The addition of Tirofiban infusion to heparin for intraoperative heparin resistance associated with Marfan Syndrome

  • Maria José Fernandez-Turizo Clínica El Rosario. Medellín, Colombia.
  • David Benavidez-Zora Clínica Medellín Grupo Quironsalud. Medellín, Colombia.
  • Augusto Enrique Anaya-Hoyos Clínica las Américas. Medellín, Colombia.
  • Sebastian Portillo-Gómez Clínica Medellín Grupo Quironsalud. Medellín, Colombia.
  • Hernán Darío Castro-Arias a. Clínica Medellín Grupo Quironsalud. Medellín, Colombia. b. Cardiovascular Anesthesiology Program, Universidad CES. Medellín, Colombia.
Keywords: Cardiopulmonary bypass, Heparin, Resistance, Antithrombin III Deficiency, Anticoagulation, Platelet Aggregation Inhibitors, Anesthesiology


Marfan syndrome classically presents with aortic root aneurysms. Aortic ectasia causes diverse blood flow alterations, influencing the behavior of coagulation factors and platelet activity. Heparin resistance has also been reported associated with Marfan Syndrome in a small number of patients, probably due to antithrombin III (ATIII) deficiency or various mutations. The ascending aorta and the aortic valve are replaced with prosthetic material during Bentall- de Bonno procedures. Resistance to anticoagulation during extracorporeal circulation, represents a significant challenge for both anesthesiologists and the surgical team. Resistance to heparin was observed in a patient with Marfan syndrome undergoing a Bentall procedure. ATIII concentrate was not available, and ACT did not increase despite high doses of heparin. An alternate anticoagulation approach was used successfully.


Kornhuber K, Seidel H, Pujol C, Meierhofer C, Röschenthaler F, Pressler A et al. Hemostatic abnormalities in adult patients with Marfan syndrome. Cardiovasc Diagn Ther. 2019;9(S2):S209-20. doi:

Bogren H, Mohiaddin R, Yang G, Kilner P, Firmin D. Magnetic resonance velocity vector mapping of blood flow in thoracic aortic aneurysms and grafts. J Thorac Cardiovasc Surg. 1995;110(3):704-14. doi:

Geiger J, Markl M, Herzer L, Hirtler D, Loeffelbein F, Stiller B et al. Aortic flow patterns in patients with Marfan syndrome assessed by flow-sensitive four-dimensional MRI. J Magn Reson Imaging. 2011;35(3):594-600. doi:

Bellini C, Korneva A, Zilberberg L, Ramirez F, Rifkin D, Humphrey J. Differential ascending and descending aortic mechanics parallel aneurysmal propensity in a mouse model of Marfan syndrome. J Biomechanics. 2016;49(12):2383-9. doi:

Hathcock J. Flow Effects on Coagulation and Thrombosis. Arteriosclerosis, Thrombosis, and Vascular Biology. 2006;26(8):1729-37. doi:

Gogia S, Neelamegham S. Role of fluid shear stress in regulating VWF structure, function and related blood disorders. Biorheology. 2016;52(5-6):319-35. doi:

Finley A, Greenberg C. Heparin Sensitivity and Resistance. Anesthesia & Analgesia. 2013;116(6):1210-22. doi:

FitzGerald D, Patel A, Body S, Garvin S. The relationship between heparin level and activated clotting time in the adult cardiac surgery population. Perfusion. 2009;24(2):93-6. doi:

Bull B, Korpman R, Huse W, Briggs B. Heparin therapy during extracorporeal circulation. J Thorac Cardiovasc S. 1975;69(5):674-84. doi:

Brister S, Ofosu F, Buchanan M. Thrombin Generation during Cardiac Surgery: Is Heparin the Ideal Anticoagulant?. Thrombosis and Haemostasis. 1993;70(02):259-62. doi:

Shore-Lesserson L, Baker R, Ferraris V, Greilich P, Fitzgerald D, Roman P, et al. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines — Anticoagulation During Cardiopulmonary Bypass. Ann Thorac Surg. 2018;105(2):650-62. doi:

