Effects of aprotinin on short-term and long-term outcomes after coronary artery bypass grafting surgery

Fibrinogen is an independent preoperative predictor of hospital length of stay among patients undergoing coronary artery bypass grafting

OBJECTIVE

This study aims to examine the impact of preoperative fibrinogen concentration on the short-term outcomes and hospital length of stay (LOS) of patients undergoing Coronary Artery Bypass Grafting (CABG).

METHODS

Between January 2010 and June 2022, a retrospective analysis comprised 633 patients who sequentially received isolated, primary CABG. These patients were categorized into normal fibrinogen group (fibrinogen < 3.5 g/L) and high fibrinogen group (fibrinogen ≥ 3.5 g/L) according to preoperative fibrinogen concentration. The primary outcome was LOS. To correct for confounding and investigate the effect of preoperative fibrinogen concentration on the short-term outcomes and LOS, we employed propensity score matching (PSM). The correlation between fibriongen concentration and LOS in subgroups was examined using subgroup analysis.

RESULTS

We categorized 344 and 289 patients in the "normal fibrinogen group" and "high fibrinogen group", respectively. After PSM, compared to the normal fibrinogen group, the high fibrinogen group had a longer LOS [12.00 (9.00-15.00) vs. 13.00 (10.00-16.00), P = 0.028] and higher incidence of postoperative renal impairment [49 (22.1%) vs. 72 (32.4%), P = 0.014]. Cardiopulmonary bypass (CPB) or non-CPB CABG patients showed similar correlations between various fibrinogen concentrations and LOS, according to subgroup analyses.

CONCLUSIONS

Fibrinogen is an independent preoperative predictor of both the LOS and the postoperative renal impairment that occurs after CABG. Patients with high preoperative fibrinogen concentration had a higher incidence of postoperative renal impairment and a longer LOS, emphasizing the significance of preoperative fibrinogen management.

Outcome impact of different tranexamic acid regimens in cardiac surgery with cardiopulmonary bypass (OPTIMAL): Rationale, design, and study protocol of a multicenter randomized controlled trial

Tranexamic acid (TxA) reduces perioperative blood transfusion in cardiac surgery; however, the optimal dose of TxA remains unknown. METHODS AND RESULTS: This large-scale, double-blind, randomized controlled trial with a 1-year follow-up enrolls patients undergoing elective cardiac surgery with cardiopulmonary bypass. Patients are randomly assigned 1:1 into either the high-dose TxA group (intravenous bolus [30 mg/kg] after anesthesia followed by intravenous maintenance [16 mg/kg/h] throughout the operation, and a pump prime dose of 2 mg/kg) or the low-dose TxA group (intravenous bolus and maintenance are 10 mg/kg and 2 mg/kg/h, respectively, and a pump prime dose of 1 mg/kg). The primary efficacy end point is the rate of perioperative allogeneic red blood cell (RBC) transfusion defined as the number (%) of patients who will receive at least 1 RBC unit from operation day to discharge. The primary safety end point is the 30-day rate of the composite of perioperative seizures, renal dysfunction, myocardial infarction, ischemic stroke, deep vein thrombosis, pulmonary embolism, and all-cause mortality. The secondary end points are perioperative allogeneic RBC transfusion volume, the non-RBC blood transfusion rate, postoperative bleeding, reoperation rate, mechanical ventilation duration, intensive care unit stay, hospital length of stay, total hospitalization cost, each component of composite primary safety end point, and the 6-month/1-year follow-up mortality and morbidity. We estimated a sample size of 3,008 participants. CONCLUSIONS: The study is designed to identify a TxA dose with maximal efficacy and minimal complications. We hypothesize that the high dose has superior efficacy and noninferior safety to the low dose.

Which factor is the most effective one in metabolic Sydrome on the outcomes after coronary artery bypass graft surgery? A cohort study of 5 Years

Background

Metabolic Syndrome and diabetes mellitus are risk factors for cardiovascular disease. However, the effects of Metabolic Syndrome with or without diabetes on perioperative and long-term morbidity and mortality after Coronary Artery Bypass Graft remain unclear.

Methods

An retrospective study was performed on 1166 patients who received isolated primary Coronary Artery Bypass Graft in Fuwai hospital. They were divided into three groups: control, Metabolic Syndrome of three factors together with diabetes and Metabolic Syndrome of three factors without diabetes (n = 868, 76 and 222 respectively). Analysis of variance, Chi-rank test, Fisher’s exact test, Log-rank test, Cox and Logistic regression models were used for data processing. Outcomes were postoperative and 5-year survival and morbidities.

