Comparaison des effets de l’aprotinine et de l’acide tranexamique sur le saignement en chirurgie cardiaque

Abstract

ObjectivesTo compare the efficacy of aprotinin (APR) and tranexamic acid (TRA) in reducing blood loss and transfusion requirements after cardiac surgery under extracorporeal circulation (ECC). Study designRandomized controlled trial. PatientsOne hundred and four adults undergoing either coronary artery bypass grafting (CABG) (n=55), or aortic valve replacement (AVR) (n=49), allocated into three groups. Methodsa) APR !roup (23 CABG and 20 AVR) recei· ved aprotinin, 2×106 KIU (280mg) after induction, followed by an infusion 0.5×106KIU·h−1 (70mg·h−1) until chest closure, with a supplement to the oxygenator prime of 2×106KW ; b) TRA group (22 CABG and 19 AVR) received tranexamic aeid, 15mg·kg−1 between the injection of heparin (400IU·kg−1) and the beginning of ECC, 15mg·kg−1 after protamin injection (1.3mg/100IU of heparin); c:) CTR group (10 CABG and 10 AVR), the control group, was not treated w1th an antifibrinolytic agent. The amount of blood collected from the chest tube drainage was measured at admission to ICU, as weil as 4, 8 and 18h after the insertion of drains and at the time of their removal. Packed red cells where given when the haematocrit was under 20% during ECC, 25% at the end of surgery and 30% alter extubation. ResultsThe blood loss was lower in APR group (834±448mL) than in TRA group (1015±409mL) (P=0.009), and in CTR group (1416±559ML) (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 post-operative bleeding. However there was no difference between APR and TRA concerning the transfusion requirements. In CABG cases the ECC was of shorter duration and blood loss was 1127±540mL vs 894±422mL in AVR cases (P=0.03). ConclusionsBoth 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 allergie reactions, its use in a high dose regimen is only recommended for reoperations, in patients treated with salicylates and in case of sepsis.