Young J, Kisker C, Doty D. Adequate Anticoagulation During Cardiopulmonary Bypass Determined by Activated Clotting Time and the Appearance of Fibrin Monomer. Ann Thorac Surg. 1978;26(3):231-40. doi:

Sniecinski R, Bennett-Guerrero E, Shore-Lesserson L. Anticoagulation Management and Heparin Resistance During Cardiopulmonary Bypass. Anesthesia & Analgesia. 2019;129(2):e41-4. doi:

Choudhury M, Kiran U, Saxena N, Saxena R. Heparin resistance and Marfan syndrome: Is there any correlation?. J Cardiothorac Vasc Anesth. 2002;16(1):75-9. doi:

Levy J, Connors J. Heparin Resistance — Clinical Perspectives and Management Strategies. New Engl J Med. 2021;385(9):826-32. doi:

Durand M, Lecompte T, Hacquard M, Carteaux J. Heparin-induced thrombocytopenia and cardiopulmonary bypass: anticoagulation with unfractionated heparin and the GPIIb/IIIa inhibitor tirofiban and successful use of rFVIIa for post-protamine bleeding due to persistent platelet blockade. European Journal of Cardio-Thoracic Surgery. 2008;34(3):687-9. doi:

Koster A, Loebe M, Mertzlufft F, Kuppe H, Hetzer R. Cardiopulmonary bypass in a patient with heparin-induced thrombocytopenia II and impaired renal function using heparin and the platelet GP IIb/IIIa inhibitor tirofiban as anticoagulant. The Annals of Thoracic Surgery. 2000;70(6):2160-2161. doi:

Koster A, Kukucka M, Bach F, Meyer O, Fischer T, Mertzlufft F et al. Anticoagulation during Cardiopulmonary Bypass in Patients with Heparin-induced Thrombocytopenia Type II and Renal Impairment Using Heparin and the Platelet Glycoprotein IIb–IIIa Antagonist Tirofiban. Anesthesiology. 2001;94(2):245-251. doi:

Koster A, Chew D, Kuebler W, Habazettl H, Bauer M, Hausmann H et al. Effects of tirofiban on hemostatic activation and inflammatory response during cardiopulmonary bypass. Am J Cardiol. 2003;91(3):346-7. doi:

Warkentin T, Greinacher A. Heparin-induced thrombocytopenia and cardiac surgery. The Annals of Thoracic Surgery. 2003;76(6):2121-31. doi:

Murphy G, Marymont J. Alternative Anticoagulation Management Strategies for the Patient With Heparin-Induced Thrombocytopenia Undergoing Cardiac Surgery. J Cardioth Vascula Anesth. 2007;21(1):113-26. doi:

Tanaka K, Katori N, Szlam F, Sato N, Kelly A, Levy J. Effects of tirofiban on haemostatic activation in vitro. British J Anaesth. 2004;93(2):263-9. doi:

Casserly I, Topol E, Jia G, Lange R, Hamm C, Meier B et al. Effect of abciximab versus tirofiban on activated clotting time during percutaneous intervention and its relation to clinical outcomes—observations from the TARGET trial. The Am J Cardiol. 2003;92(2):125-9. doi:

Moorehead M, Westengard J, Bull B. Platelet Involvement in the Activated Coagulation Time of Heparinized Blood. Anesthesia & Analgesia. 1984;63(4):394-8. doi:

How to Cite
Fernandez-Turizo MJ, Benavidez-Zora D, Anaya-Hoyos AE, Portillo-Gómez S, Castro-Arias HD. The addition of Tirofiban infusion to heparin for intraoperative heparin resistance associated with Marfan Syndrome. Colomb. J. Anesthesiol. [Internet]. 2022 Mar. 16 [cited 2023 Dec. 5];50(4). Available from:


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How to Cite
Fernandez-Turizo MJ, Benavidez-Zora D, Anaya-Hoyos AE, Portillo-Gómez S, Castro-Arias HD. The addition of Tirofiban infusion to heparin for intraoperative heparin resistance associated with Marfan Syndrome. Colomb. J. Anesthesiol. [Internet]. 2022 Mar. 16 [cited 2023 Dec. 5];50(4). Available from:
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