COMPARATIVE EFFECTS OF APROTININ AND TRAN EXAMIC ACID ON BLOOD-LOSS IN CARDIAC-SURGERY

Objectives: To compare the efficacy of aprotinin (APR) and tranexamic acid (TRA) in reducing blood loss and transfusion requirements after c ardiac surgery under extracorporeal circulation (ECC). Study design: R andomized controlled trial. Patients: One hundred and four adults unde rgoing either coronary artery bypass grafting (CABG) (n = 55), or aort ic valve replacement (AVR) (n = 49), allocated into three groups. Meth ods: a) APR group (23 CABG and 20 AVR) received aprotinin, 2 x 10(6) K IU (280 mg) after induction, followed by an infusion of 0.5 x 106 KIU . h(-1) (70 mg . h(-1)) until chest closure, with a supplement to the oxygenator prime of 2 x 10(6) KIU ;b) TRA group (22 CABG and 19 AVR) r eceived tranexamic acid, 15 mg . kg(-1) between the injection of hepar in (400 IU . kg(-1)) and the beginning of ECC, 15 mg . kg(-1) after pr otamin injection (1.3 mg/100 IU of heparin); c) CTR group (10 CABG and 10 AVR), the control group, was not treated with an antifibrinolytic agent. The amount of blood collected from the chest tube drainage was measured at admission to ICU, as well as 4, 8 and 18 h after the inser tion of drains and at the time of their removal. Packed red cells wher e given when the haematocrit was under 20 % during ECC, 25 % at the en d of surgery and 30 % after extubation. Results: The blood loss was lo wer in APR group (834 +/- 448 mL) than in TRA group (1015 +/- 409 mL) (P = 0.009), and in CTR group (1416 +/- 559 ML) (P = 0.004). The rates of transfused patients in groups APR, ATR and CTR were 35, 37 and 60 % respectively and the numbers of units administered per patient were 0.8, 0.8 and 1.7 respectively. In AVR cases, APR and TRA had a similar efficacy. In CABG cases, only aprotinin decreased postoperative bleed ing. However there was no difference between APR and TRA concerning th e transfusion requirements. In CABG cases the ECC was of shorter durat ion and blood loss was 1127 +/- 540 mL vs 894 +/- 422 mL in AVR cases (P = 0.03). Conclusions: Both APR and TRA decrease blood loss. APR is more efficient after CABG than TRA as far as blood loss is concerned, whereas the transfusion requirements are similar. As APR is about 100 times more expensive and carries a risk for allergic reactions, its us e in a high dose regimen is only recommended for reoperations, in pati ents treated with salicylates and in case of sepsis.