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Ann Thorac Surg 2001;72:470-475
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Tranexamic acid in off-pump coronary surgery: a preliminary, randomized, double-blind, placebo-controlled study

Valter Casati, MDa, Chiara Gerli, MDa, Annalisa Franco, MDa, Giorgio Torri, MDa, Armando D’Angelo, MDb, Stefano Benussi, MDc, Ottavio Alfieri, MDc

a Department of Anesthesiology, University of Milan, Division of Cardiac Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy
b Coagulation Service and Thrombosis Research Unit, San Raffaele Hospital, Milan, Italy
c Division of Cardiac Surgery, San Raffaele Hospital, Milan, Italy

Accepted for publication April 27, 2001.

Address reprint requests to Dr Casati, Division of Cardiac Anesthesia and Intensive Care, Policlinico di Monza, via Amati 111, 20052 Monza (Milano), Italy
e-mail: valter.casati{at}tin.it


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. We evaluated the hemostatic effects of tranexamic acid, a synthetic antifibrinolytic drug, in patients undergoing beating-heart coronary surgery.

Methods. Forty consecutive patients were in a double-blind manner, prospectively randomized into two groups: 20 patients received tranexamic acid (bolus of 1 g before skin incision, followed by continuous infusion of 400 mg/hr during surgery), and 20 patients received saline. As primary outcomes, bleeding and allogeneic transfusions were considered. D-dimer and fibrinogen plasma levels were also evaluated to monitor the activation of fibrinolysis. Major postoperative thrombotic events, as a potential consequence of antifibrinolytic treatment, were recorded.

Results. The treatment group had significantly lower postoperative bleeding (median [25th to 75th percentiles]: 400 mL [337 to 490 mL] vs 650 ml [550 to 862 mL], p < 0.0001), lower need for allogeneic blood products (1,200 vs 5,300 mL, p < 0.001), and lower postoperative D-dimer plasma levels. No postoperative thrombotic complications were observed in either group.

Conclusions. In this initial series of patients undergoing off-pump coronary surgery, tranexamic acid appears to be effective in reducing postoperative bleeding and the need for allogeneic blood products.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Since its reintroduction by Buffolo and associates and Benetti and associates in the early 1990s [1, 2], off-pump coronary artery bypass surgery (OPCAB) has recently gained new interest, and is the first-choice technique in an increasing number of cardio-surgical centers [3, 4]. The principal aim of avoiding the use of cardiopulmonary bypass (CPB) is to eliminate its possible complications: many previous studies showed a relationship between the activation of coagulation, fibrinolysis, and inflammatory cascade due to CPB, and perioperative inflammatory and hemorrhagic events [5, 6]. Although avoidance of CPB has been shown to significantly reduce perioperative bleeding, hemorrhagic complications and the consequent need for allogeneic transfusions are still major problems after OPCAB [7]. In many centers, because of its proven hemostatic properties, tranexamic acid, a synthetic antifibrinolytic drug, is now administered to CABG patients on a routine basis [8]. The aim of our study was to evaluate the hemostatic effects of this drug in OPCAB surgery.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
After obtaining institutional review board approval and informed consent, from November 1, 1998 to February 28, 1999, 40 consecutive patients, scheduled for OPCAB at our institution, were enrolled in the study. Exclusion criteria were advanced chronic renal insufficiency (creatinine > 2 mg/dL), active chronic hepatitis or cirrhosis, and history of hematological disorders. Following these criteria, 4 patients were not considered for the study. Patients treated with aspirin or heparin before operation were enrolled. Premedication was obtained with intramuscolar morphine (0.1 mg/kg) and scopolamine (0.5 mg), and oral diazepam (0.1 mg/kg). Induction and maintenance of anesthesia were performed with propofol and fentanyl; muscle relaxation was achieved with pancuronium bromide. In patients with left ventricular ejection fraction below 35%, midazolam was used instead of propofol.

