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Colson P, Fellahi JL, Gaudard P, Provenchère S, Rozec B. Cost Analysis of Aprotinin Reintroduction in French Cardiac Surgery Centres: A Real-World Data-Based Analysis. Adv Ther 2023; 40:1803-1817. [PMID: 36867329 PMCID: PMC10070296 DOI: 10.1007/s12325-023-02464-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/14/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION The European Medicines Agency restored aprotinin (APR) use for preventing blood loss in patients undergoing isolated coronary artery bypass graft (iCABG) in 2016 but requested the collection of patient and surgery data in a registry (NAPaR). The aim of this analysis was to evaluate the impact of APR reintroduction in France on the main hospital costs (operating room, transfusion and intensive unit stay) compared to the current use of tranexamic acid (TXA), which was the only antifibrinolytic available before APR reinstatement. METHODS A multicenter before-after post-hoc analysis to compare APR and TXA was carried out in four French university hospitals. APR use followed the ARCOTHOVA (French Association of Cardiothoracic and Vascular Anesthetists) protocol, which had framed three main indications in 2018. Data from 236 APR patients were retrieved from the NAPaR (N = 874); 223 TXA patients were retrospectively retrieved from each center database and matched to APR patients upon indication classes. Budget impact was evaluated using both direct costs associated with antifibrinolytics and transfusion products (within the first 48 h) and other costs such as surgery duration and ICU stay. RESULTS The 459 collected patients were distributed as: 17% on-label; 83% off-label. Mean cost per patient until ICU discharge tended to be lower in the APR group versus the TXA group, which resulted in an estimated gross saving of €3136 per patient. These savings concerned operating room and transfusion costs but were mainly driven by reduced ICU stays. When extrapolated to the whole French NAPaR population, the total savings of the therapeutic switch was estimated at around €3 million. CONCLUSION The budget impact projected that using APR according to ARCOTHOVA protocol resulted in decreased requirement for transfusion and complications related to surgery. Both were associated with substantial cost savings from the hospital's perspective compared with exclusive use of TXA.
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Affiliation(s)
- Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34295, Montpellier, France.
- Montpellier University, INSERM, CNRS, Institut de Génomique Fonctionnelle, Montpellier, France.
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care Medicine, Louis Pradel Hospital, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France
- Laboratoire CarMeN, Inserm U1060, Université Claude Bernard Lyon 1, Lyon, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, 371 avenue du doyen Gaston Giraud, 34295, Montpellier, France
- University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Sophie Provenchère
- Department of Anesthesiology and Critical Care Medecine, AP-HP, Bichat-Claude-Bernard Hospital, Paris, France
- INSERM Clinical Investigation Center 007, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, hôpital Laënnec, Centre Hospitalier Universitaire, 44093, Nantes, France
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, 44093, Nantes, France
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Tolkmitt J, Brendel H, Zatschler B, Brose S, Brunssen C, Kopaliani I, Deussen A, Matschke K, Morawietz H. Aprotinin does not Impair Vascular Function in Patients Undergoing Coronary Artery Bypass Graft Surgery. Horm Metab Res 2023; 55:65-74. [PMID: 36599358 DOI: 10.1055/a-1984-0255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Bleeding is a major complication in coronary artery bypass graft surgery. Antifibrinolytic agents like serine protease inhibitor aprotinin can decrease postoperative bleeding and complications of cardiac surgery. However, the effects of aprotinin on vascular function are not completely elucidated. We compared the ex vivo vascular function of left internal mammary arteries from patients undergoing coronary artery bypass graft surgery with and without intraoperative application of aprotinin using a Mulvany Myograph. Human internal mammary arteries were treated with aprotinin ex vivo and tested for changes in vascular function. We analyzed the impact of aprotinin on vascular function in rat aortic rings. Finally, impact of aprotinin on expression and activity of endothelial nitric oxide synthase was tested in human endothelial cells. Intraoperative application of aprotinin did not impair ex vivo vascular function of internal mammary arteries of patients undergoing coronary artery bypass graft surgery. Endothelium-dependent and -independent relaxations were not different in patients with or without aprotinin after nitric oxide synthase blockade. A maximum vasorelaxation of 94.5%±11.4vs. 96.1%±5.5% indicated a similar vascular smooth muscle function in both patient groups (n=13 each). Long-term application of aprotinin under physiological condition preserved vascular function of the rat aorta. In vitro application of increasing concentrations of aprotinin on human endothelial cells resulted in a similar expression and activity of endothelial nitric oxide synthase. In conclusion, intraoperative and ex vivo application of aprotinin does not impair the endothelial function in human internal mammary arteries and experimental models.
