Tranexamic acid reduces bleeding in off-pump coronary bypass surgery

By Andrew Czyzewski

Patients undergoing off-pump coronary artery bypass grafting (OPCAB) who are given a tranexamic acid infusion show a modest reduction in postoperative bleeding and blood transfusion relative to their placebo-treated peers, a clinical trial shows.

Further studies are, however, needed to better determine the risk tranexamic acid poses for thrombotic events such as coronary graft occlusion, myocardial infarction, stroke, and death, say Guyan Wang (Peking Union Medical College, China) and co-authors.

In all 231 consecutive patients scheduled for elective OPCAB were randomly assigned to receive either tranexamic acid (bolus 1 g before surgical incision followed by an infusion of 400 mg/h during surgery; n=116) or a placebo (infusion equivalent volume of saline solution; n=115).

Compared with patients in the placebo group, those who received tranexamic acid reported significantly lower average chest tube drainage at 6 hours (416 versus 270 mL) and at 24 hours (891 vs 654 mL).

There was also a significant reduction in the number of patients requiring allogeneic red blood cell transfusions in the tranexamic acid group relative to control group (31.9 vs 47%) and fresh frozen plasma transfusions (17.2 vs 29.6%).

In an accompanying editorial Janet Martin and Davy Cheng (Western University, London, Ontario, Canada) point out that for every seven OPCAB patients receiving tranexamic acid prophylaxis, there will be one less patient exposed to transfusion than if no tranexamic acid had been used.

"The real question is whether the reduction in blood loss or blood exposure for OPCAB patients is worth the potential added risks (seizures, and other unknown adverse events not yet discovered) and costs, and what the optimal dosage is," they commented.

They called for large trials that are powered to measure the outcomes "that matter most to our patients," including the risk for death, stroke, myocardial infarction, renal failure, reoperation for bleeding, and need for revascularization over the spectrum of months and years.

The research is published in Anesthesia and Analgesia.

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