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Chivasso P, Bruno VD, Marsico R, Annaiah AS, Curtis A, Zebele C, Angelini GD, Bryan AJ, Rajakaruna C. Effectiveness and Safety of Aprotinin Use in Thoracic Aortic Surgery. J Cardiothorac Vasc Anesth 2017; 32:170-177. [PMID: 29217251 DOI: 10.1053/j.jvca.2017.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the effectiveness and safety of aprotinin use in adult patients undergoing thoracic aortic surgery. DESIGN Single-center, retrospective study. SETTING All cases performed at a single university hospital. PARTICIPANTS Between January 2004 and December 2014, 846 adult patients underwent thoracic aortic surgery. Due to missing or duplicated data on primary outcomes, 314 patients were excluded. The final sample of 532 patients underwent surgery on the thoracic aorta. INTERVENTIONS The patients were divided in the following 2 groups: 107 patients (20.1%) received aprotinin during the surgery, which represented the study group, whereas the remaining 425 patients (79.9%) underwent surgery without the use of aprotinin. MEASUREMENTS AND MAIN RESULTS To adjust for patient selection and preoperative characteristics, a propensity score-matched analysis was conducted. Mean total blood loss at 12 hours after surgery was similar between the 2 groups. The blood product transfusion rates did not differ in the 2 groups, except for the rate of fresh frozen plasma transfusion being significantly higher in the aprotinin group. Re-exploration for bleeding and the incidence of a major postoperative bleeding event were similar between the groups. Rates of in-hospital mortality, renal failure, and cerebrovascular accidents did not show any statistically significant difference. Aprotinin did not represent a risk factor for mortality over the long term (hazard ratio 1.14, 95% confidence interval 0.62-2.08, p = 0.66). CONCLUSIONS The use of aprotinin demonstrated a limited effect in reducing postoperative bleeding and prevention of major bleeding events. Aprotinin did not adversely affect early outcomes and long-term survival.
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Affiliation(s)
- Pierpaolo Chivasso
- Department of Cardiac Surgery, Bristol Heart Institute, University Hospitals Bristol, Bristol, United Kingdom.
| | - Vito D Bruno
- Department of Cardiac Surgery, Bristol Heart Institute, University Hospitals Bristol, Bristol, United Kingdom
| | - Roberto Marsico
- Department of Cardiac Surgery, Bristol Heart Institute, University Hospitals Bristol, Bristol, United Kingdom
| | | | - Alexander Curtis
- Department of Cardiac Surgery, Bristol Heart Institute, University Hospitals Bristol, Bristol, United Kingdom
| | - Carlo Zebele
- Department of Cardiac Surgery, Bristol Heart Institute, University Hospitals Bristol, Bristol, United Kingdom
| | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, University Hospitals Bristol, Bristol, United Kingdom
| | - Alan J Bryan
- Department of Cardiac Surgery, Bristol Heart Institute, University Hospitals Bristol, Bristol, United Kingdom
| | - Cha Rajakaruna
- Department of Cardiac Surgery, Bristol Heart Institute, University Hospitals Bristol, Bristol, United Kingdom
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Gerstein NS, Brierley JK, Windsor J, Panikkath PV, Ram H, Gelfenbeyn KM, Jinkins LJ, Nguyen LC, Gerstein WH. Antifibrinolytic Agents in Cardiac and Noncardiac Surgery: A Comprehensive Overview and Update. J Cardiothorac Vasc Anesth 2017; 31:2183-2205. [DOI: 10.1053/j.jvca.2017.02.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Indexed: 12/19/2022]
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Briquez PS, Lorentz KM, Larsson HM, Frey P, Hubbell JA. Human Kunitz-type protease inhibitor engineered for enhanced matrix retention extends longevity of fibrin biomaterials. Biomaterials 2017; 135:1-9. [PMID: 28477492 DOI: 10.1016/j.biomaterials.2017.04.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 04/26/2017] [Accepted: 04/26/2017] [Indexed: 12/18/2022]
Abstract
Aprotinin is a broad-spectrum serine protease inhibitor used in the clinic as an anti-fibrinolytic agent in fibrin-based tissue sealants. However, upon re-exposure, some patients suffer from hypersensitivity immune reactions likely related to the bovine origin of aprotinin. Here, we aimed to develop a human-derived substitute to aprotinin. Based on sequence homology analyses, we identified the Kunitz-type protease inhibitor (KPI) domain of human amyloid-β A4 precursor protein as being a potential candidate. While KPI has a lower intrinsic anti-fibrinolytic activity than aprotinin, we reasoned that its efficacy is additionally limited by its fast release from fibrin material, just as aprotinin's is. Thus, we engineered KPI variants for controlled retention in fibrin biomaterials, using either covalent binding through incorporation of a substrate for the coagulation transglutaminase Factor XIIIa or through engineering of extracellular matrix protein super-affinity domains for sequestration into fibrin. We showed that both engineered KPI variants significantly slowed plasmin-mediated fibrinolysis in vitro, outperforming aprotinin. In vivo, our best engineered KPI variant (incorporating the transglutaminase substrate) extended fibrin matrix longevity by 50%, at a dose at which aprotinin did not show efficacy, thus qualifying it as a competitive substitute of aprotinin in fibrin sealants.
