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Antiphospholipid syndrome; its implication in cardiovascular diseases: a review

Antiphospholipid syndrome; its implication in cardiovascular diseases: a review Antiphospholipid syndrome (APLS) is a rare syndrome mainly characterized by several hyper-coagulable complications and therefore, implicated in the operated cardiac surgery patient. APLS comprises clinical features such as arterial or venous thromboses, valve disease, coronary artery disease, intracardiac thrombus formation, pul- monary hypertension and dilated cardiomyopathy. The most commonly affected valve is the mitral, followed by the aortic and tricuspid valve. For APLS diagnosis essential is the detection of so-called antiphospholipid antibodies (aPL) as anticardiolipin antibodies (aCL) or lupus anticoagulant (LA). Minor alterations in the anticoagulation, infec- tion, and surgical stress may trigger widespread thrombosis. The incidence of thrombosis is highest during the fol- lowing perioperative periods: preoperatively during the withdrawal of warfarin, postoperatively during the period of hypercoagulability despite warfarin or heparin therapy, or postoperatively before adequate anticoagulation achieve- ment. Cardiac valvular pathology includes irregular thickening of the valve leaflets due to deposition of immune complexes that may lead to vegetations and valve dysfunction; a significant risk factor for stroke. Patients with APLS are at increased risk for thrombosis and adequate anticoagulation is of vital importance during cardiopul- monary bypass (CPB). A successful outcome requires multidisciplinary management in order to prevent thrombotic or bleeding complications and to manage perioperative anticoagulation. More work and reporting on anticoagula- tion management and adjuvant therapy in patients with APLS during extracorporeal circulation are necessary. Introduction restenosis of the coronaries and the grafts after percuta- Antiphospholipid syndrome (APLS) [1,2] comprises clini- neous interventions or CABG respectively, causing signifi- cal features such as arterial or venous thromboses and the cant morbidity and mortality [6,7]. Especially, APLS detection of so-called antiphospholipid antibodies (aPL) as patients can develop vasculo-occlusive complications anticardiolipin antibodies (aCL) or lupus anticoagulant before operation with the reversal of preoperative anti- (LA). APLS may be the most common acquired hypercoa- coagulation, intraoperatively due to inadequate anticoagu- gulable state, occurring in up to 2% of the general popula- lation during bypass and postoperatively before the tion [3,4]. However, not all patients with these antibodies achievement of adequate anticoagulation [8]. Therefore, will develop the antiphospholipid syndrome, as antipho- the management of APLS patient can be quite challenging spholpid antibodies have been found in about 5% of the both for cardiologist and cardiac surgeon. healthy population [5]. Patients with APLS have a signifi- cant involvement of the cardiovascular system. Coronary Etiology-Pathophysiology artery disease and valvular abnormalities constitute the Anticardiolipin (aCL) antibodies are a heterogeneous most frequent manifestations representing more than two- family of auto-antibodies directed against protein- thirds of cases [5]. Several studies have demonstrated that phospholipid complexes [6]. It is now generally hypercoagulability of APLS patients predisposes to high accepted that there is a group of patients in whom rates of thromboembolic events as well as high rate of high titers of aCL antibodies, usually the IgG class, and thrombotic features occur without clinical manifesta- * Correspondence: [email protected] tions of systemic lupus erythematosus (SLE): primary Cardiothoracic Surgery Department. University of Patras, School of Medicine. APLS [2,6]. Anticardiolipin antibodies can be also Patras Greece observed in patients with SLE, or other autoimmune Full list of author information is available at the end of the article © 2010 Koniari et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 2 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 diseases (e.g. rheumatoid arthritis): secondary APLS. Table 1 Pathways and mechanisms resulting in a prothrombotic state in APLS Moreover, it has been proved that the pathogenic anti- bodies accountable for the APLS main symptoms are Pathway Mechanism not direct aPL against phospholipids itself; as produced Activation of expression of adhesion molecules or tissue endothelial cells: factor (2,13,14) in infections (e.g. syphilis), neoplastic disorders or Activation of induction of thromboxane A2, increased induced by certain drugs (e.g. phenothiazines, quini- thrombocytes: adhension (15) dine) but rather indirect “aPL” directed against certain Activation of A. tissue factor production (activation of phospholipid depending proteins [2,9]. The targets of coagulation cascade: extrinsic pathway: monocytes (14) pathogenic antibodies in APLS are plasma or vascular B. via thrombin activation (direct mechanism) cell proteins. Specifically, the main target antigens (2,10) reported in patients with APLS include beta-2-glyco- C. via cell activation (indirect mechanism) (2) protein-1 (b2GPI), prothrombin and annexin V [2,10]. Inhibition of A. inhibition of plasminogen/plasmin (2,16) anticoagulation: Other putative antigens are thrombin, protein C, pro- B. inhibition of t-PA by displacement from annexin II (16) tein S, thrombomodulin, tissue plasminogen activator, C. inhibition of protein C by thrombomodulin kininogens (high or low molecular), prekallikrein, fac- (2,11) tor VII/VIIa, factor XI, factor XII, complement compo- D. inhibition of protein S (11) nent C4, heparan sulfate proteoglycan, heparin, oxidised low-density lipoproteins [10,11]. The main autoantigens are attracted to negatively charged phos- (-) usually thrombotic APLS patients who develop throm- pholipids (PL ) exposed on the outer side of cell bocytopenia [18]. However, thrombocytopenia is not membranes in great amounts only under special cir- protective against thrombosis. Several explanations exist cumstances such as damage or apoptosis (e.g. endothe- as to why increased aCL may contribute to increased lial cell) or after activation (e.g. platelets) [2,12]. thrombotic risk, including platelet damage, interference Several membrane receptors have been recognized as with antithrombin III activity, and inhibition of prekal- signal transducers and after intracellular processing of likrein or protein C activation by thrombomodulin the signal, the expression of adhesion molecules as E- [19,20]. In addition, thrombotic complications appear to selectin, vascular-cell-adhesion-molecule-1 (VCAM-1) result from aPL-mediated displacement of annexin-V or intracellular adhesion-molecule-1 (ICAM-1) increase from phospholipid surfaces [21]. This displacement of the adhesion of immunocompetent cells further acti- annexin-V increases the quantity of coagulation factor vating endothelial cells [2,13]. Furthermore, the binding sites potentially leading to a procoagulant state production of tissue factor or inhibition of tissue- [22]. Because many individuals with high aPL antibody factor-pathway-inhibitor (TFPI) activates the extrinsic titers remain asymptomatic, several studies have pro- coagulation pathway [2,14], while the simultaneous posed a 2-hit hypothesis. The presence of aPL antibo- decreased production of prostacyclin induces vasocon- dies induces endothelial dysfunction (first hit) and striction and platelet aggregation. The activation of another condition (second hit) such as pregnancy infec- platelets results in the production of thromboxane A2 tion, or vascular injury trigger thrombosis [8,23]. with further platelet activation and increased adhesion to collagen [15]. On the other hand, the displacement Clinical manifestations of APLS of tissue type plasminogen activator (t-PA) from Cardiac manifestations in APLS include valvular disease, annexin II, an endothelial cell membrane receptor and coronary artery disease, intracardiac thrombus forma- simultaneously enhancer to t-PA [16] could reduce the tion, pulmonary hypertension and dilated cardiomyopa- plasmin activation leading in deceleration of fibrinoly- thy [5,8]. Cardiac valvular pathology includes irregular sis [2]. The above potential activated pathways cause a thickening of the valve leaflets due to deposition of prothrombotic state in APLS (table 1). immune complexes that may lead to vegetations and Generally, the binding of aPL to platelet membrane valve dysfunction. These lesions are frequent and may phospholipid-bound proteins may initiate platelet aggre- be a significant risk factor for stroke [8]. Noninfectious gation and thrombosis. Thrombosis may comprise the and noninflammatory but rather thrombotic or fibrotic/ final common pathway of many processes, each based calcific lesions are found in patients with primary APLS on its own particular autoantibody profile [8,17]. Indeed, [2,24]. APLS is combined with SLE in about 40% of all in nearly 30% of patients with APLS, aPL antibodies APLS patients and consequently heart valvular lesions react with phospholipids on the surface of activated pla- can also be caused by a SLE specific mechanism [24]. telets causing platelet adhension and thrombocytopenia. Non-autoimmunogenic reasons for heart valve failure in As only activated platelets expose phospholipid, it is Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 3 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 APLS-patients are possible as well [2]. The most com- note, acute diffuse alveolar haemorrhage may be present monly affected valve is the mitral, followed by the aortic in fully anticoagulated patients that could be attributed and tricuspid valves; because the surface of the left- to a non-thrombotic pathogenesis in contrast to typical sided valves is more vulnerable to micro injuries due to alveolar haemorrhage. Catastrophic APLS (cAPLS) is an stress, jet effect and turbulence [2,8]. Notably, the inci- acute condition with multiple vascular occlusions result- dence of arterial embolization is estimated to be 77% in ing in failure of several organs simultaneously or over a patients with APLS and simultaneous mitral valve dis- short period of time (days to weeks) [2,37]. It can be ease [8,25]. Several studies have demonstrated a positive triggered by surgery, infection or changes in anticoagu- correlation between the aCL titers and valvular heart lation therapy [3,4]. cAPLS presents a mortality of 50% disease severity [5,7]. Most patients develop a mild form and can resemble syndromes such as heparin-induced of valvular regurgitation while 4-6% of patients progress thrombocytopenia (HIT), disseminated intravascular to severe valvular regurgitation necessitating replace- coagulation (DIC), systemic inflammatory response syn- ment surgeries [5,26]. The rather young age of the drome (SIRS), SLE vasculitis, thrombotic thrombocyto- patients and the most often necessary long-term antic- penic purpura (TTP) or sepsis [2]. oagulation for APLS seem to make a mechanical valve the first choice if a replacement is needed but throm- Diagnosis boembolic complications render a mechanical valve in Diagnosis of APLS includes clinical criteria of thrombo- danger of dysfunction [2,27]. The advantage of a bio- sis and/or pregnancy morbidity and laboratory proof of prosthesis is the independence of oral anticoagulation, lupus anticoagulants and/or anticardiolipin antibodies in however valve failure due to excessive pannus and con- medium or high titers on two or more occasions at least secutive stenosis renders replacement inevitable after twelve weeks apart [2,25]. aPL antibodies are a heteroge- some years [2,28]. Additionally, accelerated atherosclero- neous group and thus diagnosis requires more than one sis increases the risk of coronary artery disease; the test. The two main antibody groups are aCL antibodies etiology seems to be more related with inflammatory and LA; however patients with aCL antibodies are five and immunopathologic factors as compared with tradi- times more common than those with LA [18]. Results of tional Framingham cardiovascular risk factors [8,29]. aCL assays are expressed as IgG and IgM phospholipids The presence of intracardiac thrombus is a rare but units (GPL or MPL units) based on standard curves. potentially a life-threatening manifestation of APLS. According to the updated classification criteria for APLS Thrombus formation, a potential cause of pulmonary [1] the diagnosis of APLS requires at least one of the and systemic emboli, may occur in any cardiac chamber following clinical (vascular thrombosis or complications but most frequently on the right side [8]. Antiphospholi- of pregnancy) and one of the laboratory criteria. pid antibodies have been associated with various other thrombogenic complications such as recurrent thrombo- Diagnostic (classification) criteria of APLS (1) sis, thrombocytopenia and serious bleeding abnormal- I. Clinical criteria ities [30-32]. Of those patients with APLS who present 1. Vascular thrombosis Arterial, venous or small vessel with thrombosis, 30 ± 55% will present with venous thrombosis in any tissue or organ, to be confirmed by thrombosis, especially of the lower limbs [18]. Repeat objective validated criteria (imaging studies or histo- episodes of thrombosis are often of the same type [33]. pathology). For histopathologic confirmation, thrombo- However, it is paradox that despite the well-documented sis should be present without significant evidence of coexistence of autoantigens and its antibodies in blood inflammation in the vessel wall. of APLS patients for long periods, thrombotic events 2. Pregnancy morbidity -One or more unexplained occur only sporadically. Eventually, it can be assumed deaths of a morphologically normal fetus beyond the that thrombotic events occur much more often but only 10th week of gestation or in microvasculature or smaller vessels, resulting in dete- -One or more premature births of a morphologically rioration of organ function such as renal failure, cerebral normal neonate before the 34th week of gestation damages or impairment of the myocardial function by because of eclampsia or preeclampsia or placental multiple recurrent microthromboses or microemboli insufficiency. [26]. Neurologic manifestations of APLS have been -Three or more unexplained consecutive spontaneous reported to include recurrent cerebral infarcts, head- abortions before the 10th week of gestation. aches, migraines and visual disturbances [34,35]. Other II. Laboratory criteria manifestations of APLS include skin ulcers (pyoderma 1. Lupus anticoagulants in plasma. gangrenosum- like or livedoid vasculitis) due to fibrin 2. Anticardiolipin antibody of IgG and/or IgM isotype deposition within the lumens of superficial dermal ves- in serum or plasma, present in medium or high titer sels as well as diffuse alveolar haemorrhage [36]. Of (i.e. >40 GPL or MPL). Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 4 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 3. Anti-beta2Glycoprotein1-antibodies of IgG and/or c. aPTT test may differ because of different ingredi- IgM isotype in serum or plasma. ents concerning its sensitivity towards the LA effect. Especially, the activator (e.g. kaolin, silica, ellagic acid or Laboratory tests: approaching potential celite), the phospholipid source (several animal or plant limitations sources) and finally the clot-detection method/instru- The definition of “APLS” requires the positive testing for ments (photo-optical, mechanical, manual) can vary lupus anticoagulant, anti-cardiolipin or anti-b2GPI twice widely, influencing the test result [2,40]. Similar to at least 12 weeks apart [1]. The double testing contri- aPTT is the principle of the dRVVT. At least, both butes to the exclusion of patients with a transient reac- these tests should always be performed when plasma is tivity by direct antiphospholipid-antibodies due to tested for an LA-effect [1]. Anti-cardiolipin test, the infections or other contributory factors [2,38]. “Lupus classic solid phase assay test, should be considered only anticoagulant” is a misnomer for a group of various as a differential diagnosis in a positive test result, phospholipid inhibitors, observed usually without under- because direct antibodies to CL are not pathogenic for lying SLE and in vivo related not to bleeding but to APLS. One of test limitations, is that both patient’s thrombotic complications. Coagulation tests used to serum and buffer solution (usually bovine serum) pro- reveal lupus anticoagulant include: activated partial vide homologous b2GPI, introducing an extra amount thromboplastin time (aPTT), diluted Russell’sviper of target antigens [41]. Therefore, the test result can be venom test (dRVVT), taipan venom test, textarin influenced in case of a present human autoantibody venom/ecarin venom clotting time ratio, kaolin clotting (especially isotype IgM) that reacts exclusively with time and tissue thromboplastin inhibition test [38]. Gen- human b2GPI [2,41]. Fact that makes the colour reac- erally, tests are sensitive but usually need a meticulous tion less powerful and false-negative as the strength of interpretation. For example, a prolongation of clotting reaction is significant for APLS diagnosis; consequently tests such as aPTT, usually is an indication of a bleeding only moderate to high titer antibodies are considered as tendency, but in APLS patients is correlated with a high “positive aCL” for APLS [1,2]. Moreover, as mentioned risk for thrombotic/thromboembolic events [2,39]. Espe- already for the LA-tests the plasma should be platelet (-) cially, some tests such as prothrombin time (PT), aPTT, depleted; otherwise exposed PL on the surface of acti- or dRVVT based on both calcium and phospholipids vated platelets attract b2GP. A final pitfall of anti-cardi- adequacy for further activation of several clotting factors olipin test is that CL represents one of several negatively (Factor II, VII, IX, X) [40]. If the measured time of clot charged phospholipids rendering possible to miss a few (-) forming after addition of Ca2+ and PL is prolonged, a cases in which specific autoantibodies react with b2GPI (-) possible explanation is the existence of antibodies inter- only when bound to another PL , e.g. phosphatidylser- acting with phospholipids. If the clotting time is not ine [2]. Finally, anti-b2GPI and anti-prothrombin ELISA corrected by addition of normal plasma (mixing step - tests promise a more specific diagnosis of APLS. Beyond corrects missing coagulation factors) but tends to be anti-b2GPI, ELISA tests for antiPT, with prothrombin normal by adding an excessive amount of phospholipids directly fixed on a plate or via phosphatidylserine (confirmation step by adding activated thrombocytes) (antiPS-PT) add further information especially if tests the LA effect is considered “positive” [2,29]. However, for LA, aCL or anti-b2GPI are persistently negative LA testing presents several drawbacks: [2,42]. It is debating if these tests have to be repeated a. LA test, considered highly sensitive but not very for confirmation of the diagnosis APLS because they are specific concerning thromboembolic risk in APLS theoretically not influenced by non-pathogenic antibo- patients, can only be reliable if potential sources for dies, cancer or drugs [2,42]. phospholipids are removed before testing. In daily rou- tine plasma for clotting tests is prepared by centrifuga- Relation of aCL with restenosis following tion of a blood sample, removing red and white blood percutaneous coronary interventions (PCI) cells. However, the smaller and lighter thrombocytes in CAD patients stay mainly in the supernatant providing a rich source The role of serum aCL levels in natural history and (-) of PL [2,38]. prognosis of acute coronary syndromes (ACS) is still b. The prothrombin time is a routine test depending undetermined. However, anticardiolipin antibodies have (-) on Ca2+ and PL in factor VII, X and II [29]. The acti- been found to be associated with arterial and venous vator, tissue thromboplastin, is extracted from animal thrombosis [43]. Angioplasty-induced arterial injury (-) tissues bounding in PL , rendering this test useless for leads to platelet aggregation, adhesion, and thrombosis. APLS diagnosis. Recently a modified test with an exact Several factors that are involved in the thrombogenesis amount of recombinant TF and synthetic phospholipids may influence the restenosis rate after PTCA as throm- [2,38] is available allowing the detection of LA. bosis is one of the possible mechanisms of restenosis. Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 5 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 Different mechanisms are associated with high aCL-IgG secondary to excessive anticoagulation or APLS asso- levels and restenosis after PCI [6]. Contradictory results ciated clotting factor deficiencies (especially factor II) have been demonstrated concerning the effect of aCL [18]. In the meantime, minor alterations in anticoagulant antibodies on restenosis. Eber, et al [44] showed that therapy, infection, or a surgical insult may trigger wide- aCL-IgM was an independent risk factor for restenosis spread thrombosis. Moreover, deep hypothermic circula- after PTCA in 65 men with coronary artery disease, tory arrest (DHCA) complicates the problem of however, no correlation was found between aCL-IgG anticoagulation during cardiac surgery because of the and restenosis. Ludia, et al [45] reported that restenosis combination of blood stasis and changes in enzymatic was more frequent in aCL positive patients with activity associated with the extreme temperature differ- ischemic heart disease. Gurlek et al [6] studied the fol- ences [56,57]. Therefore, the management of anticoagula- low-up coronary angiography in two groups of 80 tion during CPB can be quite challenging and close patients with acute coronary syndrome, in comparison cooperation with the haematology department is essen- to IgM and IgG aCL levels measured before hospital dis- tial. There is no consensus in the literature as to the opti- charge. The results suggested that restenosis occurs mal method for assuring perioperative anticoagulation in more frequently in anticardiolipin positive patients. In APLS. While, monitoring anticoagulation in APLS contrast, Chiarugi, et al [46] observed no association patient during cardiac surgery remains problematic, as between the presence of aCL and clinical restenosis, aPL often interfere with in vitro tests of hemostasis by however, the presence of aCL with elevated lipoprotein impeding the binding of coagulation proteins to phos- a [Lp(a)] levels, acting synergistically, increased the risk pholipid surfaces [21]. Especially, during CPB, blood con- of restenosis. Finally, in a recent study, Sharma S et al tact with extracorporeal surfaces causes stimulation of [47], failed to demonstrate any significant correlation the coagulation cascade. To prevent clotting, unfractio- between the level of IgG anticardiolipin antibodies and nated heparin is administered before CPB. Heparin con- in-stent restenosis in patients having undergone PCI centrations of greater than/equal to 3 u/ml ± 1 are with bare metal or drug eluting stents. The corellation generally accepted as therapeutic for CPB [58], but indi- of elevated aCL levels and post-ACS cardiovascular vidual patient responses to a standardized heparin dose events is still controversial. The largest study on this vary. Heparin activity is assessed using the activated clot- issue was recently reported by Bili et al, [48] who stu- ting time (ACT) which is a phospholipid dependent test died 1150 AMI patients, demonstrating that elevated and may be prolonged by LA antibodies [18]. In the nor- aCL-IgG and low aCL-IgM antibodies were independent mal patient, a heparin concentration of 3 uml ± 1 typi- risk factors for recurrent cardiovascular events. Zucker- cally produces a kaolin ACT of more than 450 seconds. man et al, [49] suggested that the presence of aCL is a LMWH is attractive in this setting as it causes a highly marker for increased risk for myocardial reinfarction predictable anticoagulant effect for a given dose, decreas- and thromboembolic events after acute myocardial ing the need for monitoring [18]. Suggested alternative infarction (MI). However, Hamsten and colleagues [50] methods for monitoring anticoagulation during bypass in demonstrated that antibodies to cardiolipin are markers APLS patients include empirically doubling the baseline for a high risk of recurrent cardiovascular events in ACT or to reach an ACT twice the upper limit of normal young survivors of MI; but their study was small in [2], obtaining heparin concentrations by protamine titra- scope. On the contrary, Sletnes, et al [51] in 597 acute tion (Hepcon) [59], performing anti-factor Xa assays, or MI survivors, using multivariate analysis, failed to prove performing heparin/ACT titration curves preoperatively that aCL is an independent risk for mortality, cerebral to determine patient specific target ACT levels [18]. The thromboembolism, or recurrent MI. Analogous results in vitro heparin/ACT titration curve is a test of an indivi- were obtained by Cortellaro et al, [52] in their study of dual patient’s responsiveness to heparin. Moreover, preo- 74 young MI patients and Phadke et al, [53] who mea- peratively, anti-Xa factor activity assays can be correlated sured aCL in 299 survivors of acute MI. Eventually, with the patient specific preoperative in vitro heparin Gurlek et al, [6] found no association between aCL anti- ACT titration curve [18]. Anti-Xa monitoring is generally bodies with recurrent cardiovascular events (reinfarction considered the"gold standard” laboratory measure of and intracardiac thrombus formation) in ACS patients. heparin therapy for use in situations in which the aPTT may be adversely affected [22]. By using this testing Intraoperative management of coagulation: method, known concentrations of purified coagulation a crucial problem factor Xa and antithrombin are mixed with a sample of Patients with APLS are at increased risk for thrombosis the patient’s heparin-containing plasma [18,22]. Anti-fac- and adequate anticoagulation is of vital importance dur- tor Xa levels of 1.5 ± 2.0 u/ml ± 1 are considered thera- ing cardiopulmonary bypass (CPB) [18,30,31,54,55]. Peri- peutic for CPB [18]. Postoperatively, levels greater than operative risks include thrombosis and/or bleeding 1.0 u/ml ± 1 may be associated with excess blood loss Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 6 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 [60]. When treating venous thromboembolism, the target may not correlate well with diagnosis or outcome in rangeofanti-factor Xa activity is 0.6±1.0u/ml±1[6]. APLS [71]. Although the risk of thrombosis is reduced However, the turnaround time for anti-factor Xa assays with increased anticoagulation, there is an associated are currently incompatible with the time constraints of increased risk of significant bleeding [18]. Protamine to CPB [18,60]. Generally, various anticoagulation methods antagonise heparin should be administered only in a for dosing heparine during CPB have been performed. stepwise manner or in low dose continuously intrave- Especially, Sheikh et al [61] elected to empirically double nous, e.g. 50 mg/h [2], until the bleeding tendency slows the ACT to more than 999 seconds; as obtaining factor down to an acceptable amount. Also, a scrutinised opera- Xa or plasma heparin concentrations was considered tive technique and haemostasis to avoid any unnecessary impractical. On the other hand, East et al [22] elected to surgical bleeding site are of great importance [2]. In perform heparin-celite ACT titration curves preopera- patients with secondary APLS and thrombosis, there is tively on each patient to assess the effect of APL antibo- an ongoing endothelial disturbance secondary to the dies on ACT monitoring. Based on the patient-specific underlying vasculitis and the risk of recurrent thrombotic titration curve, therapeutic anticoagulation (heparin con- events is high [2]. Anti-platelet therapy as well as war- centration 3.0 U/mL) for CPB was achieved in patients at farin anticoagulation is indicated. Moreover, additional celite ACT values exceeding 550 s. Also, laboratory based factors of thrombosis such as hypertension, diabetes mel- anti-Xa monitoring was performed concurrently during litus, hyperlipidaemia should be treated optimally or CPB as a secondary confirmatory measure [22]. In retro- avoided (e.g. smoking) [2]. Generally, antiplatelet therapy spective studies, a lower incidence of recurrences (arterial may be added but the effectiveness of low-dose aspirin or and venous) episodes of thrombosis was observed in the newer antiplatelet agents is unproven. In cases where patients kept at a high intensity of oral anticoagulation thrombosis continues despite adequate anticoagulation, [62-64] leading to the recommendation that patients with additional treatment is aimed either at preventing anti- antiphospholipid antibodies who have had a documented body formation or reducing antibody titres and may major thrombotic event should receive life-long oral include corticosteroids, immunosuppressive agents, i.v. anticoagulant treatment to achieve an INR of 3.0 or immuneglobulin, or plasmapheresis. Particularly, Dor- higher [62,65,66]. In spite of anticoagulant treatment, man R [18] described the perioperative course and suc- recurrence of thrombosis is frequent in patients with the cessful treatment of a 31-yr-old woman with primary APLS [63,67], especially in those carrying lupus anticoa- APLS requiring a mitral valve replacement; that post- gulant (LA) [68] and/or high titers of anticardiolipin anti- operatively, developed acute global biventricular failure bodies [63,67]. Especially, Della Valle et al [63] showed requiring extracorporeal membrane oxygenation support that INR determinations obtained with a recombinant PT and plasmapheresis. Alternative methods for anticoagula- reagent substantially overestimate the actual degree of tion during CPB are essential and multiple options are anticoagulation of most lupus anticoagulants patients available today [56]. These options include ancrod, hiru- due to interference of lupus anticoagulant IgG in PT din, lepirudin, argatroban, prostacyclin, platelet IIb/IIIa assays carried out at low test plasma dilution, as occurs inhibitors, complement inhibitors, IL-3 and bivalirudin with plain and recombinant thromboplastin reagents. [56,72]. Also, tissue plasminogen activator has been used Also, according to the Duration of Anticoagulation Study successfully in one case report of APLS with ST changes Group, patients with anti-cardiolipin IgG antibodies and normal coronary arteries [73]. Bivalirudin is a biva- require prolonged anticoagulation to avoid recurrences lent reversible direct thrombin inhibitor and has been of venous thromboembolism [69]. In addition, while on used safely for CPB in HIT-positive patients [56,72, oral anticoagulant treatment targeted at an INR between 74-76]. It is also successfully used during off-pump/ 2.0 and 2.85, the recurrence rate increased with the antic- on-pump coronary artery bypass grafting and heart trans- ardiolipin antibody titter, but