The main aim of this review is to summarize the literature with respect to the impact of anticoagulation monitoring strategies and therapeutic strategies to manage heparin resistance and optimize anticoagulation with cardiac surgery.

This review was generated using peer-reviewed manuscripts pertinent to this topic that were identified using a computer-based Medline search.

There are a small number of well-controlled prospective, randomized studies, some of which suggest that bleeding and transfusion can be attenuated by refining heparin monitoring techniques by sustaining better anticoagulation during cardiopulmonary bypass especially when applied to operative cases that involve complex procedures that require long intervals on cardiopulmonary bypass. Recent studies indicate that antithrombin III concentrates can be used to treat heparin resistance and thereby enhance preservation of the hemostatic system during CPB. A few recent retrospective analyses suggest that low ATIII concentration is associated with negative outcomes.

The literature indicates that enhanced anticoagulation via more sophisticated heparin monitoring schemes can reduce bleeding and transfusion and that antithrombin III concentrates can be used to effectively manage heparin resistance during cardiac surgery. Well-controlled, randomized studies are needed to better define the relative importance of AT IIII supplementation with respect to either the management of heparin resistance or with respect to optimization of anticoagulation during CPB and specifically if these interventions are able to decrease the incidence of bleeding and/or thrombotic complications.