Surgical protocol
All patients were operated on through full median sternotomy. The left internal thoracic artery, isolated with a pleurotomy access, was used in all cases; when required, a tract of the great saphenous vein was also harvested through a standard open approach. A heparin dose of 1 mg/kg was administered to obtain an ACT greater than 250 seconds. No drug was administered to control heart rate. After standard pericardiotomy, the target site of the coronary artery to be grafted was stabilized by means of a negative pressure device (Medtronic Italia SpA, Octopus System; Medtronic, Milan, Italy). Coronary occlusion was achieved by means of proximal and distal 4-0 polypropylene sutures, passed through a silicone tube, to avoid direct contact between the tourniquet and the wall of the coronary artery. After the end of the grafting procedure, heparin effect was reversed by protamine administration (1:1 ratio). Before chest closure, mediastinal and pleural drains were positioned, and a low-grade suction was instituted.

Pharmacological protocol
After enrollment, the patients were prospectively randomized, in a double-blind fashion, into two groups: a placebo control group (20 patients), who received an infusion of saline; and a treatment group (20 patients), who received tranexamic acid: a bolus of 1 g over 20 minutes after the induction of anesthesia, but before skin incision, and a continuous infusion of 400 mg/hr during the whole surgical time. Both the staff of the operating room and that of the intensive care unit (ICU) were blinded regarding the treatment; the correct treatment option was assured by means of coded infusion syringes, prepared by an anesthesiologist-in-training who was not directly involved in perioperative clinical treatment of the randomized patients.

Sampling times
Blood samples for evaluation of hemoglobin, hematocrit, platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen, D-dimer, creatinine, creatine phosphokinase, and creatine phosphokinase myocardial band isoenzyme were taken before the induction of anesthesia (time 1), after the arrival in ICU (time 2), 4 hours after the arrival in ICU (time 3), and 24 hours after surgery (time 4).

Criteria for allogeneic transfusions and surgical reexploration
Intraoperative and postoperative criteria for allogeneic transfusions were standardized: packed red blood cells (PRBC) were transfused if the hemoglobin value was less than 8 g/dL, and the hematocrit value less than 24%, with signs or symptoms of hypovolemia (hypotension and/or tachicardia). Fresh-frozen plasma (FFP) was infused after protamine administration, if prothrombin time was 1.5 times longer than the baseline, with diffuse bleeding. Criteria for transfusions of platelet concentrates (PLTC) were the presence of diffuse bleeding and a platelet count less than 50.000/mm3. The total amount of allogeneic transfusions in the groups was calculated as the sum of the single units of all products: one bag of PRBC 300 mL, one bag of FFP 200 mL, and one unit of PLTC 50 mL.

Blood loss was recorded during the first 24 hours, and the bleeding was defined as excessive if greater than 600 mL/24 hours. Chest drains were removed when bleeding was less than 100 mL in the last 4 hours.

Surgical reexploration was considered when bleeding in the first 2 postoperative hours was greater than 300 mL/hr, or if greater than 200 mL/hr for 4 consecutive hours, with normal coagulation data.

Postoperative evaluation
During the first 24 postoperative hours, major thrombotic complications, as a potential consequence of antifibrinolytic therapy, were recorded: myocardial infarction (new q-waves at electrocardiogram and creatine phosphokinase myocardial band isoenzyme/creatine phosphokinase ratio greater than 10%), acute renal insufficiency (creatinine value twice the baseline or need for dialysis), major neurological dysfunction (transient ischemic attack or stroke), deep vein thrombosis, and pulmonary embolism.

Statistical analysis
To test the normality of the distribution of the continuous variables, the Shapiro-Wilk statistic was performed. Normally distributed data, at each time, were analyzed with two-tailed unpaired, Student’s t-test, and expressed as means and standard deviations. Nonnormally distributed variables were evaluated with the Mann-Whitney U test, and expressed as medians and 25th to 75th percentiles. Categorical data were analyzed with {chi}2 test or Fisher’s exact test, as appropriate. Two-way analysis of variance for repeated measures was used to evaluate, within each group, the changes of the variables over time. A p value less than 0.05 was considered significant. Data were analyzed with the SPSS 6.0 statistical package (SPSS, Inc, Chicago, IL).


