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Aprotinin does not compromise graft patency in coronary bypass surgery
APROTININ
DOES NOT COMPROMISE
GRAFT PATENCY IN CORONARY
BYPASS SURGERY.
C. VEDRlNNE, 0. JEGADEN, R. ROSSI, Ph. MIKAELOFF, S. ESTANOVE. Hopital CARDIOLOGIQUE L. PRADEL, BP Lyon-Montchat, 69394 Lyon Cedex 03, FRANCE INTRODUCTION
A substantial reduction of blood loss and blood requirement after cardiopulmonary bypass (CPB) has been shown by prophylactic treatment with the proteinase inhibitor aprotinin (1,2). However, Bohrer (3) speculated that the administration of high dose of aprotinin increased the degree of thrombus formation on non-heparin coated pulmonary artery catheters. Hence, aprotinin may promote thrombus formation on other surfaces. The aims of this retrospective study was to answer the question of whether or not aprotinin increases the possibility of graft occlusion in coronary artery bypass surgery. PATIENTS AND METHODS - From January to October 1991, 52 patients (men ; age 60i8years) who had undergone coronary artery bypass grafting (CABG) with aprotinin infusion and had had early postoperative angiographic study (18*4 days) were included in this study. 11 patients had two vessel disease and 41 patients had three vessels disease. The left ventricular ejection fraction was 64_+13%. - At the induction of anaesthesia, all patients received 3 mg per kg of aprotinin (AntagosanHoechst 50 ml = 70 mg = 500 000 KIU of aprotinin) over 20 to 30 minutes. Additionally, aprotinin 3 mg per kg was injected into the priming solution of CPB. Subsequently aprotinin, 1 mg per kg, was administered after the injection of protamine sulphate at the end of CPB (mean 470f70 mg of aprotinin per patient). Anaesthesia was induced with high dose fentanyl and pancuronium. Operative procedure and CPB were similar in all patients. The surgical procedure and post angiographic study were performed by the same surgeon (OJ) and the same radiologist (RR). Patients were heparinized before CPB with 300 IU/kg with additional doses to maintain the activated clotting time beyond 400 seconds. Heparin was neutralized after the end of CPB with protamine sulphate (1 mg/lOO IU heparin). Heparin (1 mg/kg) and dipyridamole (50 mg per day) were introduced postoperatively as soon as possible starting at least 6 hours after surgery and on condition that there was less than 20 ml blood loss per hour into the chest drains for two hours consecutively.
RESULTS Mean aortic cross clamping time was 50f12 min and CPB time was 62f16 min. 37 patients (71%) had complete myocardial revascularization (2.75kO.6, mean number of distal anastomoses per patient). Only in situ arterial grafts were used : internal mammary arteries (one : 18, two : 34, including 13 sequential) and gastroepiploic artery (43). Six hours blood losses were 233f146ml (35-420) and there was no reoperation because of bleeding. Twelve patients (23%) required postoperative blood transfusion (30 units). There were no reoperations secondary to bleeding and no postoperative deaths. A new Q wave infarction was noted in one patient. All 143 distal anastomoses were well demonstrated. The patency rate was 99% (142/143), with an efficacious myocardial revascularisation in 140 cases. There was one anastomosis occlusion, one anastomosis stenosis and one unfunctional anastomosis because of flow competition. CONCLUSION Blood loss and blood requirement are similar to that of reference studies despite the use of a lower aprotinin dose (470 mg). Although aprotinin is administered in an attempt to increase clotting, decrease fibrinolytic activity and obtain platelet protective activity, it does not compromise arterial graft patency in coronary bypass surgery. REFERENCES l- ROYSTON D, BIDSTRUP BP, TAYLOR KM, SAPSFORD RN. Effect of Aprotinin on need for blood transfusion after repeat open-heart surgery. Lancet, II : 1289-1291,1987. 2- WILDEVUUR CH RH, EIJSMAN L, ROOZENDAAL KJ, HARDER MP, CHANG M, VAN OEVEREN W. Platelet preservation during cardiopulmonary bypass with aprotinin. Eur. J. CardioThorac. Surg. 3 : 533-538,1989. 3- BOHRER H, FLEISHER F, LANG J, et al. Early formation of thrombi on pulmonary artery catheters in cardiac surgical patients receiving high-dose Aprotinin. J. Cardiothorac. Anesth. 4 : 222-225,199o.