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Affiliation(s)
- Priscilla S Briquez
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; Institute for Molecular Engineering, University of Chicago, Chicago, IL 60637, United States
| | - Kristen M Lorentz
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; Anokion, Inc., Cambridge MA 02139, United States
| | - Hans M Larsson
- Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Peter Frey
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland
| | - Jeffrey A Hubbell
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; Institute for Molecular Engineering, University of Chicago, Chicago, IL 60637, United States.
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Deanda A, Spiess BD. Aprotinin revisited. J Thorac Cardiovasc Surg 2012; 144:998-1002. [PMID: 22795461 DOI: 10.1016/j.jtcvs.2012.06.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Revised: 05/29/2012] [Accepted: 06/15/2012] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Abe Deanda
- Department of Cardiothoracic Surgery, NYU-Langone Medical Center, New York, NY, USA.
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Szabó G, Veres G, Radovits T, Haider H, Krieger N, Bährle S, Niklisch S, Miesel-Gröschel C, van de Locht A, Karck M. The novel synthetic serine protease inhibitor CU-2010 dose-dependently reduces postoperative blood loss and improves postischemic recovery after cardiac surgery in a canine model. J Thorac Cardiovasc Surg 2010; 139:732-40. [DOI: 10.1016/j.jtcvs.2009.10.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Revised: 10/04/2009] [Accepted: 10/31/2009] [Indexed: 11/27/2022]
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Ngaage DL, Bland JM. Lessons from aprotinin: is the routine use and inconsistent dosing of tranexamic acid prudent? Meta-analysis of randomised and large matched observational studies. Eur J Cardiothorac Surg 2010; 37:1375-83. [PMID: 20117944 DOI: 10.1016/j.ejcts.2009.11.055] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Revised: 11/15/2009] [Accepted: 11/18/2009] [Indexed: 10/19/2022] Open
Abstract
In view of the safety concerns that led to the withdrawal of aprotinin, should antifibrinolytics be used indiscriminately in cardiac surgery? This meta-analysis examines the efficacy and safety profile of tranexamic acid, and in comparison to aprotinin. We identified randomised trials and large observational studies investigating the use tranexamic acid from January 1995 to January 2009 using Pubmed/Cochrane search engine and included them in a two-tier meta-analysis. There were 25 randomised trials and four matched studies with a total of 5411 and 5977 patients, respectively, reporting tranexamic acid use in varying dosages. Tranexamic acid is administered intravenously either as single dose, infusion or both, sometimes added to pump prime or applied topically. Total intravenous dose of tranexamic acid varies from 1g to 20 g, administered over a period of 20 min to 12h. Compared with placebo, tranexamic acid is associated with a lower mean difference in blood loss (random effect -298 ml, 95% confidence [CI] -367 to -229, p<0.001) and decease in rates of re-operation for bleeding by 48%, transfusion of packed red cell by 47% and use of haemostatic blood products by 67%. A non-significant tendency for postoperative neurological events but a decrease in operative mortality was observed in patients treated with tranexamic acid compared with non-treatment group. Compared to aprotinin, tranexamic acid has less effective blood-conserving effect and mortality risk. Given the potential to increase neurological complications, the current trend towards indiscriminate use of tranexamic acid for all cardiac patients needs to be re-evaluated. Further studies are needed to clarify the neurological risk, appropriate indications and dosing of tranexamic acid.
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Affiliation(s)
- Dumbor L Ngaage
- Cardiothoracic Centre, Castle Hill Hospital, Kingston-Upon-Hull, East Yorkshire, United Kingdom.
