[HSF] Aprotinin

Ben Bidstrup benjamin.bidstrup at bigpond.com
Sun Sep 23 22:22:27 EDT 2007 

Maybe Hal could comment.



>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            
>Fax +27-21-9006412      Mobile +27-83-3309587
>
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon

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