• Janne Moilanen, Marika Pada, Pasi Ohtonen, Timo Kaakinen, Panu Taskinen, Eeva-Riitta Savolainen, and Tiina Erkinaro.
• From the Translational Medicine Research Unit, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu (JM, MP, PO, TK, PT, TE), Department of Anesthesiology, Vaasa Central Hospital, Wellbeing Services County of Ostrobothnia, Vaasa (MP), Translational Medicine Research Unit, University of Oulu (PO) and Nordlab Oulu Hematology Laboratory, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland (E-RS).
• Eur J Anaesthesiol. 2025 Feb 7.

BackgroundAfter cardiac surgery, complete heparin reversal with protamine is essential. Accordingly, there is a need for an accurate and precise point-of-care device to detect possible residual heparin after protamine administration.ObjectivesTo compare two different activated clotting time (ACT) tests and thromboelastometry in detecting postprotamine heparin activity after cardiac surgery.DesignA single-centre prospective, observational study.SettingUniversity Hospital from September 2021 to February 2023.ParticipantsFifty-five adult, elective cardiac surgical patients.InterventionsThe ACT-LR and ACT+ tests of Hemochron Signature Elite device, and the coagulation time (CT) ratio from INTEM and HEPTEM tests of ROTEM Sigma device, were analysed after protamine administration and compared to baseline values.Main Outcome MeasuresBased on postprotamine antifactor Xa (anti-fXa) activity, the patients were divided into heparin (anti-fXa ≥0.2 IU ml-1) and no heparin (anti-fXa ≤0.1 IU ml-1) groups.ResultsThere was a mean bias of 44 [95% confidence interval (CI) 40 to 47] celite seconds between ACT-LR and ACT+ measurements. The absolute changes in ACT-LR, ACT+ and INTEM:HEPTEM CT ratio were variable and did not differ between the groups. The mean ± SD percentage changes between postprotamine and baseline ACT-LR and ACT+ values were 5.9 ± 17.5 and 5.9 ± 16.9% in the no residual heparin group, compared to 1.4 ± 8.4 and 9.9 ± 12.5% in the residual heparin group. Receiver operator characteristic curves for postprotamine INTEM:HEPTEM CT ratio and for percentage changes in ACT-LR and ACT+ to detect an anti-fXa at least 0.2 IU ml-1 had areas under the curve of 0.496 (95% CI, 0.329 to 0.663), 0.425 (95% CI, 0.260 to 0.591) and 0.583 (95% CI, 0.417 to 0.749), respectively.ConclusionBoth the ACT-LR and ACT+ tests of Hemochron Signature Elite device and the INTEM:HEPTEM CT ratio of ROTEM Sigma device have poor ability to detect residual heparin shortly after protamine administration.Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society of Anaesthesiology.

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