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Efficacy of Nafamostat Mesilate as Anticoagulation during Cardiopulmonary Bypass on Early Surgery in Patients with Active Infective Endocarditis Complicated by Stroke
Yutaka Okita, Toshihito Sakamoto, kenji Okada, Hiroya Kano, Katsuhiro Yamanaka, Shunsuke Miyahara, Takeshi Inoue, Naoto Izawa, Yasuko Gotake, Masamichi Matsumori.
Kobe University, Kobe, Japan.

Objective: Recent brain complications (bleeding or infarction) in patients with active infective endocarditis are recognized as a contraindication for early surgery if full heparinization is utilized. Nafamostat mesilate (NM) is a synthetic protease-inhibiting agent which has not only potent inhibitory activity against coagulation factors (Xlla, Xa) but anti-inflammatory effect. We report our successful surgical experience using NM with low dose heparinization in patients with active infective endocarditis complicated by recent cerebral complications. Patients and Methods: Twenty seven patients with mean age of 54.9 ± 18.7 who underwent active infective native valve (n=20) or prosthetic valve (n=7) endocarditis were retrospectively reviewed (8 aortic, 16 mitral, 2 aortic/mitral, and 1 tricuspid). Twenty two of 27 patients were accompanied with preoperative stroke and 5 with active brain bleeding. Surgery was performed after the onset of stroke on 2.4±2.1 days. NM (209 ± 152 mg) with low dose heparin (3796±1218 IU, 67.4±20.3 IU/kg) was used for anticoagulation during cardiopulmonary bypass. ACT was maintained between 350 and 450 by fine administration of NM into a cardiotomy reservoir (0.5 mg/kg/h) and a venous reservoir (sliding controlled dose at 1.5 mg/kg/h). Results: Cardiopulmonary bypass time was 181.3 ± 92.6 min. Five patients (18.5%) died during hospitalization because of persistent sepsis in three and brain death caused by massive brain embolism before the establishment of cardiopulmonary bypass in one patient, and pneumonia in one patient. There was no further aggravation of intracranial bleeding or no new hemorrhage stroke. Conclusions: Nafamostat mesilate with low dose heparinization might be useful for the early surgery in patients with active infective endocarditis complicated by stroke without the deterioration of the cerebral lesions.

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