Replacement of aprotinin by tranexamic acid during on-pump cardiac surgery: A retrospective evaluation of clinical outcome and cost-effectiveness

Aims: The antifibrinolytics aprotinin and tranexamic acid (TXA) are established blood saving agents in surgical treatment including cardiac surgery. Methods: Because of the anticipated better risk/benefit ratio of TXA the established antifibrinolytic treatment with aprotinin was replaced by a TXA treatment regimen that achieves TXA target values above 300µM. Objective: To assess clinical utility and cost-effectiveness of tranexamic acid (TXA) with that of aprotinin in routine cardiac surgery using cardiopulmonary bypass. Design: Single-centre, retrospective cohort study Patients: All consecutive patients who were scheduled for coronary artery bypass grafting with cardiopulmonary bypass during May 2005 and October 2005. Interventions: Starting from July 2005 standard antifibrinolytic treatment with aprotinin (1×1.000.000 KIE bolus followed by 0.5×1.000.000 KIE/h) during cardiopulmonary bypass was replaced by TXA treatment (1g bolus followed by 1g/h. Results: Four-hundred-twenty-one patients received aprotinin treatment and 440 patients were treated with TXA. Both cohorts were comparable with respect to baseline characteristics including risk profiles such as renal dysfunction and nonstopped exposure to ASS and/or clopidogrel and operative data. Mean postoperative bleeding was 766±817ml in the TXA group versus 557.4±610ml in the aprotinin group (p=0.001). The aprotinin group received fewer transfusions of packed red blood cells, platelets, and fresh frozen plasma. Conclusions: Aprotinin reduces bleeding and transfusion requirements more effectively than TXA. The rate of major adverse events was identical in both groups.