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J Thorac Cardiovasc Surg 1999;118:765
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Is a high hematocrit value an independent risk factor for adverse outcome after coronary artery bypass grafting?

Cardiac Surgical Unit
The Royal Hospital
Grosvenor RdBelfast, BT12 6BA, Northern Ireland

To the Editor:

We read with great interest the recently published article by Spiess and colleagues. ¹ In an observational study of 2202 patients undergoing coronary artery bypass grafting (CABG) in 24 different centers, they found on multivariate analysis that the most significant predictor of Q-wave myocardial infarction was a hematocrit greater than 33% on entry to the intensive care unit. They also noted that patients with a hematocrit less than 25% had the lowest rates of both Q-wave myocardial infarction and severe left ventricular dysfunction and concluded that morbidity after CABG might be decreased by allowing the hematocrit to be low immediately postoperatively. These findings have the potential to make an enormous clinical and financial impact given the frequency of this operation world-wide. However, before these results can be accepted as valid, it is essential to know whether any of the patients included in this study had perioperative administration of aprotinin, either as part of a clinical protocol or as part of a concurrent trial. This information is not detailed in the article.

Aprotinin administration has been shown to reduce bleeding and increase postoperative hemoglobin levels after CABG when compared with placebo. ^2,3 Its use has been associated in some studies with increased perioperative myocardial infarction ^4,5 and decreased vein graft patency rates, ^2,5,6 although these findings are not universal. ^3,7 Patients who have been given aprotinin would be expected to have a higher postoperative hematocrit level but may also have been at increased risk of myocardial infarction as a result of an independent effect of aprotinin causing a hypercoagulable state. ⁸ Therefore, if any patients in the study reported by Spiess and associates had received aprotinin, the multivariate analysis should be repeated to confirm that a higher hematocrit value was indeed an independent risk factor for Q-wave myocardial infarction and severe left ventricular dysfunction.

References

1. Spiess BD, Ley C, Body SC, Siegel LC, Stover EP, Maddi R, et al. Hematocrit value on intensive care unit entry influences the frequency of Q-wave myocardial infarction after coronary artery bypass grafting: the Institutions of the Multicenter Study of Perioperative Ischemia (McSPI) Research Group. J Thorac Cardiovasc Surg 1998;116:460-7.[Abstract/Free Full Text]
   
2. Alderman EL, Levy JH, Rich JB, Nili M, Vidne B, Schaff H, et al. Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE) trial. J Thorac Cardiovasc Surg 1998;116:716-30.[Abstract/Free Full Text]
   
3. Levy JH, Pifarré R, Schaff HV, Horrow JC, Albus R, Spiess B, et al. A multicenter, double-blind, placebo-controlled trial of aprotinin for reducing blood loss and the requirement for donor-blood transfusion in patients undergoing repeat coronary artery bypass grafting [see comments]. Circulation 1995;92:2236-44.[Abstract/Free Full Text]
   
4. Cosgrove DM, Heric B, Lytle BW, Taylor PC, Novoa R, Golding LA, et al. Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study [see comments]. Ann Thorac Surg 1992;4:1031-6; discussion 1036-8.
   
5. van der Meer J, Hillege HL, Ascoop CA, Dunselman PH, Mulder BJ, van Ommen GV, et al. Aprotinin in aortocoronary bypass surgery: Increased risk of vein-graft occlusion and myocardial infarction? Supportive evidence from a retrospective study. Thromb Haemost 1996;75:1-3.[Medline]
   
6. Lass M, Welz A, Kochs M, Mayer G, Schwandt M, Hannekum A. Aprotinin in elective primary bypass surgery: graft patency and clinical efficacy. Eur J Cardiothorac Surg 1995;9:206-10.[Abstract]
   
7. Kalangos A, Tayyareci G, Pretre R, Di Dio P, Sezerman O. Influence of aprotinin on early graft thrombosis in patients undergoing myocardial revascularization. Eur J Cardiothorac Surg 1994;8:651-6. [Abstract]
   
8. Feindt P, Seyfert U, Volkmer I, Huwer H, Kalweit G, Gams E. Is there a phase of hypercoagulability when aprotinin is used in cardiac surgery? Eur J Cardiothorac Surg 1994;8:308-13; discussion 313-4.[Abstract]
   

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