Eur J Cardiothorac Surg 2004;25:839-843
© 2004 Elsevier Science NL
Intra-operative heparin release during lung surgery
Mahmoud Ashoura*,
Waseem Hajjara,
Khaled Al-Kattana,
Mohammed Essaa,
Abed Al-Rhaman Al-Motrafib,
Ahmed Al-Saddiquec,
Abdelkareem El-Bakryd
a Division of Thoracic Surgery (37), King Khalid University Hospital, College of Medicine, King Saud University, P.O. Box 7805, Riyadh 11472, Saudi Arabia
b Department of Pharmacology, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
c Division of Cardiac Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
d Division of General Surgery, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia
Received 27 October 2003;
received in revised form 7 December 2003;
accepted 15 December 2003.
* Corresponding author. Tel.: +966-1-467-1994/1575; fax: +966-1-467-9493
e-mail: mashour90{at}hotmail.com
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Abstract
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Objectives: Heparin has long been thought to be biosynthesized and stored in the granules of mast cells that are most prevalent in the lungs and gastro-intestinal tract. In response to stimuli such inflammation and trauma, mast cells degranulate and consequently release heparin. This prospective study was designed to investigate if operative trauma during lung mobilization could enhance heparin release into both the pulmonary and systemic circulations. Methods: Prospective investigations and data collection were carried out on 34 patients undergoing elective thoracotomies for 19 patients with chronic inflammatory disease and 15 with lung carcinoma. Heparin assay using the high performance liquid chromatography method was carried out on four blood samples from each patient. Sample 1 was taken pre-operatively from the radial artery. Intra-operatively following lung mobilization and prior to excision, sample 2 was taken from the draining pulmonary vein and at the same time, sample 3 from the radial artery. Postoperatively, the next morning, sample 4 was taken from the radial artery. Results: The mean values for serum heparin levels in pg/ml of samples 1–4 were found to be 205.1 (SD±282.1), 366.0 (SD±371.7), 337.2 (SD±225.3) and 250.8 (SD±282.2), respectively. These results show that intraoperative serum heparin levels (samples 2 and 3) are significantly higher (P=0.0016, P=0.0014, respectively) than pre-operative values (sample 1). The difference between sample 2 (pulmonary) and sample 3 (systemic circulation) was not significant (P=0.6508). Although postoperative heparin levels (sample 4) were found to be higher than pre-operative values, yet it was not statistically significant (P=0.1340). The mean of pre-operative heparin levels in patients with lung carcinoma and inflammatory diseases were 136.2 (SD±62.6) and 259.4 (SD±368.3), respectively. Intra-operatively, heparin levels increased to 260.9 (SD±139.7) and 449 (SD±470.7), respectively. These results suggest that the mean heparin level for patients with inflammatory lung diseases was higher than that for carcinoma patients. Conclusions: Within the context of lung surgery for carcinoma or inflammatory diseases, it appears that operative trauma enhances heparin release into both the pulmonary and systemic circulations, possibly through pulmonary mast cell degranulation. Thus, an episodic auto anti-coagulant effect is established during the course of surgery. Such findings may partly provide an understanding of the excessive bleeding encountered during some thoracotomies and the recognized reduced incidence of thrombo-embolic complications among thoracic surgical patients. Should an unexplained bleeding occur during the course of surgery, an excess of heparin release is recommended to be kept in mind as a possible cause.
Key Words: Mast cells • Operative lung trauma • Degranulation • Heparin release
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1. Introduction
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Heparin is biosynthesized, stored and released by mast cells [1]. Typically, pharmaceutical heparin is prepared from tissues rich in mast cells, such as bovin lungs [2]. Various stimuli including stress and trauma are reported to degranulate mast cells and consequently release heparin [3,4]. This prospective study is designed to examine if operative trauma during lung surgery could enhance heparin release into both the pulmonary and systemic circulations. The clinical implications relating to this observation are discussed as well.
To our knowledge, this is the first report that addresses the fluctuation of heparin levels during the course of lung surgery.
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2. Material and methods
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2.1. Patients
From October 2001 to December 2002, 34 patients undergoing elective thoracotomies for various indications were admitted to the study. An approval by the ethical committee of the College of Medicine, King Saudi University and a written informed consent were secured. Patients involved, included 20 males and 14 females with age ranging from 7 to 70 years and a mean age of 40 years. Those with thrombo-embolic disease or receiving anti coagulant therapy were not entered to the study. Lung carcinoma (N=15) and inflammatory lung diseases (N=19) were the indications for surgery. In general, a lobectomy or pneumonectomy was performed.
2.2. Methods
Each patient involved in the study during this time frame, had heparin level measurement performed during the pre-operative, intra and post-operative course of surgery. Pharmaceutical heparin was not given to any patient involved in the study, either in the form of prophylaxis or treatment. Furthermore, heparin was not added to the arterial or central lines.
