[HSF] Aprotinin

[Edward Bender]

Ben:
I agree with all that you say, and doubt that the aprotinin alone was  
responsible.  I just wonder, in the absence of aprotinin, would  
things have been different.  One of the benefits of operating on  
Jehovah's Witness patients is that they usually live a clean life,  
are intelligent and understanding, and are great patients.  This lady  
has improved dramatically after colon resection and iliostomy.

Grafts are open I think (ie, no myocardial ischemic changes and  
tolerated septic shock).
TEE in the OR (2 days before colectomy) showed no thrombus, and a-fib  
was coincident with septic onset.

Probable atheroembolus to the right colic artery is my working  
diagnosis.

Ed Bender, MD


On Sep 20, 2007, at 3:25 PM, Ben Bidstrup wrote:
>>
> E,
>
> I firstly must confess my potential conflict as a very long time  
> investigator of aprotinin and recipient of research funding and  
> honoraria from Bayer for that work.
>
> This lady has several issues.
>
> Here an IABP, a mechanical battering ram in a atherosclerotic aorta  
> next to the origin of the blood supply to the bowel. She has had  
> not stent thrombosis if I read this correctly but ongoing intimal  
> proliferation that has led to in stent stenosis. This still occurs  
> despite what our colleagues state about DES.
> How long after the cath was the procedure performed? When was the  
> IABP removed?
> The pathology of the specimen may not show a lot apart from  
> atherosclerotic arteries and patchy thrombosis that is likely  
> secondary to the changes that occur with ischemia, edema and  
> inflammation.
> How have your grafts fared?
> If there was a systemic problem, they could be affected.
> The A fib did you do a TEE to look for clot in the LA?
> Better do one now to make sure that has not been missed. It usually  
> takes according to the literature about 48 hours in a person who  
> has not been subjected to a period of CBP to develop clots. How  
> long in a post cardiotomy patient? I am not sure of that answer,  
> but may be longer.
> Seems also that the ischemia developed very quickly - which would  
> put embolism in my book a little higher than a thrombotic occlusion  
> of the mesenteric blood supply.
>
>  Was the R colon in a watershed area?
>
> Al the studies have not flagged bowel ischemia as a common problem  
> after aprotinin use. That is not to say it has not happened.
>
> I have seen it as a complication all too often and the patients  
> have had a (usually) good cause for that dreaded complication.
>
> So on your list it would seem IABP related embolism would be no 1,  
> post CBP (or rather peri CBP) inflammatory changes no 2,  Afib no  
> 3, and something related to aprotinin no 4.
> -- 
> Ben Bidstrup FRACS FRCSEd FEBCTS
> Consultant Cardiothoracic Surgeon
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