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Affiliation(s)
- Josephine Tolkmitt
- Department of Medicine III, Division of Vascular Endothelium and Microcirculation, Technische Universität Dresden, Dresden, Germany
| | - Heike Brendel
- Department of Medicine III, Division of Vascular Endothelium and Microcirculation, Technische Universität Dresden, Dresden, Germany
| | - Birgit Zatschler
- Institute of Physiology, Technische Universität Dresden, Dresden, Germany
| | - Stefan Brose
- Department of Cardiac Surgery, University Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Coy Brunssen
- Division of Vascular Endothelium and Microcirculation, Technische Universität Dresden, Dresden, Germany
| | - Irakli Kopaliani
- Institute of Physiology, Technische Universität Dresden, Dresden, Germany
| | - Andreas Deussen
- Institute of Physiology, Technische Universität Dresden, Dresden, Germany
| | - Klaus Matschke
- Department of Cardiac Surgery, University Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Henning Morawietz
- Department of Medicine III, Division of Vascular Endothelium and Microcirculation, Technische Universität Dresden, Dresden, Germany
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Nteliopoulos G, Nikolakopoulou Z, Chow BHN, Corless R, Nguyen B, Dimarakis I. Lung injury following cardiopulmonary bypass: a clinical update. Expert Rev Cardiovasc Ther 2022; 20:871-880. [PMID: 36408601 DOI: 10.1080/14779072.2022.2149492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Cardiopulmonary bypass (CPB) is an integral component of cardiac surgery; however, one of its most critical complications is acute lung injury induced by multiple factors including systemic inflammatory response. AREAS COVERED The objective of this review is to investigate the multiple factors that can lead to CPB-induced lung injury. These include contact of blood components with the artificial surface of the CPB circuit, local and systemic inflammatory response syndrome (SIRS), lung ischemia/re-perfusion injury, arrest of ventilation, and circulating endotoxins. We also focus on possible interventions to curtail the negative impact of CPB, such as off-pump surgery, impregnation of the circuit with less biologically active substances, leukocyte depletion filters and ultrafiltration, and pharmacological agents such as steroids and aprotinin. EXPERT OPINION Although many aspects of CPB are proposed to contribute to lung injury, its overall role is still not clear. Multiple interventions have been introduced to reduce the risk of pulmonary dysfunction, with many of these interventions having shown promising results, significantly attenuating inflammatory mediators and improving post-operative outcome. However, since lung injury is multifactorial and affected by inextricably linked components, multiple interventions tackling each of them is required.
