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Eur J Cardiothorac Surg 2007;32:682. doi:10.1016/j.ejcts.2007.06.021
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Letters to the Editor

Re: Topical use of antifibrinolytic agents reduces postoperative bleeding: a double-blind, prospective, randomized study

^a Pindara Private Hospital, Australia
^b University of Queensland, Australia

Received 5 May 2007; accepted 19 June 2007.

^_* Corresponding author. Address: PO Box 20, Terranora, NSW 2486, Australia. Tel.: +61 7 55905740; fax: +61 7 55905872. (Email: Benjamin.bidstrup{at}bigpond.com).

Key Words: Cardiac pharmacology • Extracorporeal circulation • Pericardium

Dr Baric and colleagues are to be congratulated for their study of topical agent use to reduce post cardiotomy bleeding [1]. The systemic effects of tranexamic acid and aprotinin are both well described regarding their efficacy and safety in open heart surgery using cardiopulmonary bypass [2].

The authors report statistically significant reductions in chest drainage after surgery in a wide variety of cardiac procedures, including off-pump coronary artery bypass (CAB) (approx 50% of cases), on-pump CAB (approx 25%) and the remainder a range of operations seen in a busy CT unit.

Many of these procedures would be considered to be at low risk of bleeding; especially given antiplatelet agents were ceased five or more days prior to surgery and all cases were primary procedures [3].

The blood loss data shows an absolute reduction in the first 12 h of 190 ml in the tranexamic acid group and 222 ml in the aprotinin group. This is less than half a bag of packed red cells. Similar changes were reported in the other time periods. Of more interest, there was no reduction in transfusion requirements, nor was there any difference in reexploration rates. The early studies of prophylactic aprotinin given systemically in CAB patients showed not only reductions in chest drainage, but also blood use as well as a marker of red cell loss (haemoglobin loss) [4,5].

A therapy of any type has risk and benefits. A benefit should not only be statistically significant but also clinically relevant. The use in this population of tranexamic acid and aprotinin offers no useful clinical advantage as reported in this study.

It is somewhat hard to see what relevance the use of either agent is in off-pump CAB; a procedure touted for its minimal bleeding and blood use. Baric reports the 24 h bleeding and transfusion was neither statistically significant nor clinically relevant.

What advantage does topical tranexamic acid or aprotinin offer these patients?

References

1. Baric D, Biocina B, Unic D, Sutlic Z, Rudez I, Vrca VB, Brkic K, Ivkovic M. Topical use of antifibrinolytic agents reduces postoperative bleeding: a double-blind, prospective, randomized study. Eur J Cardiothorac Surg 2007;31:366-371.[Abstract/Free Full Text]
2. Henry DA, Moxey AJ, Carless PA, O’Connell D, McClelland B, Henderson KM, Sly K, Laupacis A, Fergusson D. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2001:CD001886, 2008.
3. Ferraris VA, Ferraris SP, Moliterno DJ, Camp P, Walenga JM, Messmore HL, Jeske WP, Edwards FH, Royston D, Shahian DM, Peterson E, Bridges CR, Despotis G. The Society of Thoracic Surgeons practice guideline series: aspirin and other antiplatelet agents during operative coronary revascularization (executive summary). Ann Thorac Surg 2005;79:1454-1461.[Free Full Text]
4. Bidstrup BP, Hunt BJ, Sheikh S, Parratt RN, Bidstrup JM, Sapsford RN. Amelioration of the bleeding tendency of preoperative aspirin after aortocoronary bypass grafting. Ann Thorac Surg 2000;69:541-547.[Abstract/Free Full Text]
5. Bidstrup BP, Royston D, Sapsford RN, Taylor KM. Reduction in blood loss and blood use after cardiopulmonary bypass with high dose aprotinin (Trasylol). J Thorac Cardiovasc Surg 1989;97:364-372.[Abstract]

This article has been cited by other articles:

				D. Baric, D. Unic, and B. Biocina Reply to Bidstrup and Yellowlees Eur. J. Cardiothorac. Surg., October 1, 2007; 32(4): 682 - 683. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Benjamin Bidstrup Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bidstrup, B. Articles by Yellowlees, J. Search for Related Content PubMed PubMed Citation Articles by Bidstrup, B. Articles by Yellowlees, J. Related Collections Cardiac - pharmacology Extracorporeal circulation Pericardium