Ahmet KÖROĞLU, Ayda TÜRKÖZ, İsmail TEMEL, Rıza TÜRKÖZ, M. Özcan ERSOY

Koroner arter cerrahisinde aprotinin ve traneksamik asit: II) Miyokard, akciğer ve santral sinir sistemi üzerine etkileri

Kan kaybını azaltmak amacıyla kullanılan aprotinin ve traneksamik asitin kontrol grubu ile karşılaştırmalı olarak miyokard, akciğer ve santral sinir sistemi üzerine etkilerini primer koroner arter bypass greftlemesi yapılacak olgularda araştırmayı amaçladık.Altmış olgu üç gruba ayrıldı: Aprotinin uygulananlar (total doz 6x106 KIU, n=20, Grup A), traneksamik asit uygulananlar (total 10 g, n=20, Grup T) ve kontrol grubu (n=20, Grup K). Miyokard enzimleri (troponin I, CKMB, SGOT, LDH,), akciğer kompliyansı, rezistansı, PaO2/PAO2 ve PaO2/FiO2, laktat düzeyleri ve hemodinamik ölçümler kardiopulmoner bypass (KPB) öncesi ve sonrası çeşitli zaman periyotlarında belirlendi. Postoperatif mortalite, kognitif fonksiyon bozuklukları, yoğun bakımda kalış ve taburcu oluş süreleri kaydedildi. Troponin I düzeyi KPB'ın 6. saattinde kontrol grubunda diğer iki gruba göre anlamlı olarak yüksekti, ancak bu enzim yüksekliği normal sınırlar içerisindeydi (Grup A: 8.70±2.10; Grup T: 11.80±1.80; Grup K: 20.80±4.09 ng.ml-1 p=0.012). Postoperatif miyokard infaktüsü insidansı yine benzerdi (Grup A: 1 olgu; Grup T: 0 olgu; Grup K: 2 olgu). Akciğer rezistans, kompliansı, PaO2/PAO2 ve PaO2/FiO2 oranları, laktat düzeyleri ve hemodinamik değerler tüm ölçüm zamanlarında gruplar arasında istatistiksel olarak farklılık göstermedi. Postoperatif kognitif fonksiyon bozukluğu traneksamik asit grubunda istatistiksel olarak daha fazla saptandı (Grup A: 0 olgu; Grup T: 6 olgu; Grup K: 2 olgu; p=0.044). Mortalite, yoğun bakım ve hastanede kalış süreleri yine gruplar arasında farklı değildi. Bu bulgular yüksek doz aprotinin ve traneksamik asidin miyokard üzerine ilave yararlı veya zararlı etkisinin olmadığını desteklemektedir. Yine KPB'a bağlı akciğerde oluşan değişiklikleri önlemede her iki ilacın ilave bir etkisini gözlemedik. Kognitif fonksiyon bozukluğu insidensi traneksamik asit tedavisiyle daha yüksek olduğu bulundu. Sonuç olarak kalp ameliyatlarında primer hemostatik amaçlı kullanılan aprotinin ve traneksamik asidin kalp, akciğer ve santral sinir sistemi üzerine ilave koruyucu etkisini gözlemlemezken traneksamik asit grubunda kognitif fonksiyon bozukluğunun daha sık olarak oluşması dikkat çekiciydi.

Anahtar Kelimeler:

Akciğer, Kardiyopulmoner bypass, Toraks cerrahisi, Traneksamik asit, Miyokard, Aprotinin, Merkezi sinir sistemi, Varyans analizi

Aprotinin and tranexamic acid in coronary artery bypass surgery: II) The effects on myocardium, lung and central nervous system

The effects of aprotinin and tranexamic acid (TA), used mostly to reduce the blood loss on myocardium, lung and central nervous system were investigated and compared with control group in a prospective and randomized study following primary coronary artery bypass grafting. Sixty patients were allocated into three groups: aprotinin (total dose 6 x 106 KIU, n=20, Group A), TA (total 10 g, n=20 Group T), and nonmedicated controls (n=20, Group C). Myocardial enzymes (troponin I, creatine kinase isoenzyme (CKMB), SGOT, LDH), pulmonary compliance, resistance, PaO2/PAO2 and PaO2/FIO2, lactate level and hemodynamics parameters were assessed before CPB (cardiopulmonary bypass) and following CPB in various periods. Postoperative mortality, cognitive dysfunction, stay in intensive care unit and hospital discharge times were recorded. Troponin I levels increased in the control group compared with the remaining two groups 6 hours after CPB but this increase was within normal ranges (Group A: 8.70±2.10; Group T: 11.80±1.80; Group K: 20.80±4.09 ng.mL-1; p=0.012). The incidence of postoperative myocardial infarction was similar in all groups (Group A: 1 patient; Group T: none; Group K: 2 patients). Pulmonary resistance, compliance, PaO2/PAO2 and PaO2/FiO2 , lactate level and hemodynamic parameters were not statistically different after CPB. Postoperative cognitive dysfunction was statistically significant in Group T (Group A: none; Group T: 6 patients; Group C: 2 patients; p=0.044). Mortality, stay in intensive care unit and hospital discharge times were not different within the groups. Our results suggested that high dose aprotinin and TA had no additional benefit or harmful effect on myocardium. Also, we did not observe any additional positive effect to prevent CPB induced lung injury in both drugs. The cognitive dysfunction incidence was higher with TA therapy. In conclusion, for aprotinin and TA used for primary hemostasis in cardiac surgery, the additional protective effects on the heart, lung and central nervous system have not been confirmed, whereas for TA , cognitive dysfunction has been found to be strikingly more common.

Keywords:

Lung, Cardiopulmonary Bypass, Thoracic Surgery, Tranexamic Acid, Myocardium, Aprotinin, Central Nervous System, Analysis of Variance,

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