Aprotinin in Cardiac Surgery: A Different Point of View

Authors

  • Franz F. Immer
  • Philipp Jent
  • Lars Englberger
  • Mario Stalder
  • Erich Gygax
  • Thierry P. Carrel
  • Hendrik T. Tevaearai

DOI:

https://doi.org/10.1532/HSF98.20071149

Abstract

Aprotinin is widely used in cardiac surgery to reduce postoperative bleeding and the need for blood transfusion. Controversy exists regarding the influence of aprotinin on renal function and its effect on the incidence of perioperative myocardial infarction (MI) and cerebrovascular incidents (CVI). In the present study, we analyzed the incidence of these adverse events in patients who underwent coronary artery bypass grafting (CABG) surgery under full-dose aprotinin and compared the data with those recently reported by Mangano et al [2006]. For 751 consecutive patients undergoing CABG surgery under full-dose aprotinin (>4 million kalikrein-inhibitor units) we analyzed in-hospital data on renal dysfunction or failure, MI (defined as creatine kinase-myocardial band > 60 iU/L), and CVI (defined as persistent or transient neurological symptoms and/or positive computed tomographic scan). Average age was 67.0 ± 9.9 years, and patient pre- and perioperative characteristics were similar to those in the Society of Thoracic Surgeons database. The mortality (2.8%) and incidence of renal failure (5.2%) ranged within the reported results. The incidence rates of MI (8% versus 16%; P < .01) and CVI (2% versus 6%; P < .01) however, were significantly lower than those reported by Mangano et al. Thus the data of our single center experience do not confirm the recently reported negative effect of full-dose aprotinin on the incidence of MI and CVI. Therefore, aprotinin may still remain a valid option to reduce postoperative bleeding, especially because of the increased use of aggressive fibrinolytic therapy following percutaneous transluminal coronary angioplasty.

References

Alderman EL, Levy JH, Rich JB, et al. 1998. Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE). J Thorac Cardiovasc Surg 116:716-30.nBechtel JF, Prosch J, Sievers HH, Bartels C. 2002. Is the kaolin or celite activated clotting time affected by tranexamic acid? Ann Thorac Surg 74:390-3.nBeierlein W, Scheule AM, Dietrich W, Ziemer G. 2005. Forty years of clinical aprotinin use: a review of 124 hypersensitivity reactions. Ann Thorac Surg 79:741-8.nBasran S, Frumento RJ, Cohen A, et al. 2006. The association between duration of storage of transfused red blood cells and morbidity and mortality after reoperative cardiac surgery. Anesth Analg 103:15-20.nD'Ambra MN, Akins CW, Blackstone EH, et al. 1996. Aprotinin in primary valve replacement and reconstruction: a multi-center, double-blind, placebo-controlled trial. J Thorac Cardiovasc Surg 112:1081-9.nDietrich W, Dilthey G, Spannagel M, Jochum M, Braun SL, Richter JA. 1995. Influence of high-dose aprotinin on anticoagulation, heparin requirement, and celite- and kaolin-activated clotting time in heparin-pretreated patients undergoing open-heart surgery. a double-blind, placebo-controlled study. Anesthesiology 83:679-89.nFeindt PR, Walcher S, Volkmer I, et al. 1995. Effects of high-dose aprotinin on renal function in aortocoronary bypass grafting. Ann Thorac Surg 60:1076-80.nFerraris VA, Bridges CR, Anderson RP. 2006. Aprotinin in cardiac surgery. N Engl J Med 354:1953-7.nLevy JH, Ramsay JG, Guyton RA. 2006. Aprotinin in cardiac surgery. N Engl J Med 354:1953-7.nLevy JH, Pifarre R, Schaff HV, et al. 1995. A multicenter, double-blind, placebo-controlled trial of aprotinin for reducing blood loss and the requirement for donor-blood transfusion in patients undergoing repeat coronary artery bypass grafting. Circulation 92:2236-44.nMangano DT, Tudor IC, Dietzel C. 2006. The risk associated with aprotinin in cardiac surgery. N Engl J Med 354:353-65.nSedrakyan A, Treasure T, Elefteriades JA. 2004. Effect of aprotinin on clinical outcomes in coronary artery bypass graft surgery: a systematic review and meta-analysis of randomized clinical trials. J Thorac Cardiovasc Surg 128:442-8.nSundt TM III, Kouchoukos NT, Saffitz JE, Murphy SF, Wareing TH, Stahl DJ. 1993. Renal dysfunction and intravascular coagulation with aprotinin and hypothermic circulatory arrest. Ann Thorac Surg 55:1418-23.n

Published

2008-02-12

How to Cite

Immer, F. F., Jent, P., Englberger, L., Stalder, M., Gygax, E., Carrel, T. P., & Tevaearai, H. T. (2008). Aprotinin in Cardiac Surgery: A Different Point of View. The Heart Surgery Forum, 11(1), E9-E12. https://doi.org/10.1532/HSF98.20071149

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