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Eur J Cardiothorac Surg 2007;32:682-683. doi:10.1016/j.ejcts.2007.06.022
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Letters to the Editor |
Department of Cardiac Surgery, University Hospital Dubrava, 10000 Zagreb, Croatia
Received 18 June 2007; accepted 19 June 2007.
* Corresponding author. Tel.: +385 1 290 2530; fax: +385 1 290 3819. (Email: dbaric{at}kbd.hr).
Key Words: Cardiac surgery • Postoperative bleeding • Aprotinin • Tranexamic acid
We appreciate the interest of Dr Bidstrup in our study ‘Topical use of antifibrinolytic agents reduces postoperative bleeding: a double-blind, prospective, randomized study’ [1]. In his letter to the editor [2], Dr Bidstrup is questioning the clinical relevance of our results.
It is rare that something shown to be statistically significant has no clinical importance (vice versa situation happens more often). The absolute reduction of bleeding at 12 h in the tranexamic acid group was 220 mL and in the aprotinin group 180 mL. As pointed out in the paper, decrease of mean blood loss at 24 h was 30% (270 mL) in tranexamic acid group and 20% (169 mL) in aprotinin group, compared to placebo. We find that 30% reduction in postoperative bleeding could hardly be termed clinically irrelevant, especially given the fact that no known risk is associated with this method. In our opinion, the trade of 250 mL of saline with an inexpensive drug for 220 mL of blood products transfused is more than a good bargain.
As for the fact that in spite of statistically significant difference in bleeding, we did not observe any difference in transfusion requirement, we have to disclose a fact that the threshold for transfusion was, although very similar, not uniform (ITU is run by intensivists) and probably did not reach statistical significance in a sample of this size and at this amount of bleeding reduction. As we have purposely included only patients with low risk of bleeding (e.g. those where the intravenous usage of antifibrinolytics had not been expected) we believe it could be quite safely presumed that the benefits would be even greater in patients with higher risk for bleeding (reoperations, surgery of thoracic aorta, etc.).
We agree with Dr Bidstrup that systemic application of antifibrinolytics might have achieved even better results. However, unlike known risks of systemic antifibrinolytic therapy, topical application has no proven risks whatsoever.
Our study did not show statistical significance in isolated OPCAB subgroup, but, as already mentioned in the discussion section of the paper, the size of this subgroup prevents us making any definitive conclusions on that issue.
References
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