Ann Thorac Surg 2001;72:526
© 2001 The Society of Thoracic Surgeons
Invited commentary
Richard M. Engelman, MDa
a Division of Cardiac Surgery, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01107, USA
e-mail: engelman{at}bhs.org
In my experience and in fact the experience of the hematology services and hospital pharmacies in institutions performing cardiac surgery, it is not uncommon to have an antifibrinolytic agent, eg Aprotinin or EACA, administered hours after the end of the fibrinolytic insult, eg cardiopulmonary bypass, when unusual postoperative bleeding is appreciated. This is discussed in this paper by Dr Ray and colleagues where there was a double-blind, randomized, placebo controlled study in patients having excessive postoperative chest drainage. The drug or placebo was administered approximately 2 hours after the end of bypass, a not unreasonable period to determine if there is to be excessive bleeding.
The findings of the study noted no difference in the volume of chest drainage in the group as a whole depending upon the use of antifibrinolytic or placebo and no urgent reoperations in any group. The only distinction which could be appreciated was noted in the 12 patients having valvular surgery, with the four receiving Aprotonin having a trend (p = 0.06) for less chest drainage compared to the five placebo patients after the first 12 postoperative hours. The science of this paper absolutely contradicts any theoretical benefit of the drugs because there was no difference in the post-treatment plasma D-dimer levels in the Aprotinin or EACA treated patients compared to the placebo. Thus, it is presumed by the authors and supported by the data that clot lysis after bypass has progressed too far after the fact (two hours after completion of bypass) to be inhibited by the administration of an antifibrinolytic. This conclusion is supported by the data and the generally accepted belief that antifibrinolytics should be prophylactic to be effective after cardiopulmonary bypass.
Related Article
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Postoperatively administered aprotinin or epsilon aminocaproic acid after cardiopulmonary bypass has limited benefit
- Michael J. Ray, Majella M. Hales, Lee Brown, Mark F. O’Brien, and E. Gregory Stafford
Ann. Thorac. Surg. 2001 72: 521-526.
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