was not significantly differ- plantation [77-79]. Bivalirudin is a bivalent direct throm- ent in patients with (1.32 per 100 patient-years) or bin inhibitor with a short half-life of approximately 25 without (0.6 per 100 patient-years) anti-cardiolipin anti- minutes [56]. Its 20-amino acid molecule combines a car- bodies [69]. Specifically, patients with primary APLS with boxy-terminal region that recognizes thrombin’sfibrin thrombosis are treated with heparin followed by warfarin (ogen)-binding site, and an amino-terminal tetrapeptide in the usual manner [18]. There is controversy over the that inhibits the active site of thrombin [56]. Conse- intensity of anticoagulant therapy, the duration of treat- quently, thrombin inhibition of bivalirudin inactivates ment, and the method for measuring the INR. Recurrent not only fluid-phase thrombin, but also fibrin-bound thrombotic events of any type usually signal the need for thrombin [80]. Therefore, thrombus formation may be life-long anticoagulation. Recurrent thrombosis while on attenuated more effectively and anticoagulation produced standard intensity anticoagulant therapy dictates the use more predictably than by heparin [56,80]. Pharmaco- of a higher target INR at about 2,5-3,5 [70], but the INR kinetically bivalirudin is predominantly eliminated by Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 7 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 enzymatic degradation through proteases and thrombin Statins may be beneficial in APLS patients by suppressing itself (80%)and to alesserdegreebyrenal clearance the inflammatory response, which is important in case of (20%) [81]. No reversal for bivalirudin exists, but its elim- valvular lesions and vascular occlusive disease [8]. How- ination can be enhanced by hemodialysis and hemofiltra- ever, no clinical investigations using statins as anti- tion [81,82]. The theoretical potential of aprotinin to inflammatory treatment in APLS patients have been delay bivalirudin elimination and to prolong its anticoa- reported. Finally, specific therapeutic treatment for APLS gulant effect has not been demonstrated [56]. In one is not available yet. The application of peptides specifi- study aprotinin did not affect the elimination of bivaliru- cally bound by anti-b2GPI antibodies thus neutralising din [82]. Leissner et al [56], reported a case from a the functional effect of the autoantibodies [91] or pep- patient with APLS with massive thrombosis of right tides which have a similar amino acid sequence as atrium. This patient underwent DHCA by using bivaliru- domain V of b2GPI thus possibly blocking putative din, for thrombectomy to avoid potential catastrophic receptors in an antagonistic manner [2,92] constitute pulmonary embolism. During CPB the ACT was restored promising therapeutic approaches. between 500-750 sec with the initial dose of bivalirudin and during the circulatory arrest the arterial and venous Outcomes of cardiac surgery in APLS patients lines were clamped and the CPB circuit was recirculated The literature offers widely differing estimates of mor- distal to the arterial filter back to the soft-shelled venous bidity and mortality associated with APLS and cardio- reservoir to avoid pump clotting [56]. The DHCA time pulmonary bypass. In a retrospective analysis of 19 was planned to be short and lasted 19 minutes. No visible patients with APLS undergoing cardiac or vascular sur- clot formation was observed in the open-heart and gical procedures, Ciocca and colleagues reported an bypass circuit, but in the pericardial cavity as previously 84.2% incidence of postoperative thrombosis or bleeding attributed to increased blood stagnation [72,79]. cAPLS and 63.2% mortality [31]. Thirteen of the patients in is caused by a generalised thrombotic storm due to these series underwent cardiac surgery. Individual case excessive activation of “aPL” with consecutive multi reports of cardiac surgical patients frequently describe organ failure and peripheral ischaemic lesions as digital thrombotic or haemorrhagic complications including necrosis [2]. Also, acute single organ failure (e.g. acute early graft occlusion [93] haemothorax [94], pulmonary heart failure) representing complications of APLS should emboli, and limb ischaemia [95,96]. More optimistically, be treated similar to cAPLS. The baseline is an aggressive the literature includes several case reports of uneventful intravenous anticoagulation, usually heparin, later fol- cardiac surgery [97,98]. A meta analysis of heart valve lowed by oral anticoagulation with vitamin K-antagonists surgery by Gorki et al [2] demonstrated that the mortal- [2,83]. Steroids may contribute to limitation of the cyto- ity is high with 7% early deaths and 12% late deaths kine release and further treat the widespread vasculitis after a mean follow-up period of less then 3 years. The [83]. Moreover, plasmapheresis or intravenous gamma- early and late morbidity with major complications (valve globulins reduce the autoantibody load, improving the related included) respectively is significant. Only 42% of outcome [2,84]. The use of prostacyclin, fibrinolytics, the patients had an uneventful short and long-term cytotoxic drugs, splenectomy or dialysis are described but recovery. APLS-typical processes could be explanation without proven advantage for survival. In Asherson and for the majority of postoperative problems, especially for colleagues [83] most recent retrospective case series of myocardial and cerebral complications and other overt cAPLS, only anticoagulation was associated with statisti- thromboembolic events. The high proportion (about cally significant increased survival. While, in previous 20%) of valve-related complications such as valve throm- Asherson and colleagues series [84], plasmapheresis did bosis is remarkable. Colli et al [99], in a recent retro- reduce mortality. Also, there are case reports of acute spective analysis of nine patients with antiphospholipid biventricular failure in APLS with necropsy findings of syndrome that underwent heart valve surgery using myocardial microvascular thrombosis [85-89]. In this CPB, observed high morbidity (50%) and mortality situation, antithrombotic not anti-inflammatory therapy (22%) respectively. Especially, two patients died in the is likely to be effective [18]. A diagnosis of fulminant early postoperative period due to an acute cerebrovascu- myocarditis could be supported by the global nature of lar accident, four patients presented an uneventful late the myocardial dysfunction and its prompt resolution. postoperative course and one patient experienced an Fulminant myocarditis is associated with full recovery in ischemic stroke 5 years after mitral valve replacement over 90% of the patients who survive the event [89]. and developed refractory congestive heart failure requir- There is one case report of APLS associated postopera- ing heart transplantation three years postoperatively. tive fulminant myocarditis managed with immunosup- Similarly, Berkun et al [55] presented an increased mor- pressive steroids [90]. Currently, there is some scientific bidity and mortality in ten patients with APLS under- rationale for adding a statin as adjunctive treatment. going valve replacement. Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 8 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 2. Gorki H, Malinovski V, Stanbridge RDL: The antiphospholipid syndrome Conclusions and heart valve surgery. Eur J CardioThorac Surg 2008, 33:168-18. APLS is one of the most commonly acquired hypercoa- 3. Tripodi A, Chantarangkul V, Clerici M, Negri B, Galli M, Mannucci PM: gulable states. Minor alterations in the anticoagulation, Laboratory control of oral anticoagulant treatment by the INR system in patients with the antiphospholipid syndrome and lupus anticoagulant. infection, and surgical insult may trigger widespread Results of a collaborative study involving nine commercial thrombosis. The incidence of thrombosis is highest dur- thromboplastins. Br J Haematol 2001, 115:672-8. ing the following perioperative periods: preoperatively 4. 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Galli M, Luciani D, Bertolini G, Barbui T: Anti-beta 2-glycoprotein I, anticardiolipin antibodies; aPL: antiphospholipid antibodies; APLS: antiprothrombin antibodies, and the risk of thrombosis in the antiphospholipid syndrome; b2GPI: beta-2-glycoprotein-1; CPB: antiphospholipid syndrome. Blood 2003, 102:2717-23. cardiopulmonary bypass; cAPLS: catastrophic APLS; CABG: coronary artery 11. Oosting JD, Derksen RH, Bobbink IW, Hackeng TM, Bouma BN, deGroot PG: bypass grafting; DHCA: deep hypothermic circulatory arrest; dRVVT: diluted Antiphospholipid antibodies directed against a combination of Russell’s viper venom test; DIC: disseminated intravascular coagulation; HIT: phospholipids with prothrombin, protein C, or protein S: an explanation heparin-induced thrombocytopenia; INR: international normalized ratio; ICAM-1: for their pathogenic mechanism? Blood 1993, 81:2618-25. intracellular adhesion-molecule-1; Lp(a): lipoprotein a; LMWH: low-molecular- 12. Galli M, Comfurius P, Maassen C, Hemker HC, de Baets MH, van Breda- weight heparin; LA: Lupus anticoagulant; MI: myocardial infarction; aPTT: partial Vriesman PJ, Barbui T, Zwaal RF, Bevers EM: Anticardiolipin antibodies thromboplastin time; PCI: percutaneous coronary interventions; PS: (ACA) directed not to cardiolipin but to a plasma protein cofactor. phosphatidylserine; PL: phospholipids; PT: prothrombin time; SIRS: systemic Lancet 1990, 335:1544-7. inflammatory response syndrome; SLE: systemic lupus erythematosus; TTP: 13. Pierangeli SS, Espinola RG, Liu X, Harris EN: Thrombogenic effects of thrombotic thrombocytopenic purpura; TFPI: tissue-factor-pathway-inhibitor; t- antiphospholipid antibodies are mediated by intercellular cell adhesion PA: tissue type plasminogen activator; VCAM-1: vascular-cell-adhesion-molecule- molecule-1, vascular cell adhesion molecule-1, and P-selectin. Circ Res 2001, 88:245-50. 14. Roubey RA: Tissue factor pathway and the antiphospholipid syndrome. 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Perfusion 1999, 14:397-401. • No space constraints or color figure charges 95. Asherson R, Weinberger A, Kinsley R: Radial artery occlusion in primary • Immediate publication on acceptance antiphospholipid syndrome after aortic valve replacement. SAfr MedJ 1995, 85:1042. • Inclusion in PubMed, CAS, Scopus and Google Scholar 96. Sheikh F, Lechowicz A, Selut R, Rauch A, Dunn H: Recognition and • Research which is freely available for redistribution management of patients with antiphospholipid antibody syndrome undergoing cardiac surgery. J Cardiothorac Vasc Anesth 1997, 11:764-6. Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cardiothoracic Surgery Springer Journals

