[HSF] Aprotinin

[Ben Bidstrup]

Mea culpa. I apologise to members of the Forum and the world at large 
for trying to use a bit of evidence.

Woe is me woe is me.

>Ben,
>Stop bringing in logic, common sense, and your many years of experience into
>this - obviously it must be the apro. - the lawyers say it much be so.
>
>-michael
>
>
>On 9/20/07, Ben Bidstrup <benjamin.bidstrup at bigpond.com> wrote:
>>
>>  >Two days ago I did an aortic valve, cabg on a 77 year old Jehovah's
>>  >Witness patient.  She had drug eluting stents placed two months
>>  >previously in the ramus and LAD.  She returned to the ER with an MI,
>>  >a 90% ostial and 70% mid LAD stenosis, 70% ramus stenosis, and an
>>  >aortic valve mean gradient of 50 mmHg.  Because of ongoing ischemia,
>>  >an intra-aortic balloon pump was placed in the cath lab, resolving
>>  >her chest pain and ST segment depression.  Her starting hematocrit
>>  >was 33.  She would not accept blood under any circumstance.  The
>>  >case went without a problem, and she had a post-op hematocrit of 31.
>>  >She transferred out of the ICU on post-op day 1 without any issues.
>>  >She developed shortness of breath and abdominal distention with a
>>  >drop in blood pressure that night.  The bottom line is that she got
>>  >a laparotomy this morning (post-op day 3) and had a deat right colon
>>  >removed.
>>  >
>>  >This is the only case in the last 10 years that I have used
>>  >aprotinin, and I am wondering about causation.  She had an episode
>>  >of atrial fib during the time she was developing shortness of
>>  >breath.  TEE during the heart surgery showed no left atrial clot.
>>  >The aortic annulus was not very calcified, requiring very little
>>  >debridement.  I know the etiology of the dead bowel is not
>>  >proveable, but I wonder about the effects of aprotinin.  Any
>>  >comments?
>>  >
>>  >Ed Bender, MD
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>>  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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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon