title: [Control of postoperative hemorrhage in isolated coronary bypass surgery: comparison of tranexamic acid effects in off-pump surgery with aprotinin effects in conventional surgery].
abstract: In spite of the strong criticism elicited thereafter, the results of a multicentric study on the consequences of several perioperative anti-hemorrhagic strategies in cardiac surgery, published five years ago, led to the aprotinin (Aprot) withdrawal from the market and its progressive replacement by tranexamic acid (TrAc) in many surgical departments.
  
  
  OBJECTIVE
  To evaluate the hemostatic effects and clinical consequences of TrAc use or non-use in off-pump coronary bypass surgery (CABG) and compare them with those of Aprot use or non-use in conventional (conv) CABG.
  
  
  METHODS
  Retrospective analysis of 2 groups (Gr) of patients (pts): GrA - 252 pts undergoing isolated conv CABG (GrA1 - 185 pts submitted to an intra-operative full-dose Aprot protocol; GrA2 - 67 pts operated without Aprot); GrB - 383 pts undergoing isolated off-pump CABG (GrB1 - 136 pts submitted to an intra-operative low-dose TrAc protocol; GrB2 - 247 pts operated in absence of TrAc). Pre-operative clinical characteristics (GrA1 vs GrA2, GrB1 vs GrB2): mean age (years) - 65 vs 64 (NS), 64 vs 64; female gender - 20% vs 21% (NS), 23% vs 20% (NS); logistic Euroscore - 5.1% vs 6.2% (NS), 6.3% vs 5.5% (NS); chronic renal failure - 21% vs 27% (NS), 27% vs 25% (NS); diffuse coronary artery disease - 34% vs 42% (NS), 36% vs 30% (NS); pre-operative betablocker treatment - 64% vs 55% (NS), 74% vs 71% (NS); statin therapy for &gt; 3 months - 78% vs 82% (NS), 81% vs 85% (NS). Pts have been operated by 4 surgeons largely experienced in both CABG modalities. Antiplatelet therapy was stopped =&gt; 4 days prior to surgery (but aspirin was maintained in high-risk pts). Results (GrA1 vs GrA2, GrB1 vs GrB2): 1) Bleeding (mL/pt - mean): 783 vs 1375 (p &lt; 0.001), 1061 vs 1368 (p &lt; 0.001); blood loss &gt; 1500 mL (%pts) - 5.4% vs 34% (p &lt; 0.0001), 12% vs 28% (p &lt; 0.001); surgical re-exploration for bleeding - 1.1% vs 3.0% (NS), 2.2% vs 2.0% (NS). 2) Transfusion of blood products (U/pt - mean): plasma - 0.56 vs 2.19 (p &lt; 0.001), 1.45 vs 1.03 (p &lt; 0.05); platelets - 0.09 vs 0.22 (p &lt; 0.02), 0.24 vs 0.15 (NS). 3) Renal function (%pts): increased serum cre- atinine - 56% vs 56%, 55% vs 38% (p &lt; 0.001); hemofiltration use - 1.1% vs 1.5% (NS), 1.5% vs 0.4% (NS). 4) Perioperative myocardial infarction - 21.6% vs 17.9% (NS), 17.6% vs 14.6% (NS); other ischemic events - 3.2% vs 3.0% (NS), 1.5% vs 1.2% (NS). 5) Hospital mortality: 4.8% vs 4.5% (NS), 4.4% vs 1.6% (NS).
  
  
  CONCLUSIONS
  1) TrAc does not reduce the risk of surgical re-exploration for bleeding. 2) Taking into account the differences between conv CABG and off-pump CABG, TrAc hemostatic effect seems to be inferior to that of Aprot, without offering a better safety profile in terms of lesser renal or ischemic risk as a counterpart.
authors.affiliation: Serviço de Cirurgia Cardiotorácica, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Lisboa. Portugal.
authors.forename: Alvaro D B
authors.initials: AD
authors.lastname: Bordalo
authors.forename: Angelo L
authors.initials: AL
authors.lastname: Nobre
authors.forename: Fernanda
authors.initials: F
authors.lastname: Silva
authors.forename: Carlos
authors.initials: C
authors.lastname: Serpa
authors.forename: João
authors.initials: J
authors.lastname: Cravino
mesh_terms: D000368:Aged; D007611:Aprotinin / Q000627:therapeutic use*; D001026:Coronary Artery Bypass; D047549:Coronary Artery Bypass, Off-Pump; D005260:Female; D006490:Hemostatics / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000517:prevention & control*; D012189:Retrospective Studies; D014148:Tranexamic Acid / Q000627:therapeutic use*
chemical_list: D006490:Hemostatics; D014148:Tranexamic Acid; D007611:Aprotinin