Antiphospholipid syndrome; its implication in cardiovascular diseases: a review

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Abstract

Antiphospholipid syndrome (APLS) is a rare syndrome mainly characterized by several hyper-coagulable complications and therefore, implicated in the operated cardiac surgery patient. APLS comprises clinical features such as arterial or venous thromboses, valve disease, coronary artery disease, intracardiac thrombus formation, pul- monary hypertension and dilated cardiomyopathy. The most commonly affected valve is the mitral, followed by the aortic and tricuspid valve. For APLS diagnosis essential is the detection of so-called antiphospholipid antibodies (aPL) as anticardiolipin antibodies (aCL) or lupus anticoagulant (LA). Minor alterations in the anticoagulation, infec- tion, and surgical stress may trigger widespread thrombosis. The incidence of thrombosis is highest during the fol- lowing perioperative periods: preoperatively during the withdrawal of warfarin, postoperatively during the period of hypercoagulability despite warfarin or heparin therapy, or postoperatively before adequate anticoagulation achieve- ment. Cardiac valvular pathology includes irregular thickening of the valve leaflets due to deposition of immune complexes that may lead to vegetations and valve dysfunction; a significant risk factor for stroke. Patients with APLS are at increased risk for thrombosis and adequate anticoagulation is of vital importance during cardiopul- monary bypass (CPB). A successful outcome requires multidisciplinary management in order to prevent thrombotic or bleeding complications and to manage perioperative anticoagulation. More work and reporting on anticoagula- tion management and adjuvant therapy in patients with APLS during extracorporeal circulation are necessary. Introduction restenosis of the coronaries and the grafts after percuta- Antiphospholipid syndrome (APLS) [1,2] comprises clini- neous interventions or CABG respectively, causing signifi- cal features such as arterial or venous thromboses and the cant morbidity and mortality [6,7]. Especially, APLS detection of so-called antiphospholipid antibodies (aPL) as patients can develop vasculo-occlusive complications anticardiolipin antibodies (aCL) or lupus anticoagulant before operation with the reversal of preoperative anti- (LA). APLS may be the most common acquired hypercoa- coagulation, intraoperatively due to inadequate anticoagu- gulable state, occurring in up to 2% of the general popula- lation during bypass and postoperatively before the tion [3,4]. However, not all patients with these antibodies achievement of adequate anticoagulation [8]. Therefore, will develop the antiphospholipid syndrome, as antipho- the management of APLS patient can be quite challenging spholpid antibodies have been found in about 5% of the both for cardiologist and cardiac surgeon. healthy population [5]. Patients with APLS have a signifi- cant involvement of the cardiovascular system. Coronary Etiology-Pathophysiology artery disease and valvular abnormalities constitute the Anticardiolipin (aCL) antibodies are a heterogeneous most frequent manifestations representing more than two- family of auto-antibodies directed against protein- thirds of cases [5]. Several studies have demonstrated that phospholipid complexes [6]. It is now generally hypercoagulability of APLS patients predisposes to high accepted that there is a group of patients in whom rates of thromboembolic events as well as high rate of high titers of aCL antibodies, usually the IgG class, and thrombotic features occur without clinical manifesta- * Correspondence: [email protected] tions of systemic lupus erythematosus (SLE): primary Cardiothoracic Surgery Department. University of Patras, School of Medicine. APLS [2,6]. Anticardiolipin antibodies can be also Patras Greece observed in patients with SLE, or other autoimmune Full list of author information is available at the end of the article © 2010 Koniari et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 2 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 diseases (e.g. rheumatoid arthritis): secondary APLS. Table 1 Pathways and mechanisms resulting in a prothrombotic state in APLS Moreover, it has been proved that the pathogenic anti- bodies accountable for the APLS main symptoms are Pathway Mechanism not direct aPL against phospholipids itself; as produced Activation of expression of adhesion molecules or tissue endothelial cells: factor (2,13,14) in infections (e.g. syphilis), neoplastic disorders or Activation of induction of thromboxane A2, increased induced by certain drugs (e.g. phenothiazines, quini- thrombocytes: adhension (15) dine) but rather indirect “aPL” directed against certain Activation of A. tissue factor production (activation of phospholipid depending proteins [2,9]. The targets of coagulation cascade: extrinsic pathway: monocytes (14) pathogenic antibodies in APLS are plasma or vascular B. via thrombin activation (direct mechanism) cell proteins. Specifically, the main target antigens (2,10) reported in patients with APLS include beta-2-glyco- C. via cell activation (indirect mechanism) (2) protein-1 (b2GPI), prothrombin and annexin V [2,10]. Inhibition of A. inhibition of plasminogen/plasmin (2,16) anticoagulation: Other putative antigens are thrombin, protein C, pro- B. inhibition of t-PA by displacement from annexin II (16) tein S, thrombomodulin, tissue plasminogen activator, C. inhibition of protein C by thrombomodulin kininogens (high or low molecular), prekallikrein, fac- (2,11) tor VII/VIIa, factor XI, factor XII, complement compo- D. inhibition of protein S (11) nent C4, heparan sulfate proteoglycan, heparin, oxidised low-density lipoproteins [10,11]. The main autoantigens are attracted to negatively charged phos- (-) usually thrombotic APLS patients who develop throm- pholipids (PL ) exposed on the outer side of cell bocytopenia [18]. However, thrombocytopenia is not membranes in great amounts only under special cir- protective against thrombosis. Several explanations exist cumstances such as damage or apoptosis (e.g. endothe- as to why increased aCL may contribute to increased lial cell) or after activation (e.g. platelets) [2,12]. thrombotic risk, including platelet damage, interference Several membrane receptors have been recognized as with antithrombin III activity, and inhibition of prekal- signal transducers and after intracellular processing of likrein or protein C activation by thrombomodulin the signal, the expression of adhesion molecules as E- [19,20]. In addition, thrombotic complications appear to selectin, vascular-cell-adhesion-molecule-1 (VCAM-1) result from aPL-mediated displacement of annexin-V or intracellular adhesion-molecule-1 (ICAM-1) increase from phospholipid surfaces [21]. This displacement of the adhesion of immunocompetent cells further acti- annexin-V increases the quantity of coagulation factor vating endothelial cells [2,13]. Furthermore, the binding sites potentially leading to a procoagulant state production of tissue factor or inhibition of tissue- [22]. Because many individuals with high aPL antibody factor-pathway-inhibitor (TFPI) activates the extrinsic titers remain asymptomatic, several studies have pro- coagulation pathway [2,14], while the simultaneous posed a 2-hit hypothesis. The presence of aPL antibo- decreased production of prostacyclin induces vasocon- dies induces endothelial dysfunction (first hit) and striction and platelet aggregation. The activation of another condition (second hit) such as pregnancy infec- platelets results in the production of thromboxane A2 tion, or vascular injury trigger thrombosis [8,23]. with further platelet activation and increased adhesion to collagen [15]. On the other hand, the displacement Clinical manifestations of APLS of tissue type plasminogen activator (t-PA) from Cardiac manifestations in APLS include valvular disease, annexin II, an endothelial cell membrane receptor and coronary artery disease, intracardiac thrombus forma- simultaneously enhancer to t-PA [16] could reduce the tion, pulmonary hypertension and dilated cardiomyopa- plasmin activation leading in deceleration of fibrinoly- thy [5,8]. Cardiac valvular pathology includes irregular sis [2]. The above potential activated pathways cause a thickening of the valve leaflets due to deposition of prothrombotic state in APLS (table 1). immune complexes that may lead to vegetations and Generally, the binding of aPL to platelet membrane valve dysfunction. These lesions are frequent and may phospholipid-bound proteins may initiate platelet aggre- be a significant risk factor for stroke [8]. Noninfectious gation and thrombosis. Thrombosis may comprise the and noninflammatory but rather thrombotic or fibrotic/ final common pathway of many processes, each based calcific lesions are found in patients with primary APLS on its own particular autoantibody profile [8,17]. Indeed, [2,24]. APLS is combined with SLE in about 40% of all in nearly 30% of patients with APLS, aPL antibodies APLS patients and consequently heart valvular lesions react with phospholipids on the surface of activated pla- can also be caused by a SLE specific mechanism [24]. telets causing platelet adhension and thrombocytopenia. Non-autoimmunogenic reasons for heart valve failure in As only activated platelets expose phospholipid, it is Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 3 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 APLS-patients are possible as well [2]. The most com- note, acute diffuse alveolar haemorrhage may be present monly affected valve is the mitral, followed by the aortic in fully anticoagulated patients that could be attributed and tricuspid valves; because the surface of the left- to a non-thrombotic pathogenesis in contrast to typical sided valves is more vulnerable to micro injuries due to alveolar haemorrhage. Catastrophic APLS (cAPLS) is an stress, jet effect and turbulence [2,8]. Notably, the inci- acute condition with multiple vascular occlusions result- dence of arterial embolization is estimated to be 77% in ing in failure