JCCVS
Journal of Cardiology & Cardiovascular Surgery

Journal of Cardiology & Cardiovascular Surgery scientific, open-access, double-blind peer-reviewed journal covering a wide spectrum of topics in cardiology and cardiovascular surgery.

eISSN: 2980-1397
Creative Commons CC BY-NC-ND 4.0 International License.
EndNote Style

Online Manuscript System

Index
Original Article
Should postoperative ACT in cardiac surgery be high or low?
Abstract
Aims: The aim of this study was to compare the activated clotting time (ACT) values after heparin neutralization with the values before heparin in patients undergoing cardiac surgery and to investigate the relationship with postoperative outcomes.
Methods: Between 2022 and 2023, 726 patients (518 males; mean age 58.2±11.5 years) who underwent cardiac surgery were evaluated. The patients were first divided into two groups. Group A (n=401): Patients whose ACT values before heparinization were lower than the ACT values after neutralization and Group B (n=325): Patients whose ACT values before heparinization were equal to or higher than the ACT values after neutralization.
Results: There was no difference between the groups regarding bleeding amount and blood product use. The need for postoperative exploration and subxiphoid decompression was higher in Group B than in Group A (p=0.001, and p=0.008, respectively). There was no difference between the groups in terms of hospital stay. The intubation time and intensive care unit stay were longer in Group B than in Group A (p=0.003, and p=0.04, respectively). The mortality rate was higher in Group B than in Group A (p=0.02).
Conclusion: In cardiac surgery, we found no difference in bleeding amounts and blood product use in patients with post-neutralization ACT values higher than pre-heparin ACT values compared to patients with lower ACT values. However, we found higher postoperative exploration and mortality rates and longer intubation times. Keywords: Activated clotting time, heparin, protamine sulfate, cardiac surgery, bleeding

Keywords : Activated clotting time, heparin, protamine sulfate, cardiac surgery, bleeding

Download Article


1. Edmunds LH Jr. The evolution of cardiopulmonary bypass: lessons to be learned. Perfusion. 2002;17(4):243-251. doi:10.1191/0267659102pf585oa
2. Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Cardiothoracic Anaesthesiology (EACTA), Boer C, Meesters MI, et al. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth. 2018;32(1):88-120. doi:10.1053/j.jvca.2017.06.026
3. Elassal AA, Al-Ebrahim KE, Debis RS, et al. Re-exploration for bleeding after cardiac surgery: revaluation of urgency and factors promoting low rate. J Cardiothorac Surg. 2021;16(1):166. doi:10.1186/s13019-021-01545-4
4. Taneja R, Szoke DJ, Hynes Z, Jones PM. Minimum protamine dose required to neutralize heparin in cardiac surgery: a single-centre, prospective, observational cohort study. Can J Anaesth. 2023;70(2):219-227. doi:10.1007/s12630-022-02364-4
5. Yamamoto T, Wolf HG, Sinzobahamvya N, Asfour B, Hraska V, Schindler E. Prolonged activated clotting time after protamine administration does not indicate residual heparinization after cardiopulmonary bypass in pediatric open heart surgery. Thorac Cardiovasc Surg. 2015;63(5):397-403. doi:10.1055/s-0035-1554998
6. Wang W, Wang Y, Wang J, et al. ACT values after neutralization lower than pre-heparinization ACT leads to lower operative times, bleeding, and post-operative transfusions in CABG patients: an observational study. Braz J Cardiovasc Surg. 2018;33(6):588-596. doi:10.21470/1678-9741-2018-0116
7. Boysan E, Circi R, Beyazal OF, Şener E. Bivalirudin for cardiopulmonary bypass in a patient with heparin allergy. J Cardiothorac Surg. 2023;18(1):258. doi:10.1186/s13019-023-02359-2
8. Bartoszko J, Karkouti K. Managing the coagulopathy associated with cardiopulmonary bypass. J Thromb Haemost. 2021;19(3):617-632. doi: 10.1111/jth.15195
9. De Simone F, Nardelli P, Licheri M, et al. Less is more: we are administering too much protamine in cardiac surgery. Ann Card Anaesth. 2021;24(2):178-182. doi:10.4103/aca.ACA_26_19
10. Murugesh WR, Prasad SS, Ramachandrappa Sujay K, Dinesh Kumar US. Is a fixed low-dose protamine better at reducing postoperative bleeding in off pump coronary artery bypass grafting? Asian Cardiovasc Thorac Ann. 2021;29(9):922-927. doi:10.1177/0218492321997393
11. Boer C, Meesters MI, Veerhoek D, Vonk ABA. Anticoagulant and side-effects of protamine in cardiac surgery: a narrative review. Br J Anaesth. 2018;120(5):914-927. doi:10.1016/j.bja.2018.01.023
12. Pereira RM, Magueijo D, Guerra NC, et al. Activated clotting time value as an independent predictor of postoperative bleeding and transfusion. Interdiscip Cardiovasc Thorac Surg. 2024;38(5):ivae092. doi:10.1093/icvts/ivae092
13. Zahid MA, Ahmed SS, Yousuf MS, Wadho SA, Akhtar MI, Hamid M. Post-neutralisation activated clotting time and postoperative transfusions in cardiac surgery outcome. J Coll Physicians Surg Pak. 2024;34(11):1275-1280. doi:10.29271/jcpsp.2024.11.1280
14. Stone ME, Vespe MW. Heparin rebound: an in-depth review. J Cardiothorac Vasc Anesth. 2023;37(4):601-612. doi:10.1053/j.jvca.2022. 12.019
15. Rijpkema M, Vlot EA, Stehouwer MC, Bruins P. Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass? Perfusion. 2024;39(8):1491-1515. doi:10. 1177/02676591231199218
16. Slaughter TF, LeBleu TH, Douglas JM Jr, Leslie JB, Parker JK, Greenberg CS. Characterization of prothrombin activation during cardiac surgery by hemostatic molecular markers. Anesthesiology. 1994;80(3):520-526. doi:10.1097/00000542-199403000-00007
17. Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T. What’s fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost. 2023;21(7):1714-1723. doi:10.1016/j.jtha.2023.04.005
Article available in :
Volume 4, Issue 1, 2026
Page : 14-20
https://doi.org/10.51271/JCCVS-0070
Article Information
Received : 09 Şub 2026
Accepted : 26 Mar 2026
Published : 28 Mar 2026
Corresponding Author :

Osman Fehmi Beyazal: Basaksehir Cam and Sakura City Hospital

[email protected]
Citation : Beyazal OF, Yanartaş M. Should the postoperative ACT value be higher or lower than the preoperative value in cardiac surgery? J Cardiol Cardiovasc Surg. 2026;4(1):14-20. doi:10.51271/JCCVS-0070

Read: 57
Download : 56
Cited: 0
_Footer