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J Thorac Cardiovasc Surg 2004;128:83-91
© 2004 The American Association for Thoracic Surgery

Cardiopulmonary support and physiology

Effects of tranexamic acid on postoperative bleeding and related hematochemical variables in coronary surgery: Comparison between on-pump and off-pump techniques

^a Division of Cardiovascular Anesthesia and Intensive Care, Policlinico di Monza, Monza, Italy
^b Coagulation Service and Thrombosis Research Unit, San Raffaele Hospital, Milan, Italy
^c Department of Anesthesia, San Raffaele Hospital, Milan, Italy
^d Division of Cardiac Surgery, San Raffaele Hospital, Milan, Italy
^e Epidemiology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy

Received for publication April 16, 2003; revisions received September 30, 2003; accepted for publication October 7, 2003.

^* Address for reprints: Valter Casati, MD, Division of Cardiovascular Anesthesia and Intensive Care, Policlinico di Monza, via Amati 111, Monza (20052), Italy
valter.casati{at}policlinicodimonza.it

OBJECTIVES: Bleeding and inflammation are major complications of extracorporeal circulation. Off-pump coronary artery bypass grafting may reduce the rate of complications, but it can only be applied in selected cases. Pilot studies have shown a potential benefit from the use of antifibrinolytic drugs, but efficacy in randomized double-blind studies evaluating off- and on-pump coronary artery bypass grafting has not been proved.

METHODS: We enrolled 102 patients scheduled for on-pump (n = 51) or off-pump (n = 51) coronary artery bypass grafting. Patients were separately double-blind randomly assigned to treatment with tranexamic acid (1 g as 20-minute bolus before skin incision, followed by continuous infusion of 400 mg/h, with 500 mg added to priming in patients undergoing on-pump coronary artery bypass grafting) or placebo (saline solution of equivalent volume). Bleeding in the first 24 postoperative hours was the primary outcome. Requirement for allogeneic transfusions, thrombotic complications, outcomes, and monitoring of coagulation, fibrinolysis, and inflammation were also recorded.

RESULTS: Tranexamic acid reduced total postoperative bleeding by 43% in patients undergoing on-pump coronary artery bypass grafting and by 27% in those undergoing off-pump coronary artery bypass grafting (P < .0001), with 80% reduction in bleeding exceeding 600 mL (P < .001), 58% reduction in the requirement for all allogeneic transfusions (P = .07), and no apparent effect on thrombotic complications or outcome. This was associated with a reduction in plasma D-dimer levels (P < .0001), to a greater degree in patients undergoing on-pump coronary artery bypass grafting (P < .0001), and interleukin 6 levels (P < .0001), to a greater degree in patients undergoing off-pump coronary artery bypass grafting (P < .001).

CONCLUSIONS: By affecting fibrinolysis, tranexamic acid significantly reduces bleeding both in off- and on-pump coronary artery bypass grafting and may modulate inflammation in these surgical settings.

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