of several organs simultaneously or over a patients with APLS and simultaneous mitral valve dis- short period of time (days to weeks) [2,37]. It can be ease [8,25]. Several studies have demonstrated a positive triggered by surgery, infection or changes in anticoagu- correlation between the aCL titers and valvular heart lation therapy [3,4]. cAPLS presents a mortality of 50% disease severity [5,7]. Most patients develop a mild form and can resemble syndromes such as heparin-induced of valvular regurgitation while 4-6% of patients progress thrombocytopenia (HIT), disseminated intravascular to severe valvular regurgitation necessitating replace- coagulation (DIC), systemic inflammatory response syn- ment surgeries [5,26]. The rather young age of the drome (SIRS), SLE vasculitis, thrombotic thrombocyto- patients and the most often necessary long-term antic- penic purpura (TTP) or sepsis [2]. oagulation for APLS seem to make a mechanical valve the first choice if a replacement is needed but throm- Diagnosis boembolic complications render a mechanical valve in Diagnosis of APLS includes clinical criteria of thrombo- danger of dysfunction [2,27]. The advantage of a bio- sis and/or pregnancy morbidity and laboratory proof of prosthesis is the independence of oral anticoagulation, lupus anticoagulants and/or anticardiolipin antibodies in however valve failure due to excessive pannus and con- medium or high titers on two or more occasions at least secutive stenosis renders replacement inevitable after twelve weeks apart [2,25]. aPL antibodies are a heteroge- some years [2,28]. Additionally, accelerated atherosclero- neous group and thus diagnosis requires more than one sis increases the risk of coronary artery disease; the test. The two main antibody groups are aCL antibodies etiology seems to be more related with inflammatory and LA; however patients with aCL antibodies are five and immunopathologic factors as compared with tradi- times more common than those with LA [18]. Results of tional Framingham cardiovascular risk factors [8,29]. aCL assays are expressed as IgG and IgM phospholipids The presence of intracardiac thrombus is a rare but units (GPL or MPL units) based on standard curves. potentially a life-threatening manifestation of APLS. According to the updated classification criteria for APLS Thrombus formation, a potential cause of pulmonary [1] the diagnosis of APLS requires at least one of the and systemic emboli, may occur in any cardiac chamber following clinical (vascular thrombosis or complications but most frequently on the right side [8]. Antiphospholi- of pregnancy) and one of the laboratory criteria. pid antibodies have been associated with various other thrombogenic complications such as recurrent thrombo- Diagnostic (classification) criteria of APLS (1) sis, thrombocytopenia and serious bleeding abnormal- I. Clinical criteria ities [30-32]. Of those patients with APLS who present 1. Vascular thrombosis Arterial, venous or small vessel with thrombosis, 30 ± 55% will present with venous thrombosis in any tissue or organ, to be confirmed by thrombosis, especially of the lower limbs [18]. Repeat objective validated criteria (imaging studies or histo- episodes of thrombosis are often of the same type [33]. pathology). For histopathologic confirmation, thrombo- However, it is paradox that despite the well-documented sis should be present without significant evidence of coexistence of autoantigens and its antibodies in blood inflammation in the vessel wall. of APLS patients for long periods, thrombotic events 2. Pregnancy morbidity -One or more unexplained occur only sporadically. Eventually, it can be assumed deaths of a morphologically normal fetus beyond the that thrombotic events occur much more often but only 10th week of gestation or in microvasculature or smaller vessels, resulting in dete- -One or more premature births of a morphologically rioration of organ function such as renal failure, cerebral normal neonate before the 34th week of gestation damages or impairment of the myocardial function by because of eclampsia or preeclampsia or placental multiple recurrent microthromboses or microemboli insufficiency. [26]. Neurologic manifestations of APLS have been -Three or more unexplained consecutive spontaneous reported to include recurrent cerebral infarcts, head- abortions before the 10th week of gestation. aches, migraines and visual disturbances [34,35]. Other II. Laboratory criteria manifestations of APLS include skin ulcers (pyoderma 1. Lupus anticoagulants in plasma. gangrenosum- like or livedoid vasculitis) due to fibrin 2. Anticardiolipin antibody of IgG and/or IgM isotype deposition within the lumens of superficial dermal ves- in serum or plasma, present in medium or high titer sels as well as diffuse alveolar haemorrhage [36]. Of (i.e. >40 GPL or MPL). Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 4 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 3. Anti-beta2Glycoprotein1-antibodies of IgG and/or c. aPTT test may differ because of different ingredi- IgM isotype in serum or plasma. ents concerning its sensitivity towards the LA effect. Especially, the activator (e.g. kaolin, silica, ellagic acid or Laboratory tests: approaching potential celite), the phospholipid source (several animal or plant limitations sources) and finally the clot-detection method/instru- The definition of “APLS” requires the positive testing for ments (photo-optical, mechanical, manual) can vary lupus anticoagulant, anti-cardiolipin or anti-b2GPI twice widely, influencing the test result [2,40]. Similar to at least 12 weeks apart [1]. The double testing contri- aPTT is the principle of the dRVVT. At least, both butes to the exclusion of patients with a transient reac- these tests should always be performed when plasma is tivity by direct antiphospholipid-antibodies due to tested for an LA-effect [1]. Anti-cardiolipin test, the infections or other contributory factors [2,38]. “Lupus classic solid phase assay test, should be considered only anticoagulant” is a misnomer for a group of various as a differential diagnosis in a positive test result, phospholipid inhibitors, observed usually without under- because direct antibodies to CL are not pathogenic for lying SLE and in vivo related not to bleeding but to APLS. One of test limitations, is that both patient’s thrombotic complications. Coagulation tests used to serum and buffer solution (usually bovine serum) pro- reveal lupus anticoagulant include: activated partial vide homologous b2GPI, introducing an extra amount thromboplastin time (aPTT), diluted Russell’sviper of target antigens [41]. Therefore, the test result can be venom test (dRVVT), taipan venom test, textarin influenced in case of a present human autoantibody venom/ecarin venom clotting time ratio, kaolin clotting (especially isotype IgM) that reacts exclusively with time and tissue thromboplastin inhibition test [38]. Gen- human b2GPI [2,41]. Fact that makes the colour reac- erally, tests are sensitive but usually need a meticulous tion less powerful and false-negative as the strength of interpretation. For example, a prolongation of clotting reaction is significant for APLS diagnosis; consequently tests such as aPTT, usually is an indication of a bleeding only moderate to high titer antibodies are considered as tendency, but in APLS patients is correlated with a high “positive aCL” for APLS [1,2]. Moreover, as mentioned risk for thrombotic/thromboembolic events [2,39]. Espe- already for the LA-tests the plasma should be platelet (-) cially, some tests such as prothrombin time (PT), aPTT, depleted; otherwise exposed PL on the surface of acti- or dRVVT based on both calcium and phospholipids vated platelets attract b2GP. A final pitfall of anti-cardi- adequacy for further activation of several clotting factors olipin test is that CL represents one of several negatively (Factor II, VII, IX, X) [40]. If the measured time of clot charged phospholipids rendering possible to miss a few (-) forming after addition of Ca2+ and PL is prolonged, a cases in which specific autoantibodies react with b2GPI (-) possible explanation is the existence of antibodies inter- only when bound to another PL , e.g. phosphatidylser- acting with phospholipids. If the clotting time is not ine [2]. Finally, anti-b2GPI and anti-prothrombin ELISA corrected by addition of normal plasma (mixing step - tests promise a more specific diagnosis of APLS. Beyond corrects missing coagulation factors) but tends to be anti-b2GPI, ELISA tests for antiPT, with prothrombin normal by adding an excessive amount of phospholipids directly fixed on a plate or via phosphatidylserine (confirmation step by adding activated thrombocytes) (antiPS-PT) add further information especially if tests the LA effect is considered “positive” [2,29]. However, for LA, aCL or anti-b2GPI are persistently negative LA testing presents several drawbacks: [2,42]. It is debating if these tests have to be repeated a. LA test, considered highly sensitive but not very for confirmation of the diagnosis APLS because they are specific concerning thromboembolic risk in APLS theoretically not influenced by non-pathogenic antibo- patients, can only be reliable if potential sources for dies, cancer or drugs [2,42]. phospholipids are removed before testing. In daily rou- tine plasma for clotting tests is prepared by centrifuga- Relation of aCL with restenosis following tion of a blood sample, removing red and white blood percutaneous coronary interventions (PCI) cells. However, the smaller and lighter thrombocytes in CAD patients stay mainly in the supernatant providing a rich source The role of serum aCL levels in natural history and (-) of PL [2,38]. prognosis of acute coronary syndromes (ACS) is still b. The prothrombin time is a routine test depending undetermined. However, anticardiolipin antibodies have (-) on Ca2+ and PL in factor VII, X and II [29]. The acti- been found to be associated with arterial and venous vator, tissue thromboplastin, is extracted from animal thrombosis [43]. Angioplasty-induced arterial injury (-) tissues bounding in PL , rendering this test useless for leads to platelet aggregation, adhesion, and thrombosis. APLS diagnosis. Recently a modified test with an exact Several factors that are involved in the thrombogenesis amount of recombinant TF and synthetic phospholipids may influence the restenosis rate after PTCA as throm- [2,38] is available allowing the detection of LA. bosis is one of the possible mechanisms of restenosis. Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 5 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 Different mechanisms are associated with high aCL-IgG secondary to excessive anticoagulation or APLS asso- levels and restenosis after PCI [6]. Contradictory results ciated clotting factor deficiencies (especially factor II) have been demonstrated concerning the effect of aCL [18]. In the meantime, minor alterations in anticoagulant antibodies on restenosis. Eber, et al [44] showed that therapy, infection, or a surgical insult may trigger wide- aCL-IgM was an independent risk factor for restenosis spread thrombosis. Moreover, deep hypothermic circula- after PTCA in 65 men with coronary artery disease, tory arrest (DHCA) complicates the problem of however, no correlation was found between aCL-IgG anticoagulation during cardiac surgery because of the and restenosis. Ludia, et al [45] reported that restenosis combination of blood stasis and changes in enzymatic was more frequent in aCL positive patients with activity associated with the extreme temperature differ- ischemic heart disease. Gurlek et al [6] studied the fol- ences [56,57]. Therefore, the management of anticoagula- low-up coronary angiography in two groups of 80 tion during CPB can be quite challenging and close patients with acute coronary syndrome, in comparison cooperation with the haematology department is essen- to IgM and IgG aCL levels measured before hospital dis- tial. There is no consensus in the literature as to the opti- charge. The results suggested that restenosis occurs mal method for assuring perioperative anticoagulation in more frequently in anticardiolipin positive patients. In APLS. While, monitoring anticoagulation in APLS contrast, Chiarugi, et al [46] observed no association patient during cardiac surgery remains problematic, as between the presence of aCL and clinical restenosis, aPL often interfere with in vitro tests of hemostasis by however, the presence of aCL with elevated lipoprotein impeding the binding of coagulation proteins to phos- a [Lp(a)] levels, acting synergistically, increased the risk pholipid surfaces [21]. Especially, during CPB, blood con- of restenosis. Finally, in a recent study, Sharma S et al tact with extracorporeal surfaces causes stimulation of [47], failed to demonstrate any significant correlation the coagulation cascade. To prevent clotting, unfractio- between the level of IgG anticardiolipin antibodies and nated heparin is administered before CPB. Heparin con- in-stent restenosis in patients having undergone PCI centrations of greater than/equal to 3 u/ml ± 1 are with bare metal or drug eluting stents. The corellation generally accepted as therapeutic for CPB [58], but indi- of elevated aCL levels and post-ACS cardiovascular vidual patient responses to a standardized heparin dose events is still controversial. The largest study on this vary. Heparin activity is assessed using the activated clot- issue was recently reported by Bili et al, [48] who stu- ting time (ACT) which is a phospholipid dependent test died 1150 AMI patients, demonstrating that elevated and may be prolonged by LA antibodies [18]. In the nor- aCL-IgG and low aCL-IgM antibodies were independent mal patient, a heparin concentration of 3 uml ± 1 typi- risk factors for recurrent cardiovascular events. Zucker- cally produces a kaolin ACT of more than 450 seconds. man et al, [49] suggested that the presence of aCL is a LMWH is attractive in this setting as it causes a highly marker for increased risk for myocardial reinfarction predictable anticoagulant effect for a given dose, decreas- and thromboembolic events after acute myocardial ing the need for monitoring [18]. Suggested alternative infarction (MI). However, Hamsten and colleagues [50] methods for monitoring anticoagulation during bypass in demonstrated that antibodies to cardiolipin are markers APLS patients include empirically doubling the baseline for a high risk of recurrent cardiovascular events in ACT or to reach an ACT twice the upper limit of normal young survivors of MI; but their study was small in [2], obtaining heparin concentrations by protamine titra- scope. On the contrary, Sletnes, et al [51] in 597 acute tion (Hepcon) [59], performing anti-factor Xa assays, or MI survivors, using multivariate analysis, failed to prove performing heparin/ACT titration curves preoperatively that aCL is an independent risk for mortality, cerebral to determine patient specific target ACT levels [18]. The thromboembolism, or recurrent MI. Analogous results in vitro heparin/ACT titration curve is a test of an indivi- were obtained by Cortellaro et al, [52] in their study of dual patient’s responsiveness to heparin. Moreover, preo- 74 young MI patients and Phadke et al, [53] who mea- peratively, anti-Xa factor activity assays can be correlated sured aCL in 299 survivors of acute MI. Eventually, with the patient specific preoperative in vitro heparin Gurlek et al, [6] found no association between aCL anti- ACT titration curve [18]. Anti-Xa monitoring is generally bodies with recurrent cardiovascular events (reinfarction considered the"gold standard” laboratory measure of and intracardiac thrombus formation) in ACS patients. heparin therapy for use in situations in which the aPTT may be adversely affected [22]. By using this testing Intraoperative management of coagulation: method, known concentrations of purified coagulation a crucial problem factor Xa and antithrombin are mixed with a sample of Patients with APLS are at increased risk for thrombosis the patient’s heparin-containing plasma [18,22]. Anti-fac- and adequate anticoagulation is of vital importance dur- tor Xa levels of 1.5 ± 2.0 u/ml ± 1 are considered thera- ing cardiopulmonary bypass (CPB) [18,30,31,54,55]. Peri- peutic for CPB [18]. Postoperatively, levels greater than operative risks include thrombosis and/or bleeding 1.0 u/ml ± 1 may be associated with excess blood loss Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 6 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 [60]. When treating venous thromboembolism, the target may not correlate well with diagnosis or outcome in rangeofanti-factor Xa activity is 0.6±1.0u/ml±1[6]. APLS [71]. Although the risk of thrombosis is reduced However, the turnaround time for anti-factor Xa assays with increased anticoagulation, there is an associated are currently incompatible with the time constraints of increased risk of significant bleeding [18]. Protamine to CPB [18,60]. Generally, various anticoagulation methods antagonise heparin should be administered only in a for dosing heparine during CPB have been performed. stepwise manner or in low dose continuously intrave- Especially, Sheikh et al [61] elected to empirically double nous, e.g. 50 mg/h [2], until the bleeding tendency slows the ACT to more than 999 seconds; as obtaining factor down to an acceptable amount. Also, a scrutinised opera- Xa or plasma heparin concentrations was considered tive technique and haemostasis to avoid any unnecessary impractical. On the other hand, East et al [22] elected to surgical bleeding site are of great importance [2]. In perform heparin-celite ACT titration curves preopera- patients with secondary APLS and thrombosis, there is tively on each patient to assess the effect of APL antibo- an ongoing endothelial disturbance secondary to the dies on ACT monitoring. Based on the patient-specific underlying vasculitis and the risk of recurrent thrombotic titration curve, therapeutic anticoagulation (heparin con- events is high [2]. Anti-platelet therapy as well as war- centration 3.0 U/mL) for CPB was achieved in patients at farin anticoagulation is indicated. Moreover, additional celite ACT values exceeding 550 s. Also, laboratory based factors of thrombosis such as hypertension, diabetes mel- anti-Xa monitoring was performed concurrently during litus, hyperlipidaemia should be treated optimally or CPB as a secondary confirmatory measure [22]. In retro- avoided (e.g. smoking) [2]. Generally, antiplatelet therapy spective studies, a lower incidence of recurrences (arterial may be added but the effectiveness of low-dose aspirin or and venous) episodes of thrombosis was observed in the newer antiplatelet agents is unproven. In cases where patients kept at a high intensity of oral anticoagulation thrombosis continues despite adequate anticoagulation, [62-64] leading to the recommendation that patients with additional treatment is aimed either at preventing anti- antiphospholipid antibodies who have had a documented body formation or reducing antibody titres and may major thrombotic event should receive life-long oral include corticosteroids, immunosuppressive agents, i.v. anticoagulant treatment to achieve an INR of 3.0 or immuneglobulin, or plasmapheresis. Particularly, Dor- higher [62,65,66]. In spite of anticoagulant treatment, man R [18] described the perioperative course and suc- recurrence of thrombosis is frequent in patients with the cessful treatment of a 31-yr-old woman with primary APLS [63,67], especially in those carrying lupus anticoa- APLS requiring a mitral valve replacement; that post- gulant (LA) [68] and/or high titers of anticardiolipin anti- operatively, developed acute global biventricular failure bodies [63,67]. Especially, Della Valle et al [63] showed requiring extracorporeal membrane oxygenation support that INR determinations obtained with a recombinant PT and plasmapheresis. Alternative methods for anticoagula- reagent substantially overestimate the actual degree of tion during CPB are essential and multiple options are anticoagulation of most lupus anticoagulants patients available today [56]. These options include ancrod, hiru- due to interference of lupus anticoagulant IgG in PT din, lepirudin, argatroban, prostacyclin, platelet IIb/IIIa assays carried out at low test plasma dilution, as occurs inhibitors, complement inhibitors, IL-3 and bivalirudin with plain and recombinant thromboplastin reagents. [56,72]. Also, tissue plasminogen activator has been used Also, according to the Duration of Anticoagulation Study successfully in one case report of APLS with ST changes Group, patients with anti-cardiolipin IgG antibodies and normal coronary arteries [73]. Bivalirudin is a biva- require prolonged anticoagulation to avoid recurrences lent reversible direct thrombin inhibitor and has been of venous thromboembolism [69]. In addition, while on used safely for CPB