DOES NOT COMPROMISE
GRAFT PATENCY IN CORONARY
BYPASS SURGERY.
C. VEDRlNNE, 0. JEGADEN, R. ROSSI, Ph. MIKAELOFF, S. ESTANOVE. Hopital CARDIOLOGIQUE L. PRADEL, BP Lyon-Montchat, 69394 Lyon Cedex 03, FRANCE INTRODUCTION
A substantial reduction of blood loss and blood requirement after cardiopulmonary bypass (CPB) has been shown by prophylactic treatment with the proteinase inhibitor aprotinin (1,2). However, Bohrer (3) speculated that the administration of high dose of aprotinin increased the degree of thrombus formation on non-heparin coated pulmonary artery catheters. Hence, aprotinin may promote thrombus formation on other surfaces. The aims of this retrospective study was to answer the question of whether or not aprotinin increases the possibility of graft occlusion in coronary artery bypass surgery. PATIENTS AND METHODS - From January to October 1991, 52 patients (men ; age 60i8years) who had undergone coronary artery bypass grafting (CABG) with aprotinin infusion and had had early postoperative angiographic study (18*4 days) were included in this study. 11 patients had two vessel disease and 41 patients had three vessels disease. The left ventricular ejection fraction was 64_+13%. - At the induction of anaesthesia, all patients received 3 mg per kg of aprotinin (AntagosanHoechst 50 ml = 70 mg = 500 000 KIU of aprotinin) over 20 to 30 minutes. Additionally, aprotinin 3 mg per kg was injected into the priming solution of CPB. Subsequently aprotinin, 1 mg per kg, was administered after the injection of protamine sulphate at the end of CPB (mean 470f70 mg of aprotinin per patient). Anaesthesia was induced with high dose fentanyl and pancuronium. Operative procedure and CPB were similar in all patients. The surgical procedure and post angiographic study were performed by the same surgeon (OJ) and the same radiologist (RR). Patients were heparinized before CPB with 300 IU/kg with additional doses to maintain the activated clotting time beyond 400 seconds. Heparin was neutralized after the end of CPB with protamine sulphate (1 mg/lOO IU heparin). Heparin (1 mg/kg) and dipyridamole (50 mg per day) were introduced postoperatively as soon as possible starting at least 6 hours after surgery and on condition that there was less than 20 ml blood loss per hour into the chest drains for two hours consecutively.
RESULTS Mean aortic cross clamping time was 50f12 min and CPB time was 62f16 min. 37 patients (71%) had complete myocardial revascularization (2.75kO.6, mean number of distal anastomoses per patient). Only in situ arterial grafts were used : internal mammary arteries (one : 18, two : 34, including 13 sequential) and gastroepiploic artery (43). Six hours blood losses were 233f146ml (35-420) and there was no reoperation because of bleeding. Twelve patients (23%) required postoperative blood transfusion (30 units). There were no reoperations secondary to bleeding and no postoperative deaths. A new Q wave infarction was noted in one patient. All 143 distal anastomoses were well demonstrated. The patency rate was 99% (142/143), with an efficacious myocardial revascularisation in 140 cases. There was one anastomosis occlusion, one anastomosis stenosis and one unfunctional anastomosis because of flow competition. CONCLUSION Blood loss and blood requirement are similar to that of reference studies despite the use of a lower aprotinin dose (470 mg). Although aprotinin is administered in an attempt to increase clotting, decrease fibrinolytic activity and obtain platelet protective activity, it does not compromise arterial graft patency in coronary bypass surgery. REFERENCES l- ROYSTON D, BIDSTRUP BP, TAYLOR KM, SAPSFORD RN. Effect of Aprotinin on need for blood transfusion after repeat open-heart surgery. Lancet, II : 1289-1291,1987. 2- WILDEVUUR CH RH, EIJSMAN L, ROOZENDAAL KJ, HARDER MP, CHANG M, VAN OEVEREN W. Platelet preservation during cardiopulmonary bypass with aprotinin. Eur. J. CardioThorac. Surg. 3 : 533-538,1989. 3- BOHRER H, FLEISHER F, LANG J, et al. Early formation of thrombi on pulmonary artery catheters in cardiac surgical patients receiving high-dose Aprotinin. J. Cardiothorac. Anesth. 4 : 222-225,199o.