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aprotinin and coronary artery bypass surgery

Ouattara, Alexandre; Amour, Julien

European Journal of Anaesthesiology (EJA): January 2018 - Volume 35 - Issue 1 - p 69–70
doi: 10.1097/EJA.0000000000000727

From the CHU Bordeaux, Department of Anaesthesia and Critical Care II; Univ Bordeaux and INSERM U 1034, Biology of Cardiovascular diseases; Pessac (AO) and Department of Anaesthesiology and Critical Care Medicine, UMR INSERM, IHU ICAN, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Pierre-and-Marie-Curie University, Sorbonne Universités, Paris, France (JA)

Correspondence to Alexandre Ouattara, MD, PhD, Service d’Anesthésie Réanimation II, Centre Médico-Chirurgical Magellan, Hôspital Haut-Lévêque, Avenue Magellan, Pessac, France Tel: +33 5 57 65 68 66; fax: +33 5 57 65 68 11; e-mail:


We read, with great interest, the ‘Letter to the Editor’ by Cerit1 concerning our work recently published in the European Journal of Anaesthesiology.2 First, we would like to thank our colleague for his interest in our article. Major bleeding after cardiac surgery remains a serious concern challenging physicians attending cardiac surgical patients. The main underlying mechanisms include decreased thrombin generation, fibrinolysis and platelet dysfunction.3 The origins of these changes are multifactorial; however, cardiopulmonary bypass appears to play a major role.4 Some previous trials have investigated predictive factors for excessive bleeding4–9 and attempted to develop a preoperative risk scoring system.6–9 Surprisingly, the inclusion of intraoperative variables (e.g. the use of cardiopulmonary bypass and/or temperature) does not seem to improve their predictive properties.8,9 Although their predictive performances are acceptable in cardiac surgical patients, these scoring systems are little used by clinicians and their utility remains questionable. Because the HAS-BLED [(Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly)], ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) and HEMORR2HAGES (Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk and Stroke) scores have been validated exclusively in noncardiac surgical patients with atrial fibrillation,10 their use for predicting bleeding after cardiac surgery appears to be profoundly hazardous.

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Acknowledgements relating to this article

Assistance with reply: none.

Financial support and sponsorship: AO is a member of the independent drug safety monitoring committee (DSMC) for the Nordic Aprotinin Patient Registry (NAPaR) established by Nordic Pharma BV as a requirement of the European regulatory agency. He has received honoraria as consultant to Nordic Pharma.

Conflicts of interest: none.

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1. Cerit L. Aprotinin and coronary artery bypass surgery. Eur J Anaesthesiol 2018; 35:68–69.
2. Deloge E, Amour J, Provenchère S, et al. Aprotinin vs. tranexamic acid in isolated coronary artery bypass surgery: a multicentre observational study. Eur J Anaesthesiol 2017; 34:280–287.
3. Thiele RH, Raphael J. A 2014 update on coagulation management for cardiopulmonary bypass. Semin Cardiothorac Vasc Anesth 2014; 18:177–189.
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7. Vuylsteke A, Pagel C, Gerrard C, et al. The Papworth bleeding risk score: a stratification scheme for identifying cardiac surgery patients at risk of excessive early postoperative bleeding. Eur J Cardiothorac Surg 2011; 39:924–931.
8. Goudie R, Sterne JA, Verheyden V, et al. Risk scores to facilitate preoperative prediction of transfusion and large volume blood transfusion associated with adult cardiac surgery. Br J Anaesth 2015; 114:757–766.
9. Greiff G, Pleym H, Stenseth R, et al. Prediction of bleeding after cardiac surgery: comparison of model performances: a prospective observational study. J Cardiothorac Vasc Anesth 2015; 29:311–319.
10. Apostolakis S, Lane DA, Guo Y, et al. Performance of the HEMORR2HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in patients with atrial fibrillation undergoing anticoagulation: the AMADEUS (evaluating the use of SR34006 compared to warfarin or acenocoumarol in patients with atrial fibrillation) study. J Am Coll Cardiol 2012; 60:861–867.
© 2018 European Society of Anaesthesiology