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J Thorac Cardiovasc Surg 1997;114:513-514
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Use of aprotinin after cardiac operations

Consultant Cardiothoracic Surgeon
Monash Medical Centre
Melbourne 3168, Australia

To the Editor:

The article by Çiçek and colleagues ¹ on the postoperative use of aprotinin (Trasylol) to reduce blood loss after cardiac operations, a novel concept first introduced by Angelini and colleagues ² and carefully evaluated by Kallis and associates, ³ is of unusual interest.

The authors' comments in the discussion, "the satisfactory reduction in postoperative blood loss in the aprotinin group prompted us to analyze the results of blood loss in a smaller subgroup of patients undergoing coronary artery bypass who continued to take aspirin until 1 week before the operation," are disconcerting and require an explanation.

Çiçek and colleagues ⁴ have already demonstrated such a benefit in the recent past in a similar group of patients. Is there an overlap between the patients in these two studies?

In the latter publication, ⁴ the final sentence states that "higher risk patients need to be investigated." In this article, ⁴ patients receiving aspirin within 7 days were excluded. It is this very group of 14 patients in the aprotinin group which received aspirin that is the crux of this more recent article, ¹ but we are not informed as to whether they were truly prospectively randomized on the basis of this preoperative characteristic. If not, then although the reported differences in blood loss are striking, statistically speaking, the possibility of type II error rises to beyond 20%. ^5,6 Hence the strict scientific merit is lessened.

A new prospective randomized trial addressing patients expected to be at significant risk for bleeding after cardiac operations is required to answer whether postoperative aprotinin is effective in reducing blood product use after cardiac surgery.

12/8/83068

References

1. Çiçek S, Demirkiliç U, Özal E, Kuralay E, Bingol H, Tatar H, et al. Postoperative use of aprotinin in cardiac operations: an alternative to its prophylactic use. J Thorac Cardiovasc Surg 1996;112:1462-7.
   
2. Angelini GD, Cooper GJ, Larmarra M, Bryan AJ. Unorthodox use of aprotinin to control life-threatening bleeding after cardiopulmonary bypass. Lancet 1990;355:799-800.
   
3. Kallis P, Tooze JA, Talbot S, Cowans D, Bewan HD, Treasure T. Aprotinin inhibits fibrinolysis, improves platelet adhesion and reduces blood loss: results of a double-blind randomized clinical trial. Eur J Cardiothorac Surg 1994;8:315-23.
   
4. Çiçek S, Demirkiliç U, Kuralay E, Özal E, Tatar H. Postoperative aprotinin: effect on blood loss and transfusion requirements in cardiac operations. Ann Thorac Surg 1996;61:1372-6.
   
5. Bulpitt CJ. Medical statistics. Lancet 1988;2:31-4.
   
6. Ludbrook J. Editorial review on making multiple comparisons in clinical and experimental pharmacology and physiology. Clin Exp Pharmacol Physiol 1991;18:379-92.
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Alvarez, J. M. Search for Related Content PubMed Articles by Alvarez, J. M.