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11.1 Comparison of aprotinin versus aminocaproic acid (Amicar) in repeat open heart surgery
1400- 1700
Tuesday,September 23. 1997
ion 1 I -Cardlopul Co-Chairmen:GeorgeL. Hicks, J.J. Amato Westminster Suite 11.1 Comparison of Aprotinin Versus Aminocaproic Acid (Amicar) in Repeat Open Heart Surgery R. VUAYANAGAR, N. KONDA, G. CHAN, N. SASTRY, M. DESANTZS and D. MANGAR, Tampa, Florida, USA
11.2 Heparin-Induced Thrombcytopeha Trpe II as Complication in Twelve Heart Surgery Patients: Diagnosis and Management R. SODIAN, M. LOEBE, H. RIESS and R. HETZER, Berlin Germany
Repeat cardiac surgery is associated with an increased risk of hemorrhage. Amicar and the proteinase inhibitor aprotinin have been used to reduce perioperative bleeding. The relative efficacy and financial impact of aprotinin versus Amicar is, however, unknown. Therefore, we undertook a retrospective analysis to compare aprotinin (Group I, n = 43) and Amicar (Group II, n = 42) for prevention of bleeding in patients who underwent repeat cardiac surgery between 1993-1995. The study groups were similar in demographics, bypass grafts, and preoperative chemistry: Hg, Hct, PT, FIT, bleeding time and serum creatinine. The groups had comparable total operating times (5.1 + 1.1 h versus 5.1 2 1.2 h, NS and 24 h chest tube blood drainage (771 z 533 ml versus 787 z 385m1, NS). Significantly fewer transfusions of blood products were required in Group I.
Heparin is administered in the prevention and treatment of thrombembolic complications and plays a vital role in the use of heart-lung machines during heart surgery. An especially dangerous complication of heparin therapy, however, is a heparin-induced thrombocytopenia (HIT) Type II. Bleeding, but above all, serious thrombembolic complications, which may result in crippling disabilities or even death, can develop. We report on 12 heart surgery patients who were diagnosed with a HIT Type II. Ten of the patients were diagnosed postoperatively; the other two, preoperatively. In one of these two patients, a mitral valve replacement with r-hirudin HBW 023 (Behringwerke, Marburg, Germany) was used in the heart-lung machine. Of the 10 postoperative HIT-patients, seven had had a bypass operation and each had received a mitral- or aortic valve replacement. Another patient had received an artificial biventricular support system (Berlin Heart), and was diagnosed with a HIT Type II 7 days after the operation. Because of his special condition, this patient was anticoagulated with orgaran (danaparoidnatrium). Upon suspicion of a HIT Type II, heparin therapy was immediately stopped and an alternative treatment of orgaran or r-hirudin was begun. All told, five patients with crossreactive antibodies to orgaran were treated with r-Hirudin. One patient encountered bleeding of a gastric ulcer on orgaran therapy. Conclusion: Heart surgery patients, especially patients with an artificial support system, are potentially lethally threatened by serious thrombembolic complications accompanying a HIT Type II. Therefore, these patients must be diagnosed as early as possible. Orgaran, in addition to r-hirudin, are effective heparin substitutes in patients with HIT Type II. These medications can be widely administered to heart surgery postoperatively without patients intraand p-e-, complication.
Packed RCB, units Platelets, units Fresh frozen plasma, units Cryoprecipitate, units Myocardial injury (enzymes) Renal failure
Group I
Group II
P-value
1.9 4.2 0.4 0.7 7.1 0.0
3.2 2 2.5 13.7 + 10.3 2.3 + 1.7 3.0 5 5.1 4.8 0.0
<0.012 <0.0001 <0.0001 NS NS
* t + 2
2.0 8.2 1.5 2.6
There was no difference in the incidence of perioperative myocardial injury (7% versus 4,8%, NS) and none developed renal failure. Although aprotinin was more expensive than Amicar, Group II patients incurred significantly higher costs for blood-product transfusions ($316 * 478 versus $938 + 673, P < 0.0001). As a result, the total expenditure on drug and blood products was comparable between the two groups ($766 * 478 versus $940 ‘c 672, NS). Our findings suggest that the use of aprotinin significantly reduces transfusion requirements in repeat cardiac surgery.
CARDIOVASCULAR
SURGERY
SEPTEMBER
1997
55
Tuesday,September 23. 1997
ion 1 I -Cardlopul Co-Chairmen:GeorgeL. Hicks, J.J. Amato Westminster Suite 11.1 Comparison of Aprotinin Versus Aminocaproic Acid (Amicar) in Repeat Open Heart Surgery R. VUAYANAGAR, N. KONDA, G. CHAN, N. SASTRY, M. DESANTZS and D. MANGAR, Tampa, Florida, USA
11.2 Heparin-Induced Thrombcytopeha Trpe II as Complication in Twelve Heart Surgery Patients: Diagnosis and Management R. SODIAN, M. LOEBE, H. RIESS and R. HETZER, Berlin Germany
Repeat cardiac surgery is associated with an increased risk of hemorrhage. Amicar and the proteinase inhibitor aprotinin have been used to reduce perioperative bleeding. The relative efficacy and financial impact of aprotinin versus Amicar is, however, unknown. Therefore, we undertook a retrospective analysis to compare aprotinin (Group I, n = 43) and Amicar (Group II, n = 42) for prevention of bleeding in patients who underwent repeat cardiac surgery between 1993-1995. The study groups were similar in demographics, bypass grafts, and preoperative chemistry: Hg, Hct, PT, FIT, bleeding time and serum creatinine. The groups had comparable total operating times (5.1 + 1.1 h versus 5.1 2 1.2 h, NS and 24 h chest tube blood drainage (771 z 533 ml versus 787 z 385m1, NS). Significantly fewer transfusions of blood products were required in Group I.
Heparin is administered in the prevention and treatment of thrombembolic complications and plays a vital role in the use of heart-lung machines during heart surgery. An especially dangerous complication of heparin therapy, however, is a heparin-induced thrombocytopenia (HIT) Type II. Bleeding, but above all, serious thrombembolic complications, which may result in crippling disabilities or even death, can develop. We report on 12 heart surgery patients who were diagnosed with a HIT Type II. Ten of the patients were diagnosed postoperatively; the other two, preoperatively. In one of these two patients, a mitral valve replacement with r-hirudin HBW 023 (Behringwerke, Marburg, Germany) was used in the heart-lung machine. Of the 10 postoperative HIT-patients, seven had had a bypass operation and each had received a mitral- or aortic valve replacement. Another patient had received an artificial biventricular support system (Berlin Heart), and was diagnosed with a HIT Type II 7 days after the operation. Because of his special condition, this patient was anticoagulated with orgaran (danaparoidnatrium). Upon suspicion of a HIT Type II, heparin therapy was immediately stopped and an alternative treatment of orgaran or r-hirudin was begun. All told, five patients with crossreactive antibodies to orgaran were treated with r-Hirudin. One patient encountered bleeding of a gastric ulcer on orgaran therapy. Conclusion: Heart surgery patients, especially patients with an artificial support system, are potentially lethally threatened by serious thrombembolic complications accompanying a HIT Type II. Therefore, these patients must be diagnosed as early as possible. Orgaran, in addition to r-hirudin, are effective heparin substitutes in patients with HIT Type II. These medications can be widely administered to heart surgery postoperatively without patients intraand p-e-, complication.
Packed RCB, units Platelets, units Fresh frozen plasma, units Cryoprecipitate, units Myocardial injury (enzymes) Renal failure
Group I
Group II
P-value
1.9 4.2 0.4 0.7 7.1 0.0
3.2 2 2.5 13.7 + 10.3 2.3 + 1.7 3.0 5 5.1 4.8 0.0
<0.012 <0.0001 <0.0001 NS NS
* t + 2
2.0 8.2 1.5 2.6
There was no difference in the incidence of perioperative myocardial injury (7% versus 4,8%, NS) and none developed renal failure. Although aprotinin was more expensive than Amicar, Group II patients incurred significantly higher costs for blood-product transfusions ($316 * 478 versus $938 + 673, P < 0.0001). As a result, the total expenditure on drug and blood products was comparable between the two groups ($766 * 478 versus $940 ‘c 672, NS). Our findings suggest that the use of aprotinin significantly reduces transfusion requirements in repeat cardiac surgery.
CARDIOVASCULAR
SURGERY
SEPTEMBER
1997
55