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Ann Thorac Surg 1995;59:1068
© 1995 The Society of Thoracic Surgeons
DR THOMAS X. AUFIERO (Hershey, PA): I enjoyed your report very much. Your data very closely follow those that we presented last year at the heart transplant meeting. We now have expanded our series to include 20 patients with similar results. Recently, however, because of the high cost of aprotinin, we have been interested in using Amicar, especially in patients who we have decided are at low risk, those who are not undergoing reoperations or have not had extensive pericarditis.
My first question is whether you have had any experience with Amicar or whether any of the patients who did not receive aprotinin received Amicar or tranexamic acid. My second question is, in the patients who did receive a right ventricular assist device, what type of pump was used and was it the same in all patients?
DR GOLDSTEIN: Thank you for your comments, Dr Aufiero. With regard to your first question, the Minneapolis Heart Institute group recently published a series demonstrating decreased postoperative blood loss among Amicar recipients undergoing cardiac operations, but no comparative studies have been published to our knowledge. Because of the limitations of our retrospective study, we could not evaluate which patients, if any, received Amicar. I certainly agree with you in regard to the cost implications of using Amicar in lieu of aprotinin.
In regard to your second question, I can only speak of our experience at Columbia Presbyterian. The patients who required right ventricular mechanical support received the Abiomed BVS 5000 as a right ventricular assist device.
DR BARTLEY P. GRIFFITH (Pittsburgh, PA): That was a lovely and very compelling report, and I certainly would agree that transfusion is the death knell of the right ventricle in seriously compromised patients with biventricular failure with univentricular left support. I wondered if you had an opportunity to look at the most recent time periods when the use of aprotinin was more uniform.
Also, could it be that in the most experienced centers using this device, aprotinin is the routine and that the start-up centers, which are becoming more and more numerous, with a fairly steep learning curve, have not been using aprotinin? It is kind of a tough question. You have gotten to the issue of difficulty with the multicenter trial, but what is your experience in a large center, at Columbia, with and without the use of aprotinin? Have you seen a big difference?
DR GOLDSTEIN: Thank you for your interesting comments, Dr Griffith. As I mentioned earlier, only 3 of the 16 participating centers had aprotinin available to them. Two of those centers, namely, Cleveland Clinic and us, had a large experience with aprotinin and left ventricular assist devices. To balance this, Texas Heart Institute, who have had the largest clinical left ventricular assist device experience, did not use aprotinin for any of their patients. At Columbia, we have used aprotinin for all but 2 of our left ventricular assist device recipients, so I cannot comment on our experience on patients without aprotinin. We did not dissect the experience by period; however, it is clear that with increasing clinical experience and better patient selection, the incidence of right heart failure necessitating right ventricular assist device support is decreasing, as we have seen in our experience.
DR MATTHIAS LOEBE (Berlin, Germany): You mentioned that anaphylactic reactions to aprotinin are one of the disadvantages of this medication. Can you give us any information about those patients who received heart transplants later on and then received aprotinin? Do you have any information about allergic reactions in those patients? We lost 1 of 89 patients bridged to heart transplantation with biventricular or left ventricular assist devices at our institution who received aprotinin at the time of transplantation and had a severe allergic reaction. Since then we have been very cautious about using this medication in the second operation.
DR GOLDSTEIN: Thank you. I am glad you brought that up. We did have one patient who, at the time of transplantation, became hypotensive on induction; he was supported with alpha agonists and underwent transplantation without difficulty. In patients who we know have received aprotinin in the past, our policy is not to give the dose before sternotomy. As a precaution, aprotinin infusion is started only once we are ready to cannulate and go on cardiopulmonary bypass.
DR RENEE S. HARTZ: I have one comment and question. I find it remarkable that you had patients with ventricular assist devices who required no transfusion. That alone, even though the study is retrospective, is remarkable. I find it so remarkable that I wondered if you can comment on the patency of the bypass grafts at the time of device explantation or transplantation.
DR GOLDSTEIN: The 2 patients who did not require any transfusion whatsoever were late in the study. I do not recall the cause of end-stage heart failure in these patients, so I cannot comment if they had undergone previous coronary bypass grafting and, if so, whether the grafts were patent or not at the time of transplantation.
Related Article
Ann. Thorac. Surg. 1995 59: 1063-1067.
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