Heparin level measurement in pg/ml was carried out according to ‘the high performance liquid chromatography method’ described by Toyoda et al. (1997) [5]. Four blood samples (5 ml each) from each patient were analysed. Sample 1 (N=34) was taken pre-operatively from the radial artery. Intra-operatively, subsequent to lung mobilization and prior to lung resection, Samples 2 and 3 were taken at the same time. Sample 2 (N=34) was taken from the draining pulmonary vein of the resected lung and sample 3 (N=16) from the radial artery. Sample 4 (N=34) was taken from the radial artery post-operatively, the next morning. All blood samples were kept in non-heparinized bottles and transported in an ice box to the laboratory.
2.3. Statistical methods
One-way ANOVA was used to investigate whether mean heparin levels differed significantly with regard to the timing of blood sample (pre-operative, intra-operative or post-operative), location (pulmonary circulation or systemic circulation) or aetiology of the resected lung disease (inflammatory or carcinoma). In the statistical analysis, data from the different samples were treated as if they were from independent study groups.
Because of the large variances, logarithm transformation was applied on to the data before conducting the ANOVA. Post-ANOVA pairwise comparisons of means were based on the Bonferroni method. Program 7D from the BMDP statistical software was used to conduct the ANOVA. A P-value less then 0.05 was considered to be statistically significant.
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3. Results
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3.1. Heparin level in pulmonary circulation
When applied, one-way ANOVA had indicated that the mean values of heparin levels (Table 1) for sample 1 (205.1±282.1), sample 2 (366.0±371.7) and sample 4 (250.8±282.2) differed significantly (0.0068). Post-ANOVA pairwise comparison, indicated that the means for samples 1 and 2 differed significantly (P=0.0016) and mean values for samples 1 and 4 were not significant (P=0.1340). These results clearly demonstrate that intra-operative heparin level in pulmonary circulation (sample 2) is higher than pre-operative heparin values (sample 1).
3.2. Heparin level in systemic circulation
In this regard, one-way ANOVA indicated that the mean value of heparin levels (Table 2) for sample 1 (205.1±282.1), sample 3 (337.2±225.3) and sample 4 (250.8±282.1) differed significantly (P=0.0056). Post-ANOVA pairwise comparison indicated that the means for samples 1 and 3 differed significantly (P=0.0014), and mean values for samples 1 and 4 were not significant (P=0.1051). These results clearly show that intra-operative systemic heparin level (sample 3) is higher than the pre-operative values, echoing the same alterations occurring in the pulmonary circulation. When the mean of heparin levels in pulmonary (366.0±371.7) and systemic (337.2±225.3) circulations were compared by adopting the post-ANOVA pairwise comparison, the difference was not found to be statistically significant (P=0.6508). This indicates that the rise in intra-operative heparin levels were not only limited to the pulmonary circulation but also were found in the systemic circulation (Table 3).
3.3. The impact of lung pathology on heparin level
In patients with resected lung carcinoma (Table 4), one-way ANOVA incidated that the mean values of heparin level for sample 1 (136.2±62.6), sample 2 (260.9±139.7) and sample 4 (195.9±87.4) differed significantly (P=0.0132). Post-ANOVA pairwise mean comparison indicated that the means for samples 1 and 2 differed significantly (P=0.0037) and mean values for samples 1 and 4 were marginally significant (P=0.0638).
The results of one-way ANOVA in patients with resected inflammatory lung diseases (Table 5) indicated that mean heparin level for sample 1 (259.4±368.5), sample 2 (449.0±470.7) and sample 4 (294.2±368.1) did not differ significantly (P=0.1251). However, the mean value of heparin levels, for sample 2 appeared to be quite high. Failure to detect significance in this group, may be due to the large variances in the results.
When mean levels of heparin for each sample (1, 2, 4) were compared between patients with carcinoma and inflammatory diseases (Table 6), there were no statistically significant differences. However, in each sample, the mean heparin level for patients with inflammatory diseases was higher than that for the carcinoma group.
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4. Discussion
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Mast cells, the major source of heparin [6] are found in all human tissues, yet they are most prevalent in the lung and gastro-intestinal tract [7]. Lung mast cells are generally most abundant in connective tissues surrounding small airways, blood vessels, beneath the pleura and membranous portion of trachea. Keeping in mind this anatomical location of mast cells, it become understandable how human lung was found to contain 14 µg of heparin per g of tissue [8]. Mast cells are recognized to produce and store a number of vaso-active and immuno-modulating substances and are able to release their mediator molecules when degranulating in response to cell activation by an antigen or various other stimuli including trauma [7,9].
