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High-dose aprotinin in emergency coronary artery bypass after thrombolysis
1022
Ann Thorac Surg 1992;541018-24
CORRESPONDENCE
In this day and age of neoadjunctive therapy for clinically advanced cancers and extrapleural pneumonectomies for tuberculosis and mesotheliomas, it would be totally inappropriate to embark on a randomized prospective study of stapled versus sutured bronchial closure. Many of these patients would have our listed contraindications for staple closure, and these include close proximity of the cancer, bronchial mucosal inflammation, and a thickened bronchus. Fifteen of the 20 pneumonectomy fistulas in our series received preoperative irradiation, and five received chemotherapy as well. The knowledgeable thoracic surgeon makes his or her choice for bronchial closure based on reported results as well as intraoperative pathology. The decision for staple or suture closure of the bronchus is based on reported results, such as ours, coupled with good judgment.
is not low, it is justified by the efficacy in reducing both bleeding and the need for transfusion, thus decreasing all related risks to the patient. We agree with Efstratiadis and colleagues, and we would like to underline their statement about the utility of aprotinin in the setting of urgent operations soon after thrombolysis, thus avoiding all problems associated with potential excessive bleeding.
L. Penfield Faber, M D S . Russell Vester, M D C. Frederick Kittle, M D William H . Warren, M D Robert I. Jensik, M D
References
Rush-Presbyterian-St. Luke’s Medical Center 1753 W Congress Pkwy Chicago, IL 60612
High-Dose Aprotinin in Emergency Coronary Artery Bypass After Thrombolysis To the Editor: The article by Efstratiadis and colleagues [ l ] illustrates the intraoperative use of high-dose aprotinin during emergency coronary artery bypass in a patient who underwent intracoronary thrombolysis with streptokinase. Our clinical experience with aprotinin, following a randomized trial published in The Annals in 1989 121, is now more than 800 patients. Aprotinin is being used as a routine in all patients undergoing cardiopulmonary bypass at our institution. Here we report 3 cases of patients who were taken to operation soon after thrombolytic treatment. One patient was operated on immediately after intracoronary thrombolysis with urokinase (650,000 U) for evolving acute myocardial infarction, complicated by cardiac arrest with successful resuscitation in the catheterization laboratory. He had triple coronary artery bypass grafting performed. In 2 other patients, the indication for coronary artery bypass grafting was set after thrombolysis. In 1patient, 1.5 million units of streptokinase was infused intravenously 12 hours before operation; in the other patient, thrombolysis with recombinant tissue plasminogen activator (100 mg) was undertaken 13 hours before the operation. All 3 patients had an uncomplicated postoperative course. Aprotinin treatment was used throughout the operation, according to the usual dosage: 2,000,000 KIU at the start of the operation, 500,000 KIU per hour, and 1,000,000KIU added to the pump prime [2]. Intraoperative and postoperative bleeding was trivial. Total postoperative drainage was 315 mL, 550 mL, and 555 mL, respectively, in the 3 patients, and homologous transfusion was not needed. Skinner and associates [3] reported a mean postoperative blood loss of 1,450 mL in 24 patients operated on after intracoronary thrombolysis, with 5 patients bleeding in excess of 2,000 mL; average transfusion requirement of more than 8 U of blood and 8 U of plasma was reported. The precise mechanism of action of aprotinin is still unclear. However, we believe that, although the cost of aprotinin infusion
Franco Alajmo, M D Giancarlo Calamai, M D Department of Cardiac Surgery Policlinico di Careggi vide Morgagni 85 50134 Florence, Italy
1. Efstratiadis T, Munsch C, Crossman D, Taylor K. Aprotinin used in emergency coronary operation after streptokinase treatment. Ann Thorac Surg 1991;52:132&1. 2. Alajmo F, Calamai G, Perna AM, et al. High-dose aprotinin: hemostatic effects in open heart operations. Ann Thorac Surg 1989;48:536-9. 3. Skinner JR, Phillips SJ, Zeff RH. Immediate coronary bypass following failed streptokinase infusion in evolving myocardial infarction. J Thorac Cardiovasc Surg 1984;87567-70.
Reply
To the Editor:
We would like to thank Drs Alajmo and Calamai for their comments on our report of the use of aprotinin (Trasylol; Bayer AG, Leverkusen, Germany) to control streptokinase-induced bleeding during emergency coronary operations [l]. We note with interest their similar findings in 3 patients as well as their policy of routine administration of aprotinin to all patients undergoing operations employing cardiopulmonary bypass. We have continued to use aprotinin in this particular clinical setting. In a further 4 patients to that reported in our case study, we have seen a similar reduction in blood loss and need for transfusion of blood products. As Drs Alajmo and Calamai rightly point out, the precise mode of action of aprotinin is still unclear. Although recent evidence suggests that this hemostatic effect may be implemented by preservation of platelet number and function [2], we believe that the known antiplasmidantifibrinolytic action of aprotinin is an important part of the mechanism, and hence that it is eminently logical to administer aprotinin to patients recently given urokinase, streptokinase, or tissue-type plasminogen activator. We see this application as yet another indication for the use of aprotinin in cardiac surgical practice. We d o not currently use aprotinin for uncomplicated elective primary cardiac operations, but continue to administer it to high-risk patients, including those having reoperation, septic patients, and patients with coagulation or platelet disorders.
