Parolari A, Antona C, Alamanni F, Spirito R, Naliato M, Gerometta P, Arena V, Biglioli P
Department of Cardiac Surgery, University of Milan, Centro Cardiologico, Fondazione I Monzino, Italy.
Eur J Cardiothorac Surg. 1997 Jan;11(1):149-56. doi: 10.1016/s1010-7940(96)01022-6.
To evaluate retrospectively the effect of 'high-dose' aprotinin on blood losses, donor blood requirements and morbid events on patients undergoing ascending aorta and/or aortic arch procedures with the employ of deep hypothermic circulatory arrest (HCA).
During the period 1987-1994, 39 patients underwent a thoracic aorta procedure with the employ of circulatory arrest; of these 18 (46.2%) were operated on during the period 1990-1994 and were given aprotinin intraoperatively following the 'high-dose' protocol (group I), while 21 (53.8%) who underwent surgery during the years 1987-1989, did not receive intraoperative aprotinin and served as historical controls (group II). Twenty-seven (69.2%) patients were male, 18 (46.2%) were operated on on an emergency basis, 15 (38.5%) were acute type A dissections, and two (5.1%) were redo-operations. Circulatory arrest times were not significantly different between the two groups (40 +/- 4 (S.E.) group I vs. 43 +/- 4 min group II, P = 0.62) likewise cardiopulmonary bypass (CPB) times (181 +/- 9 vs. 201 +/- 20 mm, P = 0.74) and the amount of heparin administered (32056 +/- 1435 vs. 31 691 +/- 1935 IU, P = 0.56).
Postoperative blood loss was comparable between the two groups (1213 +/- 243 (median 850) group I vs. 1528 +/- 377 (median 880) ml group II, P = 0.87), as well as the number of units of donor blood transfused (9.4 +/- 3.0 (median 6) vs. 9.9 +/- 3.6, (median 5) P = 0.87), and revisions for bleeding (2/18, 11.1% vs. 3/21, 14.3%, P = 0.77). In-hospital mortality rate was not statistically different (5/18, 27.7% group I vs. 6/21, 28.6% group II, P = 0.92). There were no significant differences between the two groups in myocardial infarction (2/18, 11.1% vs. 0/21, 0%, P = 0.21), and postoperative renal failure rates (3/18, 16.7% vs. 2/21, 9.5%, P = 0.65). On the other hand, there was a trend towards an increased incidence of permanent neurological deficit (5/18, 27.7% group I vs. 1/21, 4.8% group II, P = 0.07) and towards a more complicated postoperative course (perioperative renal failure and/or myocardial infarction and/or neurological deficit either transient or permanent) (8/18, 44.4% group I vs. 4/21, 19% group II, P = 0.09) in group I patients. Forward stepwise logistic regression analysis, performed on the whole group of patients, identified chronic obstructive pulmonary disease (P = 0.010, Odds ratio (OR) = 5.7), aprotinin use (P = 0.017, OR = 5.1), and the number of units of blood collected intraoperatively by the cellsaver (P = 0.045, OR = 1.3/unit) as independent predictors of complicated postoperative course in the whole group of patients. CPB time (P = 0.040, OR = 1.032/min), circulatory arrest time (P = 0.053, OR = 1.22/min), and overall donor blood units transfused (P = 0.067, OR = 1.37/unit) emerged as independent risk factors for in-hospital mortality at multivariate analysis.
Even when appropriate amounts of heparin are administered, 'high-dose' aprotinin probably is not an effective blood-sparing drug in deep HCA. Aprotinin should be employed cautiously in this clinical setting because of its possible correlation with an increased rate of postoperative morbid events.
回顾性评估“大剂量”抑肽酶对采用深低温停循环（HCA）进行升主动脉和/或主动脉弓手术患者的失血情况、异体血需求量及不良事件的影响。
1987 - 1994年期间，39例患者采用停循环进行胸主动脉手术；其中18例（46.2%）于1990 - 1994年期间接受手术，并按照“大剂量”方案术中给予抑肽酶（I组），而21例（53.8%）于1987 - 1989年期间接受手术，术中未接受抑肽酶，作为历史对照（II组）。27例（69.2%）患者为男性，18例（46.2%）为急诊手术，15例（38.5%）为急性A型夹层动脉瘤，2例（5.1%）为再次手术。两组间停循环时间无显著差异（I组40±4（标准误）分钟 vs. II组43±4分钟，P = 0.62），同样体外循环（CPB）时间（181±9 vs. 201±20分钟，P = 0.74）及肝素用量（32056±1435 vs. 31691±1935国际单位，P = 0.56）也无显著差异。
两组术后失血量相当（I组1213±243（中位数850）毫升 vs. II组1528±377（中位数880）毫升，P = 0.87）；异体血输注单位数相当（9.4±3.0（中位数6） vs. 9.9±3.6，（中位数5），P = 0.87）；因出血进行的再次手术情况相当（2/18，11.1% vs. 3/21，14.3%，P = 0.77）。住院死亡率无统计学差异（I组5/18，27.7% vs. II组6/21，28.6%，P = 0.92）。两组间心肌梗死发生率（2/18，11.1% vs. 0/21，0%，P = 0.21）及术后肾衰竭发生率（3/18，16.7% vs. 2/21，9.5%，P = 0.65）无显著差异。另一方面，I组患者永久性神经功能缺损发生率有升高趋势（5/18，27.7% vs. 1/21，4.8%，P = 缉範光既叱焕癸唯含沥0.07），且术后病程更复杂（围手术期肾衰竭和/或心肌梗死和/或短暂或永久性神经功能缺损）（8/18，44.4% vs. 4/21，19%，P = 0.09）。对全体患者进行向前逐步逻辑回归分析，确定慢性阻塞性肺疾病（P = 0.010，优势比（OR） = 5.7）、使用抑肽酶（P = 0.017，OR = 5.1）及术中细胞回收器收集的血量单位数（P = 0.045，OR = 1.3/单位）为全体患者术后病程复杂的独立预测因素。多因素分析显示CPB时间（P = 0.040，OR = 1.032/分钟）、停循环时间（P = 0.053，OR = 1.22/分钟）及异体血输注总单位数（P = 0.067，OR = 1.37/单位）为住院死亡的独立危险因素。
即使给予适量肝素，“大剂量”抑肽酶在深低温停循环中可能并非有效的减少用血药物。鉴于抑肽酶可能与术后不良事件发生率增加相关，在该临床环境中应谨慎使用。