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Desai PH, Kurian D, Thirumavalavan N, Desai SP, Ziu P, Grant M, White C, Landis RC, Poston RS. A randomized clinical trial investigating the relationship between aprotinin and hypercoagulability in off-pump coronary surgery. Anesth Analg 2009; 109:1387-94. [PMID: 19843776 DOI: 10.1213/ane.0b013e3181b81068] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Off-pump coronary artery bypass (OPCAB) surgery is associated with a hypercoagulable state in which the platelet thrombin receptor, protease-activated receptor-1 (PAR-1), helps propagate a thrombin burst within saphenous vein grafts. Aprotinin, used in cardiothoracic surgery mainly for its antifibrinolytic properties, also spares platelet PAR-1 activation due to thrombin. We hypothesized that this PAR-1 antagonistic property provides an antithrombotic benefit during OPCAB surgery. METHODS Patients were randomly assigned to receive saline (n = 38) or a modified full-dose regimen of aprotinin (n = 37) IV during OPCAB surgery. Blood sampled perioperatively from the coronary sinus, skin wounds, and systemic circulation was analyzed to test coagulation and platelet function. Major adverse cardiovascular events were monitored by obtaining troponin I at 24 h (myocardial infarction), predischarge computed tomography angiography (vein graft thrombosis), and by clinical examination for stroke. RESULTS Coronary sinus blood obtained immediately after OPCAB surgery showed significantly less activation in the aprotinin group, as judged by reduced formation of platelet-leukocyte conjugates (P < 0.02) and platelet-derived microparticles (P < 0.05). The aprotinin group showed inhibition of platelet aggregation induced by thrombin (P = 0.007) but not adenosine diphosphate. Thrombin generation, defined by F1.2 levels, was significantly reduced by aprotinin in the coronary sinus but not in skin wound incisions. Major adverse cardiovascular events were significantly reduced in aprotinin-treated patients (5.4% vs 29.7%, P < 0.05). Aprotinin also demonstrated antifibrinolytic properties through diminished red blood cell transfusion (P < 0.04) and reduced blood loss postoperatively (603 +/- 330 vs 810 +/- 415 mL, P < 0.004). CONCLUSION This study demonstrates that aprotinin protects patients undergoing OPCAB surgery from a hypercoagulable state by diminishing thrombin-induced platelet activation and thrombin generation within saphenous vein grafts, while maintaining systemic hemostatic and antifibrinolytic benefits. These results support further investigation of aprotinin and other PAR-1 antagonists in OPCAB surgery.
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Affiliation(s)
- Pranjal H Desai
- Department of Cardiothoracic Surgery, Boston University and School of Medicine and Boston Medical Centre, Boston, MA 02118, USA
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Ramlawi B, Otu H, Russo MJ, Novick RJ, Bianchi C, Sellke FW. Aprotinin attenuates genomic expression variability following cardiac surgery. J Card Surg 2009; 24:772-80. [PMID: 19754679 DOI: 10.1111/j.1540-8191.2009.00924.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aprotinin was the subject of recent controversy regarding adverse clinical outcomes following cardiac surgery. We compared the role of Aprotinin and epsilon-aminocaproic acid on clinical outcomes and the attenuation of the postcardiopulmonary bypass (CPB) response at the genomic expression and cytokine (protein) level. METHODS Thirty-nine low-risk patients undergoing coronary revascularization (CABG) and/or valve procedures using cardiopulmonary CPB were enrolled into a prospective cohort study. Aprotinin or epsilon-aminocaproic acid was administered to patients. Gene expression was assessed from whole blood mRNA samples collected preoperatively (PRE) and 6 hours (6H) postoperatively. Validation of gene expression was performed with SYBR Green real-time polymerase chain reaction. Cytokine values were quantified from serum preoperatively and postoperatively at 6 H and 4 days and analyzed in a blinded fashion. RESULTS No difference was detected in baseline characteristics. Inflammatory markers measured did not reveal significant difference between patients receiving Aprotinin (APR) and those receiving epsilon-aminocaproic acid (Amicar). Intraoperative parameters and postoperative outcomes were not significantly different. Compared with PRE samples, 6H samples had 264 upregulated and 548 downregulated genes uniquely in the APR group compared to 4826 upregulated and 1114 downregulated genes uniquely in the Amicar group (p < 0.001). Compared to patients in the Amicar group, APR patients had significantly different gene expression pathways involving NF-kappabeta regulation, programmed cell death and cell-cell adhesion. None of the patients developed postoperative stroke, myocardial infarction, or systemic infections. CONCLUSIONS Aprotinin leads to significantly less genomic expression variability following CPB compared to Amicar and has a differential effect on specific genomic pathways.
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Affiliation(s)
- Basel Ramlawi
- Division of Cardiothoracic Surgery, Columbia Presbyterian Medical Center, Columbia University, New York, New York, USA
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Baker RA. Suction, salvage, sutures, and potions: blood management post-aprotinin. Semin Cardiothorac Vasc Anesth 2009; 13:122-6. [PMID: 19617252 DOI: 10.1177/1089253209337159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hemostasis management of the cardiac surgical patient has changed following the withdrawal of aprotinin for use in cardiac surgical patients. The challenge to minimize blood loss and reduce exposure of cardiac surgical patients to blood products continues to grow with patients presenting being older and sicker and more complex procedures being performed. The cardiac surgery team has many options available for it to consider; although current recommendations strongly support the use of cell salvage as one process to assist in this challenge, other options need to be equally critically evaluated.
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Affiliation(s)
- Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders Medical Centre and Flinders University, Bedford Park, South Australia, Australia.
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Royston D. Aprotinin; An economy of truth? J Thorac Cardiovasc Surg 2008; 136:798-9; author reply 799. [DOI: 10.1016/j.jtcvs.2008.05.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Accepted: 05/15/2008] [Indexed: 10/21/2022]
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