Results

There were no significant differences between groups in in-hospital postoperative complications, epinephrine use, stroke, atrial fibrillation, renal failure, coma, myocardial infarction and repeated revascularization. Patients in the Metabolic Syndrome with diabetes, Metabolic Syndrome without diabetes and control groups, respectively, showed significant difference in perioperative Major Adverse Cerebral Cardiovascular Events (30.3% vs. 21.2%, 16.7%, P = 0.0071) and mortality (11.8% vs. 2.7%, 3.11%, P = 0.0003). The Metabolic Syndrome with diabetes group had higher rates of perioperative mortality than Metabolic Syndrome without diabetes (P = 0.0017, P of Fisher Test = 0.0039). Compared with non-diabetic patients with Metabolic Syndrome, those with Metabolic Syndrome and diabetes had increased long-term mortality (Adjusted HR: 4.3; 95% CI: 1.4–13.3; P = 0.0113) and Major Adverse Cerebral Cardiovascular Events (Adjusted OR: 1.7; 95% CI: 1.0–2.8; P = 0.048). Control and non-diabetic Metabolic Syndrome groups did not differ in long-term mortality but controls had lower rates of Major Adverse Cerebral Cardiovascular Events (Adjusted OR: 0.79; 95% CI: 0.64–0.98; P = 0.0329).

Conclusions

There were significance differences between the three groups in perioperative Major Adverse Cerebral Cardiovascular Events and mortality after Coronary Artery Bypass Graft. Compared with non-diabetic Metabolic Syndrome patients, patients with Metabolic Syndrome and diabetes had higher long-term Major Adverse Cerebral Cardiovascular Events and mortality. While patients free of MetS and diabetes were associated with lower incidence of long-term Major Adverse Cerebral Cardiovascular Events after Coronary Artery Bypass Graft.

Use of pulmonary artery catheter in coronary artery bypass graft. Costs and long-term outcomes

Background

Pulmonary artery catheters (PAC) are used widely to monitor hemodynamics in patients undergoing coronary bypass graft (CABG) surgery. However, recent studies have raised concerns regarding both the effectiveness and safety of PAC. Therefore, our aim was to determine the effects of the use of PAC on the short- and long-term health and economic outcomes of patients undergoing CABG.

Methods

1361 Chinese patients who consecutively underwent isolated, primary CABG at the Cardiovascular Institute of Fuwai Hospital from June 1, 2012 to December 31, 2012 were included in this study. Of all the patients, 453 received PAC during operation (PAC group) and 908 received no PAC therapy (control group). Short-term and long-term mortality and major complications were analyzed with multivariate regression analysis and propensity score matched-pair analysis was used to yield two well-matched groups for further comparison.

Results

The patients who were managed with PAC more often received intraoperative vasoactive drugs dopamine (70.9% vs. 45.5%; P<0.001) and epinephrine (7.7% vs. 2.6%; P<0.001). In addition, costs for initial hospitalization were higher for PAC patients ($14,535 vs. $13,873, respectively, p = 0.004). PAC use was neither associated with the perioperative mortality or major complications, nor was it associated with long-term mortality and major adverse cardiac and cerebrovascular events. In addition, comparison between two well-matched groups showed no significant differences either in baseline characteristics or in short-term and long-term outcomes.

Conclusions

There is no clear indication of any benefit or harm in managing CABG patients with PAC. However, use of PAC in CABG is more expensive. That is, PAC use increased costs without benefit and thus appears unjustified for routine use in CABG surgery.

Effects of metabolic syndrome with or without obesity on outcomes after coronary artery bypass graft. A cohort and 5-year study

BACKGROUND

Metabolic syndrome (MetS) and obesity are risk factors for cardiovascular disease, however, it remains unclear about effects of MetS with or without obesity on perioperative and long-term morbidity and mortality after coronary artery bypass graft (CABG).

METHODS

An observational cohort study was performed on 4,916 consecutive patients receiving isolated primary CABG in Fuwai hospital. Of all patients, 1238 patients met the inclusion criteria and were divided into three groups: control, MetS with obesity and MetS without obesity (n = 868, 76 and 294 respectively). The patient's 5-year survival and major adverse cerebral and cardiovascular events (MACCE) were studied.

RESULTS

Among all three groups, there were no significant differences in in-hospital postoperative complications, epinephrine use, stroke, ICU stay, ventilation time, atrial fibrillation, renal failure, coma, myocardial infarction, repeated revascularization, and long-term stroke. The patients in MetS without obesity group were not associated with increased perioperative or long-term morbidities and mortality. In contrast, the patients in MetS with obesity group were associated with significant increased perioperative complications including MACCE (30.26% vs. 20.75%, 16.7%, p = 0.0074) and mortality (11.84% vs. 3.74%, 3.11%, p = 0.0007) respectively. Patients in MetS with obesity group was associated with significantly increased long-term of MACCE (adjusted OR:2.040; 95%CI:1.196-3.481; P＜0.05) and 5-years of mortality (adjusted HR:4.659; 95%CI:1.966-11.042; P＜0.05).