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Affiliation(s)
| | - Zacharoula Nikolakopoulou
- Department of Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, UK
| | - Bobby Hiu Nam Chow
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | | | - Bao Nguyen
- Department of Cardiothoracic Surgery, Derriford Hospital, Plymouth, UK
| | - Ioannis Dimarakis
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK.,Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Wythenshawe Hospital, Manchester, UK
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Siemens K, Sangaran DP, Hunt BJ, Murdoch IA, Tibby SM. Antifibrinolytic Drugs for the Prevention of Bleeding in Pediatric Cardiac Surgery on Cardiopulmonary Bypass: A Systematic Review and Meta-analysis. Anesth Analg 2021; 134:987-1001. [PMID: 34633994 DOI: 10.1213/ane.0000000000005760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Bleeding is one of the commonest complications affecting children undergoing cardiac surgery on cardiopulmonary bypass. Antifibrinolytic drugs are part of a multifaceted approach aimed at reducing bleeding, though sufficiently sized pediatric studies are sparse, and dosing algorithms are heterogeneous. Our objective was to evaluate the efficacy and safety of antifibrinolytic agents as well as the effectiveness of different dosing regimens in pediatric cardiac surgery using cardiopulmonary bypass. METHODS We performed a systematic review and meta-analysis evaluating randomized controlled trials published between 1980 and 2019, identified by searching the databases MEDLINE, EMBASE, PubMed, and CENTRAL. All studies investigating patients <18 years of age without underlying hematological disorders were included. The primary outcome was postoperative bleeding; secondary end points included blood product transfusion, mortality, and safety (thromboses, anaphylaxis, renal or neurological dysfunction, and seizures). Different dosing regimens were compared. Studies were dual appraised, outcomes were reported descriptively and, if appropriate, quantitatively using the Review Manager 5 (REVMAN 5) software (The Cochrane Collaboration). RESULTS Thirty of 209 articles were included, evaluating the following drugs versus control: aprotinin n = 14, tranexamic acid (TXA) n = 12, and epsilon-aminocaproic acid (EACA) n = 4. The number of participants per intervention group ranged from 11 to 100 (median, 25; interquartile range [IQR], 20.5) with a wide age span (mean, 13 days to 5.8 years) and weight range (mean, 3.1-26.3 kg). Methodological quality was low to moderate.All agents reduced mean 24-hour blood loss compared to control: aprotinin by 6.0 mL/kg (95% confidence interval [CI], -9.1 to -3.0; P = .0001), TXA by 9.0 mL/kg (95% CI, -11.3 to -6.8; P < .00001), and EACA by 10.5 mL/kg (95% CI, -21.1 to 0.0; P = .05). Heterogeneity was low for TXA (I2 = 29%; P = .19), moderate for aprotinin (I2 = 41%; P = .11), and high for EACA (I2 = 95%; P = <.00001). All agents also reduced 24-hour blood product transfusion. There was no clear dose-response effect for TXA nor aprotinin. Studies were underpowered to detect significant differences in mortality, thromboses, anaphylaxis, and renal or neurological dysfunction. CONCLUSIONS The available data demonstrate efficacy for all 3 antifibrinolytic drugs. Therefore, the agent with the most favorable safety profile should be used. As sufficient data are lacking, large comparative trials are warranted to assess the relative safety and appropriate dosing regimens in pediatrics.
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Affiliation(s)
- Kristina Siemens
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - Dilanee P Sangaran
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - Beverley J Hunt
- Department of Hematology, St Thomas' Hospital, London, United Kingdom
| | - Ian A Murdoch
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - Shane M Tibby
- From the Pediatric Intensive Care, Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
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Biaou G, Sebestyen A, Durand M, Albaladejo P, Chavanon O. Early postoperative bleeding after isolated coronary bypasses: Changes over a period of 20 years - An observational study. Transfus Clin Biol 2021; 28:180-185. [PMID: 33578020 DOI: 10.1016/j.tracli.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/31/2021] [Accepted: 02/02/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The objectives were to analyze the evolution of the postoperative bleeding after coronary artery bypass grafting and to determine which factors impacted on this evolution. METHODS This is a single-center retrospective study including 4590 patients undergoing coronary bypass surgery between 1995 and 2017. The study period was divided into 3 same-sized periods. We analyzed the evolution of the bleeding according to: the chest volume bleeding over the first 24hours, the severity and the rate of transfusion during the hospital stay. Intrahospital outcomes were compared between "minor" and "major" bleedings. The risk factors of major bleeding were analyzed by multiple logistic regression. RESULTS The chest volume decreased particularly during the first years of the study period. Major bleedings decreased over the periods (7.3%, 4.9% and 3.8% respectively, P<0.0001), as did the rate of transfusion (26.4%, 23.5% and 19.6% respectively, P<0.0001). Major bleedings were correlated with hospital mortality (8.2% versus 1.1%, P<0.0001). The risk factors of major bleeding were the period 1 (1995 to 2003), a renal failure, a resternotomy, the EuroSCORE, the hematocrit prior to cardiopulmonary bypass and the duration of cardiopulmonary bypass. CONCLUSIONS Postoperative bleeding decreased mainly in the 1990s. Progressive changes in bleeding prevention and blood recovery, surgical techniques, haemoglobin threshold for transfusion decision and practitioners' experience have contributed to these results and must be continued to optimize the postoperative outcomes.
