Surgery Medical News about Coronary Artery Bypass Coronary Artery Bypass, Off-Pump

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A Randomized Clinical Trial Investigating the Relationship Between Aprotinin and Hypercoagulability in Off-Pump Coronary Surgery
Anesthesia & Analgesia, 10/21/09

Desai PH et al. – This study demonstrates that aprotinin protects patients undergoing OPCAB surgery from a hypercoagulable state by diminishing thrombin–induced platelet activation and thrombin generation within saphenous vein grafts, while maintaining systemic hemostatic and antifibrinolytic benefits. These results support further investigation of aprotinin and other PAR–1 antagonists in OPCAB surgery.

Exclusive Author Commentary
Robert S. Poston, 10/21/09

There has been little clinical investigation on the quesiton of how the mechanisms for hemostasis differ than for thrombosis. A series of observations from this paper provides preliminary support for the idea that PAR-1 may be responsible for thrombosis but have less effect on hemostasis: 1) Aprotinin has a potent inhibitory effect on the platelet thrombin receptor, PAR-1, a pathway that is critical for thrombosis. 2) Based on the effects of direct thrombin inhibitors on bleeding after CABG, it is clear that thrombin is required for adequate hemostasis through a variety of different mechanisms. 3) Although the clinical effect of aprotinin remains in debate (safe hemostatic vs. procoagulant agent), it certainly does not cause bleeding after cardiac surgery. A reasonable conclusion based on these observations is that the activation of PAR-1 via thrombin must be relatively unimportant for hemostasis. If so, this would be an ideal target for prevention of thrombosis after surgical procedures.

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