CONCLUSIONS

Patients with metabolic syndrome and obesity are associated with significant increased perioperative and long-term complications and mortality, while metabolic syndrome without obesity do not worsen outcomes after CABG.

The impact of body mass index on short- and long-term outcomes in patients undergoing coronary artery graft bypass

Objective

This study was designed to investigate the impact of body mass index (BMI) on short- and long-term outcomes after initial revascularization with coronary artery bypass graft (CABG) surgery.

Methods

4916 Chinese who consecutively underwent isolated, primary CABG at the Cardiovascular Institute of Fuwai Hospital from January 1, 1999 to December 31, 2005 were included in this study. They were classified based on BMI as follows: underweight: <18.5 kg/m², normal weight: 18.5 to 23.9 kg/m², overweight: 24 to 27.9 kg/m², obesity: 28 to 32 kg/m², and severe obesity: >32 kg/m². Short (in-hospital) and long-term (5-years) major post-operative complications and mortalities were compared among various BMI groups after initial revascularization.

Results

Multiple regression analysis of five years follow-up of clinical end points indicated that various BMI groups were not associated with significant differences in 5 years mortality and MACCE, however, old age, smoking, hypertension, myocardial infarction and heart failure were the risk factor for the mortality.

Conclusions

In this large-scale study with long term follow-up after primary CABG in an exclusively ethnic Chinese population, we found that different BMI groups were not significantly associated with 5-years mortality and MACCE, however, old age, smoking, hypertension, myocardial infarction and heart failure were the risk factors of post-operative mortality, and old age, hypertension and heart failure increased the rate of MACCE.

Risks of harms using antifibrinolytics in cardiac surgery: systematic review and network meta-analysis of randomised and observational studies

OBJECTIVE

To estimate the relative risks of death, myocardial infarction, stroke, and renal failure or dysfunction between antifibrinolytics and no treatment following the suspension of aprotinin from the market in 2008 for safety reasons and its recent reintroduction in Europe and Canada.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

A Cochrane review of antifibrinolytic treatments was chosen as the starting point for this systematic review. Medline, Embase, and the Cochrane register of trials were searched with no date restrictions for observational evidence.

STUDY SELECTION

Propensity matched or adjusted observational studies with two or more of the interventions of interest (aprotinin, tranexamic acid, epsilon-aminocaproic acid, and no treatment) that were carried out in patients undergoing cardiac surgery.

DATA ANALYSIS

Network meta-analysis was used to compare treatments, and odds ratios with 95% credible intervals were estimated. Meta-analyses were carried out for randomised controlled trials alone and for randomised controlled trials with observational studies.

RESULTS

106 randomised controlled trials and 11 observational studies (43,270 patients) were included. Based on the results from analysis of randomised controlled trials, tranexamic acid was associated on average with a reduced risk of death compared with aprotinin (odds ratio 0.64, 95% credible interval 0.41 to 0.99). When observational data were incorporated, comparisons showed an increased risk of mortality with aprotinin on average relative to tranexamic acid (odds ratio 0.71, 95% credible interval 0.50 to 0.98) and epsilon-aminocaproic acid (0.60, 0.43 to 0.87), and an increased risk of renal failure or dysfunction on average relative to all comparators: odds ratio 0.66 (95% credible interval 0.45 to 0.88) compared with no treatment, 0.66 (0.48 to 0.91) versus tranexamic acid, and 0.65 (0.45 to 0.88) versus epsilon-aminocaproic acid.

CONCLUSION

Although meta-analyses of randomised controlled trials were largely inconclusive, inclusion of observational data suggest concerns remain about the safety of aprotinin. Tranexamic and epsilon-aminocaproic acid are effective alternatives that may be safer for patients.

Aprotinin revisited

In 2008, we saw the withdrawal of aprotinin from the US markets after preliminary results from a large, randomized clinical trial in Canada. This drug, a potent antifibrinolytic, was used primarily in complex and/or redo cardiac surgery as an adjunct to decrease postoperative bleeding and complications. The Canadian study raised questions previously brought up in similar studies-does aprotinin increase the risk of mortality and renal failure after cardiac surgery? Recently, a re-review of the Canadian data noted flaws in the study, as well as in the interpretation of the results. The present review revisits the aprotinin controversy.