Con: Antifibrinolytics Should Not Be Used Routinely in Low-Risk Cardiac Surgery.

Abstract

GROWING AMOUNT of evidence linking transfusion of allogeneic blood products with negative patient outcomes and increased cost continues to drive interest into strategies and technologies that limit patient exposure to this risk. The single largest consumer of this resource continues to be cardiac surgery, with 20% of the worldwide use of allogeneic blood products accounted for by this cohort. 1 In cardiac surgical patients, red blood cell transfusion is known to increase postoperative morbidity, incidence of infectious complications, early and late mortality, hospital length of stay, and hospital costs. 2 In addition to the negative impact of transfusion, there has been an independent association of massive blood loss with increased mortality in cardiac surgery, 3 as well as an association of increased postoperative chest tube drainage with adverse outcomes. 4 Bleeding in cardiac surgery is multifactorial and impacted by patient comorbidities and medications, surgical procedures, and acquired defects in coagulation due to cardiopulmonary bypass. Activation of the fibrinolytic system during cardiopulmonary bypass leads to excessive consumption of fibrin by plasmin and an increased risk of significant blood loss in these patients. Two classes of antifibrinolytic agents that attempt to arrest this process, the serine protease inhibitor aprotinin (AP) and the lysine analogs tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have gained widespread use in cardiac surgery as blood-sparing agents. Multiple meta-analyses 5-7 have demonstrated the superiority of AP as compared to TXA or EACA in reducing postoperative blood loss, rates of transfusion, and need for surgical re-exploration in cardiac surgery. However, observational studies raised concern about the safety of aprotinin, 8-9 and the drug eventually was