[Hemostatic management for cardiac surgical patients in the post-aprotinin era]

Antifibrinolytic therapy is effective in reducing postoperative bleeding and allogeneic transfusion in patients undergoing cardiac surgery with cardiopulmonary bypass. Aprotinin is a bovine serine protease inhibitor which potently inhibits plasmin, and two lysine analogues, epsilon-aminocaproic acid and tranexamic acid, inhibit the activation of plasmin by binding to plasminogen. Although aprotinin has been considered more efficacious than lysine analogues in reducing blood loss, recent clinical studies in cardiac surgical patients suggested increased mortality in aprotinin compared to lysine analogues. Why could aprotinin be more harmful to high-risk cardiac surgical patients? Are there enough safety data on the use of epsilon -aminocaproic acid and tranexamic acid? Potential harms of inhibiting endogenous fibrinolytic system have not been systematically reviewed. This review article presents a current perspective on the efficacy and safety of antifibrinolytic agents based on the available basic science and clinical data. Further, the hemostatic strategies for complex cardiac surgical patients will be proposed.