in HIT-positive patients [56,72, oral anticoagulant treatment targeted at an INR between 74-76]. It is also successfully used during off-pump/ 2.0 and 2.85, the recurrence rate increased with the antic- on-pump coronary artery bypass grafting and heart trans- ardiolipin antibody titter, but was not significantly differ- plantation [77-79]. Bivalirudin is a bivalent direct throm- ent in patients with (1.32 per 100 patient-years) or bin inhibitor with a short half-life of approximately 25 without (0.6 per 100 patient-years) anti-cardiolipin anti- minutes [56]. Its 20-amino acid molecule combines a car- bodies [69]. Specifically, patients with primary APLS with boxy-terminal region that recognizes thrombin’sfibrin thrombosis are treated with heparin followed by warfarin (ogen)-binding site, and an amino-terminal tetrapeptide in the usual manner [18]. There is controversy over the that inhibits the active site of thrombin [56]. Conse- intensity of anticoagulant therapy, the duration of treat- quently, thrombin inhibition of bivalirudin inactivates ment, and the method for measuring the INR. Recurrent not only fluid-phase thrombin, but also fibrin-bound thrombotic events of any type usually signal the need for thrombin [80]. Therefore, thrombus formation may be life-long anticoagulation. Recurrent thrombosis while on attenuated more effectively and anticoagulation produced standard intensity anticoagulant therapy dictates the use more predictably than by heparin [56,80]. Pharmaco- of a higher target INR at about 2,5-3,5 [70], but the INR kinetically bivalirudin is predominantly eliminated by Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 7 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 enzymatic degradation through proteases and thrombin Statins may be beneficial in APLS patients by suppressing itself (80%)and to alesserdegreebyrenal clearance the inflammatory response, which is important in case of (20%) [81]. No reversal for bivalirudin exists, but its elim- valvular lesions and vascular occlusive disease [8]. How- ination can be enhanced by hemodialysis and hemofiltra- ever, no clinical investigations using statins as anti- tion [81,82]. The theoretical potential of aprotinin to inflammatory treatment in APLS patients have been delay bivalirudin elimination and to prolong its anticoa- reported. Finally, specific therapeutic treatment for APLS gulant effect has not been demonstrated [56]. In one is not available yet. The application of peptides specifi- study aprotinin did not affect the elimination of bivaliru- cally bound by anti-b2GPI antibodies thus neutralising din [82]. Leissner et al [56], reported a case from a the functional effect of the autoantibodies [91] or pep- patient with APLS with massive thrombosis of right tides which have a similar amino acid sequence as atrium. This patient underwent DHCA by using bivaliru- domain V of b2GPI thus possibly blocking putative din, for thrombectomy to avoid potential catastrophic receptors in an antagonistic manner [2,92] constitute pulmonary embolism. During CPB the ACT was restored promising therapeutic approaches. between 500-750 sec with the initial dose of bivalirudin and during the circulatory arrest the arterial and venous Outcomes of cardiac surgery in APLS patients lines were clamped and the CPB circuit was recirculated The literature offers widely differing estimates of mor- distal to the arterial filter back to the soft-shelled venous bidity and mortality associated with APLS and cardio- reservoir to avoid pump clotting [56]. The DHCA time pulmonary bypass. In a retrospective analysis of 19 was planned to be short and lasted 19 minutes. No visible patients with APLS undergoing cardiac or vascular sur- clot formation was observed in the open-heart and gical procedures, Ciocca and colleagues reported an bypass circuit, but in the pericardial cavity as previously 84.2% incidence of postoperative thrombosis or bleeding attributed to increased blood stagnation [72,79]. cAPLS and 63.2% mortality [31]. Thirteen of the patients in is caused by a generalised thrombotic storm due to these series underwent cardiac surgery. Individual case excessive activation of “aPL” with consecutive multi reports of cardiac surgical patients frequently describe organ failure and peripheral ischaemic lesions as digital thrombotic or haemorrhagic complications including necrosis [2]. Also, acute single organ failure (e.g. acute early graft occlusion [93] haemothorax [94], pulmonary heart failure) representing complications of APLS should emboli, and limb ischaemia [95,96]. More optimistically, be treated similar to cAPLS. The baseline is an aggressive the literature includes several case reports of uneventful intravenous anticoagulation, usually heparin, later fol- cardiac surgery [97,98]. A meta analysis of heart valve lowed by oral anticoagulation with vitamin K-antagonists surgery by Gorki et al [2] demonstrated that the mortal- [2,83]. Steroids may contribute to limitation of the cyto- ity is high with 7% early deaths and 12% late deaths kine release and further treat the widespread vasculitis after a mean follow-up period of less then 3 years. The [83]. Moreover, plasmapheresis or intravenous gamma- early and late morbidity with major complications (valve globulins reduce the autoantibody load, improving the related included) respectively is significant. Only 42% of outcome [2,84]. The use of prostacyclin, fibrinolytics, the patients had an uneventful short and long-term cytotoxic drugs, splenectomy or dialysis are described but recovery. APLS-typical processes could be explanation without proven advantage for survival. In Asherson and for the majority of postoperative problems, especially for colleagues [83] most recent retrospective case series of myocardial and cerebral complications and other overt cAPLS, only anticoagulation was associated with statisti- thromboembolic events. The high proportion (about cally significant increased survival. While, in previous 20%) of valve-related complications such as valve throm- Asherson and colleagues series [84], plasmapheresis did bosis is remarkable. Colli et al [99], in a recent retro- reduce mortality. Also, there are case reports of acute spective analysis of nine patients with antiphospholipid biventricular failure in APLS with necropsy findings of syndrome that underwent heart valve surgery using myocardial microvascular thrombosis [85-89]. In this CPB, observed high morbidity (50%) and mortality situation, antithrombotic not anti-inflammatory therapy (22%) respectively. Especially, two patients died in the is likely to be effective [18]. A diagnosis of fulminant early postoperative period due to an acute cerebrovascu- myocarditis could be supported by the global nature of lar accident, four patients presented an uneventful late the myocardial dysfunction and its prompt resolution. postoperative course and one patient experienced an Fulminant myocarditis is associated with full recovery in ischemic stroke 5 years after mitral valve replacement over 90% of the patients who survive the event [89]. and developed refractory congestive heart failure requir- There is one case report of APLS associated postopera- ing heart transplantation three years postoperatively. tive fulminant myocarditis managed with immunosup- Similarly, Berkun et al [55] presented an increased mor- pressive steroids [90]. Currently, there is some scientific bidity and mortality in ten patients with APLS under- rationale for adding a statin as adjunctive treatment. going valve replacement. Koniari et al. Journal of Cardiothoracic Surgery 2010, 5:101 Page 8 of 10 http://www.cardiothoracicsurgery.org/content/5/1/101 2. Gorki H, Malinovski V, Stanbridge RDL: The antiphospholipid syndrome Conclusions and heart valve surgery. Eur J CardioThorac Surg 2008, 33:168-18. APLS is one of the most commonly acquired hypercoa- 3. Tripodi A, Chantarangkul V, Clerici M, Negri B, Galli M, Mannucci PM: gulable states. Minor alterations in the anticoagulation, Laboratory control of oral anticoagulant treatment by the INR system in patients with the antiphospholipid syndrome and lupus anticoagulant. infection, and surgical insult may trigger widespread Results of a collaborative study involving nine commercial thrombosis. The incidence of thrombosis is highest dur- thromboplastins. Br J Haematol 2001, 115:672-8. ing the following perioperative periods: preoperatively 4. 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Galli M, Comfurius P, Maassen C, Hemker HC, de Baets MH, van Breda- weight heparin; LA: Lupus anticoagulant; MI: myocardial infarction; aPTT: partial Vriesman PJ, Barbui T, Zwaal RF, Bevers EM: Anticardiolipin antibodies thromboplastin time; PCI: percutaneous coronary interventions; PS: (ACA) directed not to cardiolipin but to a plasma protein cofactor. phosphatidylserine; PL: phospholipids; PT: prothrombin time; SIRS: systemic Lancet 1990, 335:1544-7. inflammatory response syndrome; SLE: systemic lupus erythematosus; TTP: 13. Pierangeli SS, Espinola RG, Liu X, Harris EN: Thrombogenic effects of thrombotic thrombocytopenic purpura; TFPI: tissue-factor-pathway-inhibitor; t- antiphospholipid antibodies are mediated by intercellular cell adhesion PA: tissue type plasminogen activator; VCAM-1: vascular-cell-adhesion-molecule- molecule-1, vascular cell adhesion molecule-1, and P-selectin. Circ Res 2001, 88:245-50. 14. Roubey RA: Tissue factor pathway and the antiphospholipid syndrome. Autoimmunol 2000, 15:217-20. Author details 15. Lutters BCH, Derksen RHWM, Tekelenburg WL, Lenting PJ, Arnout J, Cardiothoracic Surgery Department. University of Patras, School of Medicine. deGroot PG: Dimers of beta 2-glycoprotein I increase platelet deposition Patras Greece. Cardiac Surgery Department. University of Ioannina, School to collagen via interaction with phospholipids and the apolipoprotein E of Medicine. Ioannina Greece. Department of Clinical Anaesthesiology and receptor 2’. J Biol Chem 2003, 278:33831-8. Intensive Postoperative Care Unit. University of Ioannina, School of Medicine. 16. Ma K, Simantov R, Zhang JC, Silverstein R, Hajjar KA, McCrae KR: High Ioannina Greece. Cardiology Department. University of Ioannina, School of affinity binding of beta 2-glycoprotein I to human endothelial cells is Medicine. Ioannina Greece. mediated by annexin II. J Biol Chem 2000, 275:15541-8. 17. Mackworth-Young CG: Antiphospholipid syndrome: Multiple mechanisms. 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