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Affiliation(s)
- G Biaou
- Cardiac Surgery Department, University Hospital of Grenoble-Alpes, 38700 La Tronche, France
| | - A Sebestyen
- Cardiac Surgery Department, University Hospital of Grenoble-Alpes, 38700 La Tronche, France.
| | - M Durand
- Anesthesia and Intensive Care Department, University Hospital of Grenoble-Alpes, 38700 La Tronche, France
| | - P Albaladejo
- Anesthesia and Intensive Care Department, University Hospital of Grenoble-Alpes, 38700 La Tronche, France
| | - O Chavanon
- Cardiac Surgery Department, University Hospital of Grenoble-Alpes, 38700 La Tronche, France
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Leff J, Romano CA, Gilbert S, Nair S. Validation Study of the Transfusion Risk and Clinical Knowledge (TRACK) Tool in Cardiac Surgery Patients: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2019; 33:2669-2675. [DOI: 10.1053/j.jvca.2019.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/21/2019] [Accepted: 05/25/2019] [Indexed: 11/11/2022]
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7
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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8
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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9
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Murphy GJ, Mumford AD, Rogers CA, Wordsworth S, Stokes EA, Verheyden V, Kumar T, Harris J, Clayton G, Ellis L, Plummer Z, Dott W, Serraino F, Wozniak M, Morris T, Nath M, Sterne JA, Angelini GD, Reeves BC. Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundAnaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.Methods and resultsWorkstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.LimitationsExisting studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.ConclusionsA systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.Study registrationCurrent Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Veerle Verheyden
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gemma Clayton
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Zoe Plummer
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Mintu Nath
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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Royston D, De Hert S, van der Linden J, Ouattara A, Zacharowski K. A special article following the relicence of aprotinin injection in Europe. Anaesth Crit Care Pain Med 2017; 36:97-102. [DOI: 10.1016/j.accpm.2017.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/09/2017] [Accepted: 02/02/2017] [Indexed: 01/07/2023]
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Stevens LM, Noiseux N, Prieto I, Hardy JF. Major transfusions remain frequent despite the generalized use of tranexamic acid: an audit of 3322 patients undergoing cardiac surgery. Transfusion 2016; 56:1857-65. [DOI: 10.1111/trf.13615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 02/25/2016] [Accepted: 02/25/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Louis-Mathieu Stevens
- Division of Cardiac Surgery and the; Centre Hospitalier de l'Université de Montréal (CHUM)
- Department of Anesthesiology; Centre Hospitalier de l'Université de Montréal (CHUM)
- CHUM Research Center (CRCHUM); Montréal Québec Canada
| | - Nicolas Noiseux
- Division of Cardiac Surgery and the; Centre Hospitalier de l'Université de Montréal (CHUM)
- Department of Anesthesiology; Centre Hospitalier de l'Université de Montréal (CHUM)
- CHUM Research Center (CRCHUM); Montréal Québec Canada
| | - Ignacio Prieto
- Division of Cardiac Surgery and the; Centre Hospitalier de l'Université de Montréal (CHUM)
| | - Jean-François Hardy
- Department of Anesthesiology; Centre Hospitalier de l'Université de Montréal (CHUM)
- CHUM Research Center (CRCHUM); Montréal Québec Canada
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Abstract
PURPOSE OF REVIEW This review provides a summary of the most recent clinical trials evaluating the hemostatic agents for the treatment of coagulopathy associated with critical bleeding. In particular, antifibrinolytic agents (i.e., aprotinin, tranexamic and ε-aminocaproic acids), desmopressin, recombinant activated factor VII, fibrinogen and prothrombin complex concentrates are evaluated. RECENT FINDINGS Among the various therapeutic options available, tranexamic acid is emerging as the most promising. Indeed, a recent randomized trial has shown a benefit survival of the early administration of tranexamic acid in patients with trauma-induced coagulopathy. SUMMARY Although preliminary data document a potential therapeutic role for prohemostatic pharmacologic approaches, further evidence arising from randomized controlled trials is needed to assess the safety and efficacy of such agents in the setting of critical bleeding.
