Coagulopathy assessment by rotational thromboelastometry and current treatment practices in cardiac surgery and critical care

This thesis investigated the role of viscoelastic testing, specifically rotational thromboelastometry (ROTEM), in guiding coagulation management for patients undergoing cardiac with cardiopulmonary bypass (CPB) and patients supported by extracorporeal membrane oxygenation (ECMO). It also reviewed current coagulation correction strategies in cardiac surgery, critically ill patients, and ECMO-supported patients, aiming to improve diagnostics and treatment outcomes.
In Part I, the thesis identified that ROTEM reference ranges for cardiac surgery patients differ from manufacturer standards, indicating a somewhat hypercoagulable state without clinical symptoms. Female patients showed a slightly more hypercoagulable profile preoperatively. ROTEM interpretation showed high reliability among experts, though discrepancies between expert decisions and local transfusion protocols highlight a need for refined clinical decision tools. The transition from ROTEM Delta to ROTEM Sigma devices was explored, revealing differences in clotting time measurements in the EXTEM channel that might require local transfusion protocol adjustments.
Preoperative ROTEM profiles helped identify distinct coagulopathy subphenotypes in acute type A aortic dissection patients, with hypocoagulability linked to worse outcomes. No significant preoperative coagulation differences were found between bicuspid and tricuspid aortic valve patients. In patients supported by ECMO, ROTEM cannot predict a bleeding event better than conventional coagulation tests (all models performed poor to moderate), and combining them did not significantly improve performance.
Part II reviewed coagulation management practices, highlighting limited available evidence supporting intravenous hemostatic agents in particularly thoracic aortic surgery, and noted variable clinical approaches to reversing antithrombotic agents in critically ill patients, often lacking specific protocols. Plasma transfusions were frequently given without active bleeding or guideline-based indications in critically ill and ECMO-supported patients, underscoring the need for improved guideline adherence and targeted research to optimize coagulation management.