Comparison of aprotinin and tranexamic acid in the prevention of perioperative bleeding in non-elective cardiac procedures involving the ascending aorta.

BACKGROUND: Cardiac surgery involving the ascending aorta carries a significant risk of bleeding, needing the use of antifibrinolytic agents. However, there is still controversy regarding the optimal choice between aprotinin and tranexamic acid. Our objective was to compare the efficacy and safety of the use of aprotinin and tranexamic acid using the universal definition of perioperative bleeding (UDPB) score and considering major complications. METHODS: In total, 72 non-elective procedures involving the ascending aorta in one tertiary center were analyzed in a retrospective study: 32 treated with tranexamic acid (2016-2018) and 40 with aprotinin (2020-2022). The UDPB score served as the primary endpoint. Secondary endpoints included bleeding quantification, transfusion requirements, complications, and in-hospital mortality within 30 days. Binary logistic regression adjusting for confounders [age, sex, POBS-Card, emergency level, and cardiopulmonary bypass (CPB) duration] was used to assess the relationship between antifibrinolytic choice and bleeding severity. RESULTS: After adjustment, aprotinin was associated with lower UDPB score (P=0.02). A higher emergency level and a longer CPB duration were significantly associated with higher bleeding severity. Sex, age and POBS-Card were not significantly associated with severe or massive bleeding. Secondary outcomes revealed no significant differences in transfusion rates or major adverse events. The use of fibrinogen and prothrombin complex concentrates (PCCs) was significantly higher in the aprotinin group, whereas the use of recombinant factor VIIa (rFVIIa) was higher in the tranexamic acid group. Thirty-day mortality was not statistically different between groups (3.13% for tranexamic acid vs. 17.5% for aprotinin, P=0.07). CONCLUSIONS: In this retrospective monocentric study, aprotinin was associated with reduced perioperative bleeding severity compared with tranexamic acid in urgent cardiac interventions involving the ascending aorta. Further investigations are warranted to validate the efficacy and safety of aprotinin in contemporary aortic surgery with high-risk of bleeding.