Topische Aprotininapplikation bei kardiochirurgischen Eingriffen

Zusammenfassung

Die prospektive, randomisierte Studie untersuchte, ob eine topische Hochdosis-Aprotininapplikation (5000000KIE) die gleiche Effizienz zur Reduktion des Blutverlustes und Gabe von Blutprodukten hat, wie die herkömmliche systemische Hochdosis-Infusion bei kardiopulmonaren Bypassoperationen. Untersucht wurden 100 Patienten bei denen eine elektive Myokard Revaskularisation geplant war. 24 Stunden postoperativ ergab sich kein signifikanter Unterschied des Blutverlustes zwischen beiden Aprotininregimen (topisches Aprotinin 547±259ml versus systemisches Aprotinin 491±217 ml Blutverlust; p=NS). Hinsichtlich der Gabe von Blutprodukten (Erythrozytenkonzentrate, Fresh Frozen Plasma, Thrombozytenkonzentrate) konnte ebenfalls kein signifikanter Unterschied beobachtet werden. Die inflammatorischen Marker (Elastase, Interleukin 6, Leukozyten, C-reaktives Protein) zeigten tendenziell höhere Werte in der lokalen Applikationsgruppe ohne jedoch ein statistisches Signifikanzniveau zu erreichen.

Summary

Aprotinin, a naturally occurring serine protease inhibitor, has found widespread application during cardiac surgical procedures as a consequence of its ability to decrease blood loss and transfusion requirements. The aim of our study was to compare a systemic and a local aprotinin application in patients during coronary artery bypass grafting. A prospective, randomized, study comprising 100 patients undergoing coronary artery bypass grafting was conducted. 5×10⁷ KIU aprotinin was given systemically in 50 patients and 4 doses of 1.25×10⁷ KIU aprotinin was applied topically in 50 patients after preparation of the internal mammaria artery, after incision of the pericardium, after protamine antagonization and after closure of the pericardium. Blood samples were collected preoperatively, 5 minutes after heparin, 5 minutes after starting the extracorporeal circulation, 5 minutes before the end of extracorporeal circulation, arrival on the ICU, 6, 12 and 24 hours after the end of the operation. We determined markers of the inflammatory response (elastase, interleukin 6), coagulation system (tissue factor, TFPI, F1+2, D-dimer, factor VIIc, factor VIIa–rtf), standard hematological markers, postoperative complications, blood loss and transfused red packed cells. Exclusion criteria were defined as a surgical bleeding, redo operations, neurological-, hematological-, liver-, kidney disorders. Sex, age, and perfusion times were identical in both groups. There were no differences in mortality or in the incidence of renal failure, strokes or definite myocardial ischemia. Not only the clinical outcome, but also the determination of biochemical markers demonstrated no significant differences between the systemic and local applications of aprotinin. With regard to the inflammatory markers, interleukin 6 and elastase were tendencially higher in the local group but with a high standard deviation in each patient. Our results suggest that the perioperative application of 5×10⁷ KIU systemically given aprotinin did not differ with 1.25×10⁷ KIU locally applied aprotinin. The benefits of systemically aprotinin may be found in a reduced inflammatory response.