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The Journal of Thoracic and Cardiovascular Surgery, Vol 105, 712-720, Copyright © 1993 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
W Dietrich, H Mossinger, M Spannagl, M Jochum, P Wendt, A Barankay, H Meisner and JA Richter
The effect of high-dose aprotinin treatment on hemostatic activation during
cardiopulmonary bypass in pediatric patients having cardiac operations was
investigated. Sixty patients weighing less than 10 kg undergoing cardiac
operations for different types of congenital heart diseases were studied:
20 patients were treated with aprotinin 2 x 15,000 KIU/kg, 20 patients with
2 x 30,000 KIU/kg, and 20 patients without aprotinin treatment served as
the control group. Different split products of fibrinogen and/or fibrin and
the fibrinolytic activity on fibrin plates were measured to assess
fibrinolytic activation. F1/F2 prothrombin fragments, thrombin-antithrombin
III- complex, and fibrin monomers were measured to estimate thrombin
activation. There was a significant dose-dependent reduction in fibrin-
fibrinogen split product formation during cardiopulmonary bypass: In the
high-dose aprotinin group the concentration of the split products at the
end of bypass was 1.5 +/- 0.6 micrograms/ml, compared with 3.4 +/- 3.0
micrograms/ml in the low-dose aprotinin group and 6.7 +/- 3.5 micrograms/ml
in the control group (p < 00.5). Fibrinolytic activation on fibrin
plates was also significantly reduced by aprotinin. Fibrin monomer
formation was significantly diminished at the end of cardiopulmonary bypass
in the high-dose group: 9.2 +/- 5.2 micrograms/ml compared with 21.6 +/- 14
micrograms/ml in the control group (p < 00.5). Elastase in complex with
alpha 1-protease inhibitor at the end of bypass was increased to the same
amount in the three groups: 784 +/- 278 ng/mL (control group), 693 +/- 189
ng/ml (low-dose aprotinin), and 719 +/- 270 ng/mL (high dose aprotinin) (no
significant difference). Blood loss 6 hours postoperatively was
significantly (p < 00.5) less in the high-dose group (99 +/- 32 ml/m2)
than in the control group (164 +/- 87 ml/m2; low-dose group: 160 +/- 106
ml/m2). These observations suggest an attenuation of hemostatic activation
during cardiopulmonary bypass with less plasmin formation and, because of
inhibition of contact activation, less thrombin generation with aprotinin
treatment. Thus the thrombotic-thrombolytic equilibrium is kept more
balanced after cardiopulmonary bypass. High-dose aprotinin treatment is
recommended for pediatric patients undergoing cardiac operations.
ARTICLES
Hemostatic activation during cardiopulmonary bypass with different aprotinin dosages in pediatric patients having cardiac operations
Institute for Anesthesiology, German Heart Center, Munich.
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