   Results
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 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
All patients completed the study, and no one required conversion to CPB because of intraoperative instability or surgical complications. Demographic and baseline hematological data are shown in Tables 1 and 2; no significant differences were found between the groups. Operative data did not differ: there were no differences in number of distal anastomoses performed (1 [1 to 2] control group, vs 1 [1 to 2] treatment group); heparin administered (80 mg [70 to 100 mg] control group vs 80 mg [70 to 100 mg] treatment group); protamine administered (80 mg [69 to 100 mg] control group vs 85 mg [77 to 100 mg] treatment group); operation time (170 minutes [120 to 175 minutes] control group vs 180 minutes [120 to 190 minutes] treatment group). No patient required intraoperative allogeneic transfusions. Of the considered hematochemical data, only D-dimer plasma levels showed significant differences in the postoperative period (Table 3); they were significantly higher in the placebo group at all postoperative times (Fig 1). Instead, as shown in Figure 2, no differences were found in fibrinogen plasma levels. Postoperative bleeding and allogeneic transfusions are shown in Table 4; the placebo group patients suffered significantly greater blood loss during the first 4 postoperative hours. Also, total bleeding was significantly higher if compared with that of the patients treated with tranexamic acid. Diffences were also found in the total amount of allogeneic transfusions, which were significantly greater in the placebo group (Table 4). In particular, 2 patients (10%) treated with tranexamic acid were transfused during the first 4 postoperative hours with a total of 4 units of PRBC for anemia; each of them had low preoperative values of hematocrit and hemoglobin (respectively, 32.5% and 10.5 g/dL in the first patient, and 30% and 10 g/dL in the second), and did not show excessive bleeding (both patients bled 350 mL/24 hours). Instead, 4 patients (20%) of placebo group, showed anemia after excessive postoperative bleeding, and required administration of a total of 11 units of PRBC. Two of them also needed transfusion of FFP (a total of 10 units). None of these patients had preoperative anemia (minimum hematocrit 38% and minimum hemoglobin 13.2 g/dL). No patient of either group had transfusion of PLTC. The prevalence of excessive bleeding is impressively greater in the placebo group: 14 patients (70%) bled more than 600 mL/24 hours, versus only 1 patient of the treatment group (p < 0.001). No patient of either group showed postoperative bleeding requiring surgical reexploration. Finally, no major thrombotic events were recorded in either group.


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  		Table 1. Baseline Characteristics

 

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  		Table 2. Baseline Hematochemical Data

 

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  		Table 3. Hematochemical Data 24 Hours After Operations

 


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  		Fig 1. Median D-dimer plasma levels. For the times, see Material and Methods. Significant differences between the groups at Times 2, 3, and 4 (Mann-Whitney U-test, p < 0.05). ({blacksquare} = placebo; • = tranexamic.)

 


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  		Fig 2. Fibrinogen plasma levels (means ± standard deviations). For the times, see Material and Methods. No significant differences between the groups. ({blacksquare} = placebo; • = tranexamic.)

 

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  		Table 4. Postoperative Bleeding and Perioperative Allogeneic Transfusions

 

