Viscoelastometric Testing to Assess Hemostasis of COVID-19: A Systematic Review

Abstract

Infection by SARS-CoV-2 is associated with a high risk of thrombosis. The laboratory documentation of hypercoagulability and impaired fibrinolysis remains a challenge. Our aim was to assess the potential usefulness of viscoelastometric testing (VET) to predict thrombotic events in COVID-19 patients according to the literature. We also (i) analyzed the impact of anticoagulation and the methods used to neutralize heparin, (ii) analyzed whether maximal clot mechanical strength brings more information than Clauss fibrinogen, and (iii) critically scrutinized the diagnosis of hypofibrinolysis. We performed a systematic search in PubMed and Scopus databases until December 31st, 2020. VET methods and parameters, and patients’ features and outcomes were extracted. VET was performed for 1063 patients (893 intensive care unit (ICU) and 170 non-ICU, 44 studies). There was extensive heterogeneity concerning study design, VET device used (ROTEM, TEG, Quantra and ClotPro) and reagents (with non-systematic use of heparin neutralization), timing of assay, and definition of hypercoagulable state. Notably, only 4 out of 25 studies using ROTEM reported data with heparinase (HEPTEM). The common findings were increased clot mechanical strength mainly due to excessive fibrinogen component and impaired to absent fibrinolysis, more conspicuous in the presence of an added plasminogen activator. Only 4 studies out of the 16 that addressed the point found an association of VETs with thrombotic events. So-called functional fibrinogen assessed by VETs showed a variable correlation with Clauss fibrinogen. Abnormal VET pattern, often evidenced despite standard prophylactic anticoagulation, tended to normalize after increased dosing. VET studies reported heterogeneity, and small sample sizes do not support an association between the poorly defined prothrombotic phenotype of COVID-19 and thrombotic events.

TEG® and ROTEM® Traces: Clinical Applications of Viscoelastic Coagulation Monitoring in Neonatal Intensive Care Unit

“…TEG ® and ROTEM ® have been extensively studied and applied in adult patients, especially in major bleeding related to severe trauma and surgical fields, such as liver transplantation as well as cardiac and obstetric procedures. Their use has been largely considered in the management of trauma-induced coagulopathy because of their great precision to identify the lacking element involved in the hemostasis reaction [ 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 ].…”

Viscoelastic Hemostatic Assays for Postpartum Hemorrhage

“…This across the board delay in the use of VHAs to guide BCT and HAT has been commented on in the literature [61]. However, the meteoric use of VHAs in the first year of the COVID-19 pandemic has been reported in 1417 patients as of April 2021 [62]. This rapid acceptance by the many specialists who care for COVID-19 patients reflects the decades long history of successful resuscitation in liver transplantation, cardiac surgery, and trauma.…”

Sinus venous thrombosis as a complication of COVID-19-associated hypercoagulability

“…This should be clarified. Recently, it has been proposed to apply standardised viscoelastic tests, such as TEG, Quantra, ROTEM, or ClotPro, to assess haemostasis and the thrombotic risk in COVID-19 patients [ 9 ].…”