,
Derksen RH, PG DEG, Koike T, Meroni PL, Reber G, Shoenfeld Y,
Tincani A, Vlachoyiannopoulos PG, Krilis SA. International consensus
statement on an update of the classification criteria for definite antiphos-
pholipid syndrome (APS). J Thromb Haemost. 2006;4:295306.
 Achneck et al
23. Koster A, Chew D, Merkle F, Gruendel M, Jurmann M, Kuppe H, Oertel
R. Extracorporeal elimination of large concentrations of tirofiban by
zero-balanced ultrafiltration during cardiopulmonary bypass: an in vitro
investigation. Anesth Analg. 2004;99:989 992.
24. Massonnet-Castel S, Pelissier E, Bara L, Terrier E, Abry B, Guibourt P,
Swanson J, Jaulmes B, Carpentier A, Samama M. Partial reversal of low
molecular weight heparin (PK 10169) anti-Xa activity by protamine
sulfate: in vitro and in vivo study during cardiac surgery with extracor-
poreal circulation. Haemostasis. 1986;16:139 146.
25. Lobo B, Finch C, Howard A, Minhas S. Fondaparinux for the treatment
of patients with acute heparin-induced thrombocytopenia. Thromb
Haemost. 2008;99:208 214.
26. Favaloro EJ, Facey D, Henniker A. Use of a novel platelet function
analyzer (PFA-100) with high sensitivity to disturbances in von Wille-
brand factor to screen for von Willebrands disease and other disorders.
Am J Hematol. 1999;62:165174.
27. Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J,
Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ. Evaluation of
D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl
J Med. 2003;349:12271235.
28. Jacquemin M, Neyrinck A, Hermanns MI, Lavendhomme R, Rega F,
Saint-Remy JM, Peerlinck K, Van Raemdonck D, Kirkpatrick CJ. FVIII
production by human lung microvascular endothelial cells. Blood. 2006;
108:515517.
29. Sohngen D, Specker C, Bach D, Kuntz BM, Burk M, Aul C, Kobbe G,
Heyll A, Hollmig KA, Schneider W. Acquired factor VIII inhibitors in
nonhemophilic patients. Ann Hematol. 1997;74:89 93.
30. Ortel TL, Mercer MC, Thames EH, Moore KD, Lawson JH. Immunologic
impact and clinical outcomes after surgical exposure to bovine thrombin.
Ann Surg. 2001;233:88 96.
31. Chediak J, Ashenhurst JB, Garlick I, Desser RK. Successful management
of bleeding in a patient with factor V inhibitor by platelet transfusions.
Blood. 1980;56:835 841.
32. Smith MP, Ludlam CA, Collins PW, Hay CR, Wilde JT, Grigeri A,
Melsen T, Savidge GF. Elective surgery on factor VIII inhibitor patients
using continuous infusion of recombinant activated factor VII: plasma
Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015
Pathophysiology of Bleeding and Clotting 2077
factor VII activity of 10 IU/ml is associated with an increased incidence
of bleeding. Thromb Haemost. 2001;86:949 953.
33. Srinivasa V, Gilbertson LI, Bhavani-Shankar K. Thromboelastography:
where is it and where is it heading? Int Anesthesiol Clin. 2001;39:35 49.
34. Spiess BD, Tuman KJ, McCarthy RJ, DeLaria GA, Schillo R, Ivankovich
AD. Thromboelastography as an indicator of post-cardiopulmonary
bypass coagulopathies. J Clin Monit. 1987;3:2530.
35. Copeland JG. Multicenter bridge to transplantation with the HeartMate
assist device: evaluation from another perspective. J Thorac Cardiovasc
Surg. 2003;125:228 230.
36. Geisen U, Heilmann C, Beyersdorf F, Benk C, Berchtold-Herz M,
Schlensak C, Budde U, Zieger B. Non-surgical bleeding in patients with
ventricular assist devices could be explained by acquired von Willebrand
disease. Eur J Cardiothorac Surg. 2008;33:679 684.
37. Pagani FD, Miller LW, Russell SD, Aaronson KD, John R, Boyle AJ,
Conte JV, Bogaev RC, MacGillivray TE, Naka Y, Mancini D, Massey
HT, Chen L, Klodell CT, Aranda JM, Moazami N, Ewald GA, Farrar DJ,
Frazier OH. Extended mechanical circulatory support with a
continuous-flow rotary left ventricular assist device. J Am Coll Cardiol.
2009;54:312321.
38. Lazar RM, Shapiro PA, Jaski BE, Parides MK, Bourge RC, Watson JT,
Damme L, Dembitsky W, Hosenpud JD, Gupta L, Tierney A, Kraus T,
Naka Y. Neurological events during long-term mechanical circulatory
support for heart failure: the Randomized Evaluation of Mechanical
Assistance for the Treatment of Congestive Heart Failure (REMATCH)
experience. Circulation. 2004;109:24232427.
39. Spanier TB, Chen JM, Oz MC, Stern DM, Rose EA, Schmidt AM.
Time-dependent cellular population of textured-surface left ventricular
assist devices contributes to the development of a biphasic systemic
procoagulant response. J Thorac Cardiovasc Surg. 1999;118:404 413.
40. Yoder MC, Mead LE, Prater D, Krier TR, Mroueh KN, Li F, Krasich R,
Temm CJ, Prchal JT, Ingram DA. Redefining endothelial progenitor cells
via clonal analysis and hematopoietic stem/progenitor cell principals.
Blood. 2007;109:18011809.
KEY WORDS: coagulation endothelium heart-assist device
physiology thrombosis
Pathophysiology of Bleeding and Clotting in the Cardiac Surgery Patient: From Vascular
Endothelium to Circulatory Assist Device Surface
Hardean E. Achneck, Bantayehu Sileshi, Amar Parikh, Carmelo A. Milano, Ian J. Welsby and
Jeffrey H. Lawson

Circulation. 2010;122:2068-2077
doi: 10.1161/CIRCULATIONAHA.110.936773
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2010 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539

The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circ.ahajournals.org/content/122/20/2068

Data Supplement (unedited) at:

http://circ.ahajournals.org/content/suppl/2011/03/30/122.20.2068.DC1.html

Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published
in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial
Office. Once the online version of the published article for which permission is being requested is located,
click Request Permissions in the middle column of the Web page under Services. Further information about
this process is available in the Permissions and Rights Question and Answer document.

Reprints: Information about reprints can be found online at:

http://www.lww.com/reprints

Subscriptions: Information about subscribing to Circulation is online at:

http://circ.ahajournals.org//subscriptions/

Downloaded from http://circ.ahajournals.org/ at University of Illinois at Chicago Library on May 3, 2015