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Ann Thorac Surg 2000;70:871-872
© 2000 The Society of Thoracic Surgeons
Discussion
DR AXEL HAVERICH (Hannover, Germany): From your experience with this study and from data probably available from other GP IIb/IIIa inhibitors, do you know if there is a difference between Reopro and your compound in terms of bleeding complications after bypass surgery?
DR BHATIA: Thank you Dr Haverich. Conflicting reports have been published, however, there has not been a large study that has looked at patients that have received either Reopro or other short-acting IIb/IIIa inhibitors and undergone immediate surgery. At our institution, we reviewed 23 consecutive patients that went to surgery emergently after receiving Reopro and the transfusion requirements were considerably higher in the group of patients who went to surgery within 24 hours of administration, compared with patients in whom surgery was delayed.
DR HAVERICH: That would mimic our experience in Germany.
DR EDMUND NAGEM (Lafayette, LA): Doctor Bhatia, do you think that similarity between the placebo and the drug group was related to the short half-life of the drug and, hence, by the time surgery was concluded, the drug was already out of the system?
DR BHATIA: Dr Nagem, thank you for your question. We do feel that due to the shorter half-life of Integrelin (approximately 2 to 4 hours), it is our thought that platelet aggregation returns to near normal by the end of cardiopulmonary bypass and that this is why we are not seeing as much bleeding complications with the shorter-acting inhibitors.
DR MOHAMMED ALI MUMTAZ (Overland Park, KS): Just a comment about this previous question and a question followed by that. The comment is that Reopro, the medication that you used in this study, actually irreversibly binds to the platelets, so the half-life would not be that important. The platelets that are exposed to the drug are completely inactivated for the life of the platelet, and if there is a protective effect, it should last the whole week; the platelets are alive.
My question to you is: Was information available to you as to the total volume of transfusions used, both packed red blood cells as well as platelets in the patients that received them? And if it was, was there a difference in the total amount of transfusions used?
DR BHATIA: Thank you for your comments Dr Mumtaz. I agree with you that Reopro irreversibly binds the GP 263a receptor; this has been the rationale for the "platelets as antidote" concept when patients on Reopro require surgery. We and others, however, have reported significant differences in bleeding and transfusion in patients on Reopro who require immediate surgery versus those operated on 12 to 24 hours later.
Regarding the volume of transfusion in patients in the PURSUIT study, this was not available from the case report forums and is a recognized weakness. I wish we had that information.
DR SVEN BEHOLZ (Berlin, Germany): Thank you very much for your presentation, which shows that there is some evidence that these critically ill patients can be operated on safely. In patients treated with Aggrastat, the elimination of the drug is preceded by hemofiltration. Did you see any impact on hemofiltration during cardiopulmonary bypass or the preoperative renal function on the bleeding in any of your patients?
DR BHATIA: Well, in this group, we do not know the incidence of hemofiltration. That is a hot topic; surgeons are starting to use hemofiltration in attempts to eradicate the small-molecule IIb/IIIa inhibitors from the system. Although there are little clinical data regarding its efficacy, the in vitro work by Ken Taylor’s group in London is promising.
DR STEVEN D. HERMAN (Newark, NJ): I would like to congratulate you on showing us that you can operate upon patients who have impaired hemostatic function from drugs. A question that I have is: Within the surgical arm, do you have any information about whether utilization of antibleeding chemicals such as Trasylol, tranexamic acid, or Amicar were utilized in any fashion during the cases? Also, were there any differences in the rates of surgical reexploration, because many times transfusion requirements are obviated by the reinfusion of shed blood and may not accurately reflect the realities of the clinical situation. Need for surgical reexploration may be a better defining endpoint for hemorrhage evaluation.
DR BHATIA: Well, as I mentioned, PURSUIT was not designed as a surgical study. I do not know whether or not additional procoagulant pharmacology was instituted. Certainly, surgeons were allowed to follow their usual practice. Regarding mediastinal reexploration, 1 patient in the placebo group was reexplored.
Related Article
Ann. Thorac. Surg. 2000 70: 866-871.
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