Drugs

• Aprotinin (trasylol) – polypeptide – competitive serine protease inhibitor – inhibits plasmin (low conc), and kallikrein (which inhibits XIIa)(high conc).
• Aminocaproic acid (amicar) – amino acid lysine analogue –
• Tranexamic acid () – amino acid lysine analogue – binds to lysine receptor sites on plasmin which prevents it from binding to fibrin.

Research

Mangano et al NEJM 2006 – observational prospective cohort n=4374, composite (death,RF,MI, CVA) 2.8% vs 1.3%. AGAINST aprotinin.

BART (Blood conservation using Anti-fibrinolytics in a randomised trial) 2008 – blinded RCT – higher 30d mortality RR 1.53. AGAINST aprotinin.

International Multicenter Aprotinin Graft Patency Experience (IMAGE) 1998 –

64 RCTs between 1987-2002

Hammersmith Regime

Loading (before sternotomy) – 2 million kallikrein inhibitory units / (280mg) followed by infusion of 0.5 million KIU/h  (70mg/h). Add CPB prime – 2 million KIU (280mg)