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15
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Abstract
Abstract
Antifibrinolytic therapy reduces bleeding and chest tube drainage output in cardiac surgical patients but is associated with potential side effects. Two phase-II studies with new compounds were terminated prematurely. There is increasing evidence of adverse side effects with tranexamic acid.
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16
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Royston D. The current place of aprotinin in the management of bleeding. Anaesthesia 2015; 70 Suppl 1:46-9, e17. [PMID: 25440394 DOI: 10.1111/anae.12907] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2014] [Indexed: 12/18/2022]
Abstract
There is a considerable difference between the mechanism of action of the lysine analogues, tranexamic acid and epsilon-aminocaproic acid, and the serine protease inhibitor aprotinin. Aprotinin acts to inactivate free plasmin, but with little effect on bound plasmin, whereas the lysine analogues are designed to prevent excessive plasmin formation by fitting into plasminogen's lysine-binding site to prevent the binding of plasminogen to fibrin. Aprotinin is associated with a reduction in bleeding and transfusion requirements following major surgery, and has a dose-response profile, compared with no dose-response effect in the one study investigating tranexamic acid in cardiac surgical patients. Following its withdrawal in 2007, which is explained in detail in this review, the regulators have now licensed aprotinin for myocardial revascularisation only, which is relatively low-risk for bleeding.
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Affiliation(s)
- D Royston
- Department of Anaesthesia, Critical Care and Pain Management, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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17
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Robich MP, Koch CG, Johnston DR, Schiltz N, Chandran Pillai A, Hussain ST, Soltesz EG. Trends in blood utilization in United States cardiac surgical patients. Transfusion 2014; 55:805-14. [DOI: 10.1111/trf.12903] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 08/29/2014] [Accepted: 08/30/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Michael P. Robich
- Department of Thoracic and Cardiovascular Surgery; Heart and Vascular Institute; Cleveland Clinic; Cleveland Ohio
| | - Colleen G. Koch
- Department of Cardiothoracic Anesthesia; Cleveland Clinic; Cleveland Ohio
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular Surgery; Heart and Vascular Institute; Cleveland Clinic; Cleveland Ohio
| | - Nicholas Schiltz
- Department of Epidemiology and Biostatistics; Case Western Reserve University; Cleveland Ohio
| | | | - Syed T. Hussain
- Department of Thoracic and Cardiovascular Surgery; Heart and Vascular Institute; Cleveland Clinic; Cleveland Ohio
| | - Edward G. Soltesz
- Department of Thoracic and Cardiovascular Surgery; Heart and Vascular Institute; Cleveland Clinic; Cleveland Ohio
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Year in review in Intensive Care Medicine 2013: I. Acute kidney injury, ultrasound, hemodynamics, cardiac arrest, transfusion, neurocritical care, and nutrition. Intensive Care Med 2013; 40:147-159. [DOI: 10.1007/s00134-013-3184-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 11/29/2013] [Indexed: 02/07/2023]
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Walkden GJ, Goudie R, Verheyden V, Murphy GJ. Aprotinin revisited: rebuttal of comments by DeSantis and Lazaridis. Intensive Care Med 2013; 40:143. [PMID: 24196449 DOI: 10.1007/s00134-013-3146-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2013] [Indexed: 11/29/2022]
Affiliation(s)
- G J Walkden
- Bristol Heart Institute , University of Bristol, Bristol, BS8 1TH, UK
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DeSantis SM, Lazaridis C. Aprotinin revisited. Intensive Care Med 2013; 40:142. [PMID: 24154674 DOI: 10.1007/s00134-013-3130-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Stacia M DeSantis
- Division of Biostatistics, School of Public Health, University of Texas Health Science Center, 1200 Herman Pressler Street, RAS E809, Houston, TX, 77030, USA,
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