A propensity score case-control comparison of aprotinin and tranexamic acid in high-transfusion-risk cardiac surgery.
BACKGROUND
Cardiac surgery with cardiopulmonary bypass may result in excessive fibrinolysis and platelet (PLT) dysfunction, resulting in impaired hemostasis and excessive blood loss. Prophylactic use of the antifibrinolytic drugs aprotinin and tranexamic acid is thought to prevent these hemostatic defects. Their relative clinical utility and safety in high-transfusion-risk cardiac surgery, however, is not known.


METHODS
Using propensity scores, 449 patients who received aprotinin for high-transfusion-risk cardiac surgery were matched to 449 patients who received tranexamic acid from a pool of 10,870 consecutive patients who underwent cardiac surgery at a single center, 586 of whom received aprotinin and the remainder of whom received tranexamic acid.


RESULTS
The two matched groups were well balanced in terms of measured perioperative variables. Blood product transfusion rates were similar in the aprotinin and tranexamic acid groups: red blood cells, 79 percent versus 76 percent (p = 0.3); PLTs, 56 percent versus 50 percent (p = 0.06); and plasma, 66 percent versus 61 percent (p = 0.1). Adverse events rates were comparable in the two groups, except for renal dysfunction (defined as a greater than 50% increase in creatinine concentration during the first postoperative week to >100 micromol/L in women and >110 micromol/L in men or a new requirement for dialysis support), which occurred in 24 percent (107/449) of aprotinin patients and 17 percent (75/449) of tranexamic acid patients (p = 0.01).


CONCLUSIONS
Aprotinin and tranexamic acid have similar hemostatic effectiveness in high-transfusion-risk cardiac surgery. Within the confines of propensity score matching, our results suggest that aprotinin may be associated with renal dysfunction.
Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada. keyvan.karkouti@uhn.on.ca
Keyvan
K
Karkouti
W Scott
WS
Beattie
Kathleen M
KM
Dattilo
Stuart A
SA
McCluskey
Mohammed
M
Ghannam
Ahmed
A
Hamdy
Duminda N
DN
Wijeysundera
Ludwik
L
Fedorko
Terrence M
TM
Yau
D000328:Adult; D000933:Antifibrinolytic Agents / Q000008:administration & dosage*; D007611:Aprotinin / Q000008:administration & dosage*; D001791:Blood Platelet Disorders / Q000209:etiology / Q000517:prevention & control*; D001803:Blood Transfusion; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass / Q000009:adverse effects*; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D005342:Fibrinolysis / Q000187:drug effects*; D006490:Hemostatics / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D014148:Tranexamic Acid / Q000008:administration & dosage*
D000933:Antifibrinolytic Agents; D006490:Hemostatics; D014148:Tranexamic Acid; D007611:Aprotinin