The present study had demonstrated clearly a significant elevation in heparin level during lung surgery when compared to pre-operative values (Tables 1 and 2). This rise had continued in the post-operative period (sample 4) as well. Enhancement of intra-operative heparin release was not only localized to the pulmonary circulation (sample 2), but also seen in the systemic circulation (sample 3). The observed increase in heparin levels in both circulations was uniform and the difference between the two measurements was not statistically significant (P=0.6508).
Many studies have demonstrated an increase in the number of mast cells both intact and degranulated in the vicinity of tumour invasion and areas of on-going inflammation [10,11]. In some tumours (haemangiomas), these cells were reported to reach levels of up to 40 fold higher than those found in surrounding tissues [12]. Each of these cells was estimated to have 1–4 pg of heparin [13]. In the set-up of lung surgery for carcinoma or inflammatory diseases, it appears from this study that operative trauma enhances heparin release into both the pulmonary and systemic circulations possibly through pulmonary mast cell degranulation. Thus consequently, a temporary auto anti-coagulant effect is established during the course of surgery.
Elevated intra-operative heparin levels were seen in both lung carcinoma and inflammatory disease patients. However, the mean heparin level for patients with inflammatory lung diseases was higher than that for carcinoma patients (Table 6). This could be due to a heavier mast cell accumulation in lungs with inflammatory diseases rather than carcinoma, thus possibly setting larger number of cells for degranulation and consequent heparin release in patients with inflammatory lung diseases.
Although human heparin is similar in structure to porcine heparin (pharmaceutical heparin), yet it is 43% more active as an anticoagulant [14]. This feature was explained on the basis of increased number of anti-thrombin III binding sites in human heparin. Therefore, in the context of lung surgery, we postulate that the presence of human heparin in both the pulmonary and systemic circulations (during the intra and post-operative periods) may provide an understanding of the reported reduced incidence of thrombo-embolic complications among thoracic surgical patients. Pulmonary embolism is widely recognized to complicate abdominal and lower limb orthopaedic surgical procedures, but in comparison, it is seldom recognized to hamper the post-operative progress of patients after thoracic operations [15,16]. This low prevalence of pulmonary embolism among thoracic surgical patients was cited by other reports to be 0.7, 1.85, and 3.1% [17–19]. In Japan, peri-operative thrombo-embolic prophylaxis is not so common in patients having lung resection [20].
Neovascularization and broncho-pulmonary shunt formation, could be one reason for bleeding complications during surgery of aspergilloma complex, bronchiectasis [21,22] and infrequently lung carcinoma. During this study, we observed that the mean value of measured activated partial thromboplastine time during the course of surgery 49.47 s (SD±8.39), was significantly high (P=0.003) when compared to pre-operative measurement of 37.01 s (SD±6.38) in 10 of the patients who developed bleeding complications. With the results of this study in mind (Table 6), the presence of heparin that was released intra-operatively may provide an understanding to the observed increased measurements of activated thromboplastine time during the course of surgery and the occurrence of bleeding complications. In this regard, Tefferi et al. had isolated a heparin-like anticoagulant from the plasma of one patient who developed severe bleeding post-operatively, following radical systectomy for transitional cell carcinoma [13]. Moreover, Linhardt et al. has reported that blood coming directly from haemangiomas does not clot because of the locally released heparin from mast cells [14].
In the non-surgical setting, severe bleeding in patients with plasma cell proliferative disorders was reported to be due to the presence of significant amounts of circulating heparin-like anticoagulant [13,23,24]. These patients developed prolonged thrombin time and protamine sulfate infusions were found to improve bleeding and correct the in vitro clotting studies. In asthmatic patients it was postulated that the diminished atherosclerosis might be a consequence of elevated circulating endogenous heparin-like anticoagulant released by mast cells that heavily populate their lungs [25]. Based on our findings in this study and the mentioned reported literature, we recommend that should unexplained bleeding complications occur during the course of surgery, an excess of heparin release to be kept in mind as a possible cause.
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5. Conclusions
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Within the set-up of lung surgery for carcinoma or chronic inflammatory diseases, it appears that operative trauma enhances heparin release into both the pulmonary and systemic circulations, possibly through pulmonary mast cell degranulation. Thus consequently, a temporary auto anti-coagulant effect is established during the course of surgery. Accordingly, we postulate that the presence of elevated level of human heparin during the course of surgery may provide an understanding of the occasional bleeding complications and the recognized reduced incidence of thrombo-embolic disease among thoracic surgical patients. We recommend that an excess of heparin release is kept in mind as a cause of unexplained bleeding complications, should it occur during the course of surgery.
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Acknowledgments
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We would like to thank Mrs Charito B. Roxas for her secretarial assistance and Mr Jamal Bella El-Hardollo for his expert technical assistance.
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Footnotes
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Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.
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Abstract
1. Introduction
