Fibrinogen Levels in Cardiac Surgery

fi s p i 2 v w t THIS ISSUE OF THE Journal of Cardiothoracic and Vascular Anesthesia includes 2 interesting contributions foused on fibrinogen levels after coronary artery bypass grafting CABG) with or without cardiopulmonary bypass (CPB)1 and on fibrinogen supplementation after complex cardiac surgery (CABG plus valve surgeries or ascending aorta surgeries).2 Momeni et al,1 in an elegant study, including conventional coagulation tests and point-of-care (POC) tests (Multiplate, Verum Diagnostica GmbH, Munich, Germany and ROTEM, Tem International GmbH, Munich, Germany), found that patients undergoing CABG with CPB exhibited significantly lower values of fibrinogen during and after the surgeries compared with patients treated off-pump. In addition, they found that the values of fibrinogen obtained with the FIBTEM test using the ROTEM system correlated well with the conventional Clauss measurement. Bilecen et al2 investigated the effects of fibrinogen supplementation on a series of patients who underwent complex cardiac surgery, comparing them with a propensity-score selected patient population. They did not observe any effect of fibrinogen supplementation on decreased postoperative blood loss or allogeneic blood product transfusion containment. However, as the investigators admitted, the study was not randomized, the fibrinogen dose was lower (1-2 g in 60% of patients) than the dose reported by other investigators (often reaching 6-7 g), and the decision of giving fibrinogen and the dose used were not guided by the measurement of the fibrinogen level. Fibrinogen supplementation in cardiac surgery is certainly one of the “hot topics” of the moment. Fibrinogen concentrate currently is not available in the United States for acquired bleeding, and in Europe its use greatly varies among the different countries. In Germany, Austria, Switzerland, the Netherlands, and other countries, fibrinogen concentrate is considered the standard of care for fibrinogen supplementation in acquired bleeding.3 Conversely, in the United Kingdom and the United States, it is approved for use only in congenital fibrin-