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CARDIOVASCULAR ANESTHESIOLOGY

A Randomized Clinical Trial Investigating the Relationship Between Aprotinin and Hypercoagulabilityin Off-Pump Coronary Surgery

Pranjal H. Desai, MD^*, Dinesh Kurian, BS^*, Nannan Thirumavalavan, BA^*, Sneha P. Desai, MD^*, Pluen Ziu, MD^*, Michael Grant, BS, Charles White, MD, R. Clive Landis, PhD, and Robert S. Poston, MD^*

From the *Department of Cardiothoracic Surgery, Boston University School of Medicine, Boston, Massachusetts; Departments of Surgery, and Radiology, University of Maryland, School of Medicine, Baltimore, Maryland; and Edmund Cohen Laboratory for Vascular Research, Chronic Disease Research Center, University of the West Indies, Bridgetown, Barbados.

Address correspondence and reprint requests to Robert S. Poston, MD, Department of Cardiothoracic Surgery, Boston University and School of Medicine and Boston Medical Centre, 88 East Newton St., Robinson Building, Suite B-402, Boston, MA 02118. Address e-mail to robert.poston{at}bmc.org.

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.