[HSF] Aprotinin

Sun Sep 23 02:14:58 EDT 2007

I agree with Ben about the IABP being `a mechanical
battering ram in an atherosclerotic aorta`.

I recently did a redo CABG via thoracotomy in a
patient who had a loading dose of 300mg Clopidogrel
two days previously (they all get it before cath these
days, in anticipation of the stents!) An IABP was
inserted the day before surgery. We did 2 grafts, and
did not touch the aorta, both proximals on subclavian
artery. For the first time this year we did not give
aprotinin, as the bleeding was initially not too bad,
although his chest tube drainage was more than usual
post-op, so he got some platelets, nothing else. The
surgery went very well, and he had no hypotensive
episodes.

This guy developed some renal dysfunction later,
creatinine peaked at 420 mmol/l, liver enzymes went
up, and he developed an ileus, with severe distension,
and later diarrhoea (suspected ischaemic colitis). He
took a week to come right.

Very often aprotinin gets the knock, and the IAPB has
never been blamed. In S Africa the cardiologists
generally overuse it (I may be out of work if one of
my colleagues here forwards this to them!), and use it
often to tie a patient to the bed so he consents to
surgery, or to keep the patient from being transferred
to another hospital preferred by the health funder!
--- 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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Dr. David G. Harris, FCS, MMED,
Cardiothoracic Surgeon        
Suite 207                                
Kuils River Private Hospital,        
PO Box 1200, Kuils River, 7579, Cape Town, South Africa.            
Tel +27-21-9006411             
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