   Comment
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 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
This is the first study to evaluate the hemostatic effects of tranexamic acid in patients undergoing OPCAB. Previous works reported significant bleeding and use of allogeneic blood in OPCAB surgery. Nader and coworkers observed, in their patients undergoing OPCAB, a mean bleeding of 771 mL, and a mean use of about two units of PRBC, one unit of FFP, and two units of platelet-rich plasma per patient [7]. Cartier and coworkers reported a median postoperative bleeding of 525 mL, with a prevalence of patients transfused with allogeneic products of 31% [4]. Similarly, Ascione and coworkers described a mean bleeding of about 770 mL, with a not negligible use of allogeneic blood products [9]. It is apparent that the problem of bleeding in cardiac surgery seems far from having been resolved by simply avoiding extracorporeal circulation. Among the drugs with hemostatic properties used in cardiac surgery performed on CPB, tranexamic acid has raised increasing interest in recent years. It is a synthetic antifibrinolytic drug, which acts by binding to the lysine binding sites of plasminogen, thus blocking the interaction with specific lysine residues of fibrin [10]. Because of its demonstrated hemostatic properties and low cost, we routinely use tranexamic acid in all patients undergoing cardiac surgery with CPB [11, 12]. To investigate the potential benefits of antifibrinolytic treatment in a wider series of patients, we decided to test its effectiveness also in OPCAB surgery. The most important result of this study is the significant reduction of postoperative bleeding observed in the treatment group during the first postoperative hours, when the hemostatic effects of tranexamic acid administered during operation are still present. The efficacy of the drug is clearly evident considering the different rate of excessive bleeding in the two groups: 14 patients of placebo group bled more than 600 mL, while only 1 patient in the treatment group did. Accordingly, patients receiving placebo needed a larger amount of allogeneic transfusions. Moreover, it is worth noting that the 2 patients transfused in the treatment group required PRBC because of their preoperative anemia. Another significant difference emerging from the study concerns the increase in D-dimer plasma levels, which only occurred in the control group. Whereas the activation of coagulation and fibrinolysis during CPB is widely studied [13, 14], few studies evaluated these systems in patients undergoing OPCAB. Mariani and coworkers considered a series of patients operated without CPB either through median sternotomy or through minimally invasive anterolateral thoracotomy, and they did not find differences between the two groups [15]. Two studies compared CABG patients with patients undergoing thoracic, noncardiac surgery. The first of these, by Whitten and coworkers, specifically evaluated D-dimer plasma levels: they found an increase in D-dimer during and after CPB, whereas the control group showed an increase only 24 hours after surgery [16]. Furthermore, the authors ascertained a lack of relationship between D-dimer plasma levels and the amount of postoperative bleeding. The second of these studies, by Hunt and coworkers, evaluated a larger series of hematochemical variables [17]. Their conclusions were similar to those expressed by Whitten: the activation of coagulation and fibrinolysis is mainly due to CPB, which exerts, with its foreign surfaces, a powerful thrombotic stimulus, whereas surgical dissection has only a secondary role. Our results are not completely in line with those of the above-cited studies. In fact, we found a significant increase of D-dimer plasma levels, which is evident soon after surgery, only in patients of the placebo group, whereas no significant changes were evidenced in the group treated with tranexamic acid. Clearly, the patients undergoing OPCAB are different from those undergoing thoracic noncardiac surgery, because they undergo a greater surgical trauma (sternotomy, internal mammary artery and saphenous vein territory, pericardiotomy), manipulation of the heart, and exposure to heparin and protamine. These factors determine the activation of coagulation during OPCAB by release of tissue factor and activation of the extrinsic pathway. A recent study indicated this pathway as the most important in the activation of coagulation also in CABG [18]. Another important finding of our study is that the increase in plasma D-dimer is not related to significant variations of fibrinogen. As suggested by Comunale and coworkers, an increase of D-dimer without a concomitant decrease of fibrinogen does not signify coagulopathy; they suggest that the contemporary increase of perioperative blood loss and of D-dimer plasma levels derives from excessive bleeding, which predisposes to an increased clot formation, and through clot remodeling, to the elevation of D-dimer [19]. Thus, the greater D-dimer plasma levels observed in our OPCAB patients receiving placebo can simply derive from greater perioperative bleeding. Finally, addressing the issue of thrombotic complications as a possible consequence of antifibrinolytic therapy, Slaughter and coworkers studied the effects of {varepsilon}-aminocaproic acid, a synthetic antifibrinolytic drug similar to tranexamic acid, on fibrinolysis and thrombin generation during CPB. They found a reduction of fibrinolytic activity without a concomitant reduction of thrombin formation, suggesting that antifibrinolytic therapy can potentiate a hypercoagulable prothrombotic state during the perioperative period [20]. The same conclusions are found in the previously cited study by Mariani and coworkers, who evidenced a procoagulant activity after OPCAB not mediated by platelet-related factors [15]. For this reason, they proposed an aggressive perioperative anticoagulation policy, to reduce the risk of early graft occlusion and pulmonary embolism in the first 24 postoperative hours. Thus, the use of antifibrinolytic drugs during OPCAB can theoretically increase the risk of perioperative thrombotic events. Yet, in this initial series of patients, we did not observe major thrombotic complications. Of course, further studies involving larger numbers of patients are required to have more precise indications regarding these findings.

To conclude, in this preliminary study performed on a limited number of patients, tranexamic acid proved effective in reducing postoperative bleeding and the need for allogeneic transfusions in patients undergoing OPCAB. Further studies with larger series of patients are needed to confirm these initial data, and to fully understand the aspects of the activation of coagulation and the effects of tranexamic acid in this type of surgery.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Buffolo E., Andrade J.C.S., Branco J.N.R., Aguiar L.F., Ribeiro E.E., Jatene A.D. Myocardial revascularization without extracorporeal circulation: seven-year experience in 593 cases. Eur J Cardiothorac Surg 1990;4:504-509.[Abstract]
  2. Benetti F.J., Naselli G., Wood M., Geffner L. Direct myocardial revascularization without extracorporeal circulation: experience in 700 patients. Chest 1991;100:312-316.[Abstract/Free Full Text]
  3. Iacò A.L., Contini M., Teodori G., et al. Off or on bypass: what is the safety threshold?. Ann Thorac Surg 1999;68:1468-1469.[Free Full Text]
  4. Cartier R., Brann S., Dagenais F., Martineau R., Couturier A. Systematic off-pump coronary artery revascularization in multivessel disease: experience of three hundred cases. J Thorac Cardiovasc Surg 2000;119:221-229.[Abstract/Free Full Text]
  5. Butler J., Rocker G.M., Westaby S. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg 1993;55:552-559.[Abstract]
  6. Mammen E.F., Koets M.H., Washington B.C., et al. Hemostasis changes during cardiopulmonary bypass surgery. Sem Thromb Hemost 1985;11:281-292.[Medline]
  7. Nader N.D., Khadra W.Z., Reich N.T., Bacon D.R., Salerno T.A., Panos A.L. Blood product use in cardiac revascularization: comparison of on- and off-pump techniques. Ann Thorac Surg 1999;68:1640-1643.[Abstract/Free Full Text]
  8. Levi M., Cromheecke M.E., de Jonge E., et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999;354:1940-1947.[Medline]
  9. Ascione R., Lloyd C.T., Underwood M.J., Lotto A.A., Pitsis A.A., Angelini G.D. Economic outcome of off-pump coronary artery bypass surgery: a prospective randomized study. Ann Thorac Surg 1999;68:2237-2242.[Abstract/Free Full Text]
  10. Verstraete M. Clinical application of inhibitors of fibrinolysis. Drugs 1985;29:236-261.[Medline]
  11. Casati V., Guzzon D., Oppizzi M., et al. Hemostatic effects of aprotinin, tranexamic acid and {varepsilon}-aminocaproic acid in primary cardiac surgery. Ann Thorac Surg 1999;68:2252-2257.[Abstract/Free Full Text]
  12. Casati V., Guzzon D., Oppizzi M., et al. Tranexamic acid compared with high-dose aprotinin in primary elective heart operations: effects on perioperative bleeding and allogeneic transfusions. J Thorac Cardiovasc Surg 2000;120:520-527.[Abstract/Free Full Text]
  13. Dietrich W. Cardiac surgery and the coagulation system. Curr Opin Anaesthesiol 2000;13:27-34.
  14. Paramo J.A., Rifon J., Llorens R., Casares J., Paloma M.J., Rocha E. Intra- and postoperative fibrinolysis in patients undergoing cardiopulmonary bypass surgery. Haemostasis 1991;21:58-64.[Medline]
  15. Mariani M.A., Gu Y.J., Boonstra P.W., Grandjean J.G., van Oeveren W., Ebels T. Procoagulant activity after off-pump coronary operation: is the current anticoagulation adequate?. Ann Thorac Surg 1999;67:1370-1375.[Abstract/Free Full Text]
  16. Whitten C.W., Greilich P.E., Ivy R., Burkhardt D., Allison P.M. D-dimer formation during cardiac and non-cardiac thoracic surgery. Anesth Analg 1999;88:1226-1231.[Abstract/Free Full Text]
  17. Hunt B., Parratt R.N., Segal H.C., Sheikh S., Kallis P., Yacoub M. Activation of coagulation and fibrinolysis during cardiothoracic operations. Ann Thorac Surg 1998;65:712-718.[Abstract/Free Full Text]
  18. Burman J.F., Chung H.I., Lane D.A., Philippou H., Adami A., Lincoln J.C.R. Role of factor XII in thrombin generation and fibrinolysis during cardiopulmonary bypass. Lancet 1994;344:1192-1193.[Medline]
  19. Comunale M.E., Carr J.M., Moorman R.M., Robertson L.K. Significance of D-dimer concentrations during and after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1996;10:477-481.[Medline]
  20. Slaughter T.F., Faghih F., Greenberg C.S., Leslie J.B., Sladen R.N. The effects of {varepsilon}-aminocaproic acid on fibrinolysis and thrombin generation during cardiac surgery. Anesth Analg 1997;85:1221-1226.[Abstract]



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