LITERATURE REVIEW Frederick W. Campbell, MD, Editor

SCIENTIFIC ARTICLES

Blauhut B, Gross C, Necek S, et al: Effects of high dose of aprotinin on blood loss, platelet function, fibrinolysis, complement, and renal function after cardiopulmonary bypass. J Thorac Cardiovasc Surg 101:958-967,199l

Eighty-six men undergoing coronary artery surgery were random- ized to aprotinin (mean dose, 4.2 x lo6 KIU) or placebo groups. Aprotinin treatment reduced 24-hour postoperative blood loss by 50%. Fifteen units of packed red blood cells were transfused to 8 of 13 control patients; one red blood cell unit each was transfused to 2 of 13 aprotinin-treated patients. Platelet counts did not differ, but plasma thromboxane level was reduced in aprotinin patients. In control patients, fibrin degradation products (D-dimer) were markedly increased and A, antiplasmin decreased during and after cardiopulmonary bypass. Complement activation occurred in both groups and was slightly greater in the aprotinin patients. No adverse allergic, hemostatic, or renal effects attributable to aproti- nin were noted. Readers are referred to an accompanying invited letter concerning a proposed mechanism of aprotinin in the same issue of the Journal.

Harder MP, Eijsman L, Roozendaal KL, et al: Aprotinin reduces intraoperative and postoperative blood loss in membrane oxygenator cardiopulmonary bypass. Ann Thorac Surg 51:936-941,199l

The effects of aprotinin (4 x lo6 KIU preoperative infusion, and 2 x lo6 KIU in the pump prime) are evaluated in a prospective, randomized, double-blind, placebo-controlled trial in 80 patients undergoing coronary artery surgery. Blood loss in the aprotinin- treated patients was reduced to less than two-thirds of that in controls. Aprotinin decreased the number of postoperative blood transfusions administered and increased the number of patients not receiving donor blood (42 vs 68%). Administration of fresh frozen plasma to patients in both groups may have exaggerated these differences.

Have1 M, Teufelsbauer H, Knob1 P, et al: Effect of intraoperative aprotinin administration on postoper- ative bleeding in patients undergoing cardiopulmo- nary bypass operation. J Thorac Cardiovasc Surg 101:968-972,199l

In another randomized clinical aprotinin trial, 12 of 24 patients undergoing coronary artery surgery received high-dose aprotinin (approximately 800 mg) during extracorporeal circulation. Despite adequate clinical heparinization, intravascular coagulation is appar- ent in both patient groups; all patients had marked increases in plasma thrombin-antithrombin III complexes during bypass. How- ever, the resulting increase in fibrin degradation products was

significantly attenuated by aprotinin. Postoperative blood loss was lower in patients receiving aprotinin than in control patients (620 mL vs 1000 mL).

Steingrub JS, Celoria G, Vickers-Lahti M, et al: Therapeutic impact of pulmonary artery catheteriza- tion in the medical/surgical ICU. Chest 99:1451- 1455,199l

Before pulmonary artery catheterization in 154 patients judged to require catheterization, resident and attending physicians esti- mated patient hemodynamics and planned therapy on the basis of clinical examination. Following catheterization, observed hemody- namics were compared with those estimated and therapy was reevaluated. Pulmonary artery occlusion pressure, cardiac output, and systemic vascular resistance were classified correctly before catheterization as high, medium, or low one-half of the time. In 45% of cases, information obtained from catheterization resulted in a major change in therapy. Pulmonary artery catheterization may be helpful in patients unresponsive to initial clinically deter- mined therapy.

Crouse LJ, Harbrecht JJ, Vacek JL, et al: Exercise echocardiography as a screening test for coronary artery disease in correlation with coronary arteriogra- phy. Am J Cardiol67:1213-1218,199l

Exercise echocardiography was compared with stress electrocar- diography in 228 patients with coronary disease subsequently undergoing coronary angiography. After a baseline echocardio- gram was taken at rest, repeat imaging was performed after maximal treadmill exercise. Wall motion abnormalities were noted when any segment failed to become hypercontractile with exercise. These abnormalities were used to predict the extent of coronary disease observed at subsequent angiography. Compared with electrocardiography, exercise echocardiography was both more sensitive and more specific, and had higher positive and negative predictive accuracies for detection of angiographic coronary occlu- sions.

Steckelberg JM, Rhandheria BR, Amhalt JT, et al: Prospective evaluation of the risk of bacteremia associated with transesophageal echocardiography. Circulation 84:177-180,199l

The risk of transient bacteremia associated with transesoph- ageal echocardiography was evaluated in 47 patients. Blood cul- tures were obtained immediately before and 5, 10, and 20 minutes after the start of the procedure. Two preprocedure control blood cultures and 2 of 141 subsequent cultures were positive. All isolates were considered contaminants. No significant bacteremia caused by pathological oral flora during transesophageal echocardio- graphy was observed.

Journalof Cardiothoracic and VascularAnesthesia, Vol6, No 1 (February), 1992: pp 115-l 17 115