Theodore Efstratiadis, M D , PhD Christopher Munsch, FRCS David Crossman, MRCP Kenneth M . Taylor, M D Departments of Cardiothoracic Surgery and Cardiology Hammersmith Hospital Du Cane Rd London W12 OHS England
Ann Thorac Surg 1992;541018-24
CORRESPONDENCE
In this day and age of neoadjunctive therapy for clinically advanced cancers and extrapleural pneumonectomies for tuberculosis and mesotheliomas, it would be totally inappropriate to embark on a randomized prospective study of stapled versus sutured bronchial closure. Many of these patients would have our listed contraindications for staple closure, and these include close proximity of the cancer, bronchial mucosal inflammation, and a thickened bronchus. Fifteen of the 20 pneumonectomy fistulas in our series received preoperative irradiation, and five received chemotherapy as well. The knowledgeable thoracic surgeon makes his or her choice for bronchial closure based on reported results as well as intraoperative pathology. The decision for staple or suture closure of the bronchus is based on reported results, such as ours, coupled with good judgment.
is not low, it is justified by the efficacy in reducing both bleeding and the need for transfusion, thus decreasing all related risks to the patient. We agree with Efstratiadis and colleagues, and we would like to underline their statement about the utility of aprotinin in the setting of urgent operations soon after thrombolysis, thus avoiding all problems associated with potential excessive bleeding.
L. Penfield Faber, M D S . Russell Vester, M D C. Frederick Kittle, M D William H . Warren, M D Robert I. Jensik, M D
References
Rush-Presbyterian-St. Luke’s Medical Center 1753 W Congress Pkwy Chicago, IL 60612
High-Dose Aprotinin in Emergency Coronary Artery Bypass After Thrombolysis To the Editor: The article by Efstratiadis and colleagues [ l ] illustrates the intraoperative use of high-dose aprotinin during emergency coronary artery bypass in a patient who underwent intracoronary thrombolysis with streptokinase. Our clinical experience with aprotinin, following a randomized trial published in The Annals in 1989 121, is now more than 800 patients. Aprotinin is being used as a routine in all patients undergoing cardiopulmonary bypass at our institution. Here we report 3 cases of patients who were taken to operation soon after thrombolytic treatment. One patient was operated on immediately after intracoronary thrombolysis with urokinase (650,000 U) for evolving acute myocardial infarction, complicated by cardiac arrest with successful resuscitation in the catheterization laboratory. He had triple coronary artery bypass grafting performed. In 2 other patients, the indication for coronary artery bypass grafting was set after thrombolysis. In 1patient, 1.5 million units of streptokinase was infused intravenously 12 hours before operation; in the other patient, thrombolysis with recombinant tissue plasminogen activator (100 mg) was undertaken 13 hours before the operation. All 3 patients had an uncomplicated postoperative course. Aprotinin treatment was used throughout the operation, according to the usual dosage: 2,000,000 KIU at the start of the operation, 500,000 KIU per hour, and 1,000,000KIU added to the pump prime [2]. Intraoperative and postoperative bleeding was trivial. Total postoperative drainage was 315 mL, 550 mL, and 555 mL, respectively, in the 3 patients, and homologous transfusion was not needed. Skinner and associates [3] reported a mean postoperative blood loss of 1,450 mL in 24 patients operated on after intracoronary thrombolysis, with 5 patients bleeding in excess of 2,000 mL; average transfusion requirement of more than 8 U of blood and 8 U of plasma was reported. The precise mechanism of action of aprotinin is still unclear. However, we believe that, although the cost of aprotinin infusion
Franco Alajmo, M D Giancarlo Calamai, M D Department of Cardiac Surgery Policlinico di Careggi vide Morgagni 85 50134 Florence, Italy
1. Efstratiadis T, Munsch C, Crossman D, Taylor K. Aprotinin used in emergency coronary operation after streptokinase treatment. Ann Thorac Surg 1991;52:132&1. 2. Alajmo F, Calamai G, Perna AM, et al. High-dose aprotinin: hemostatic effects in open heart operations. Ann Thorac Surg 1989;48:536-9. 3. Skinner JR, Phillips SJ, Zeff RH. Immediate coronary bypass following failed streptokinase infusion in evolving myocardial infarction. J Thorac Cardiovasc Surg 1984;87567-70.
Reply
To the Editor:
We would like to thank Drs Alajmo and Calamai for their comments on our report of the use of aprotinin (Trasylol; Bayer AG, Leverkusen, Germany) to control streptokinase-induced bleeding during emergency coronary operations [l]. We note with interest their similar findings in 3 patients as well as their policy of routine administration of aprotinin to all patients undergoing operations employing cardiopulmonary bypass. We have continued to use aprotinin in this particular clinical setting. In a further 4 patients to that reported in our case study, we have seen a similar reduction in blood loss and need for transfusion of blood products. As Drs Alajmo and Calamai rightly point out, the precise mode of action of aprotinin is still unclear. Although recent evidence suggests that this hemostatic effect may be implemented by preservation of platelet number and function [2], we believe that the known antiplasmidantifibrinolytic action of aprotinin is an important part of the mechanism, and hence that it is eminently logical to administer aprotinin to patients recently given urokinase, streptokinase, or tissue-type plasminogen activator. We see this application as yet another indication for the use of aprotinin in cardiac surgical practice. We d o not currently use aprotinin for uncomplicated elective primary cardiac operations, but continue to administer it to high-risk patients, including those having reoperation, septic patients, and patients with coagulation or platelet disorders.
Theodore Efstratiadis, M D , PhD Christopher Munsch, FRCS David Crossman, MRCP Kenneth M . Taylor, M D Departments of Cardiothoracic Surgery and Cardiology Hammersmith Hospital Du Cane Rd London W12 OHS England