The effect of tranexamic acid to reduce blood loss and transfusion on off-pump coronary artery bypass surgery: A systematic review and cumulative meta-analysis
Introduction
Post-operative hemorrhage is considered as one of the major concerns in cardiovascular surgery [1]. And excessive postoperative bleeding after cardiac surgery increases transfusion requirements, which is associated with postoperative infections and ischemic events [2]. Since fibrinolysis can contribute to bleeding after cardiac surgery, the administration of antifibrinolytics appears to be a suitable approach to reducing postoperative bleeding in the patient presenting for on-pump CABG surgery. Results from previous trials have shown that TA reduces blood loss and transfusion in cardiopulmonary bypass surgery [3], [4], [5].
Since the early 1990s, CABG surgery performed off-pump has become an established alternative surgical technique [6]. OPCAB surgery can be performed with low risk of postoperative bleeding and blood transfusion [7]. Additionally, a greater level of activation of fibrinogen associated with OPCAB surgery compared with on-pump CABG might result in a higher incidence of adverse thrombotic events [8]. Therefore, TA may be less effective for off-pump surgery, and its safety profile may be different. The aim of this study was to provide a meta-analysis including 15 randomized controlled trails [4], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22] to examine the efficacy and safety of TA in OPCAB surgery.
Section snippets
Materials and methods
According to the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we performed this meta-analysis and we also specified and documented the analysis methods and eligibility criteria.
Characteristics of studies
A total of 15 randomized trials met the inclusion/exclusion criteria and contained the necessary data for the intended comparison, as shown in Fig. 1. We also summarized the characteristics of the selected trials, which showed differences in some respects between the 15 studies (Table 1). With relevant to drug dose, treatment regimen and thresholds for fresh frozen plasma, the trails were heterogenous. The thresholds for packed red blood cells transfusion were broadly similar (hemoglobin, 8–9
Discussion
Antifibrinolytic therapy can reduce the risk of blood loss and transfusion among patients undergoing on-pump cardiac surgery which can be associated with excessive bleeding due to several factors such as increased fibrinolysis induced by extracorporeal circulation [21], [24]. Compared with on-pump CABG surgery, OPCAB surgery is associated with less blood loss [25] and the safety profile of TA may be different. The results of the present study demonstrate that TA reduces 24-hour blood loss and
Conflict of interest statement
The authors declare that there are no conflicts of interest.
References (31)
- et al.
Does tranexamic acid reduce desmopressin-induced hyperfibrinolysis?
J Thorac Cardiovasc Surg
(2002) - et al.
Tranexamic acid is associated with less blood transfusion in off-pump coronary artery bypass graft surgery: a systematic review and meta-analysis.[J]
J Cardiothorac Vasc Anesth
(2011) - et al.
Off-pump versus on-pump coronary artery bypass grafting
Surg Clin North Am
(2009) - et al.
Tranexamic acid in off-pump coronary surgery: a preliminary, randomized, double-blind, placebo-controlled study
Ann Thorac Surg
(2001) - et al.
Tranexamic acid reduces blood loss in off-pump coronary artery bypass surgery
J Cardiothorac Vasc Anesth
(2009) - et al.
Effects of tranexamic acid on postoperative bleeding and related hematochemical variables in coronary surgery: comparison between on-pump and off-pump techniques.[J]
J Thorac Cardiovasc Surg
(2004) - et al.
Tranexamic acid in on-pump coronary artery bypass grafting without clopidogrel and aspirin cessation: randomized trial and 1-year follow-up
Ann Thorac Surg
(2013) - et al.
Sample size calculations in randomised trials: mandatory and mystical
Lancet
(2005) - et al.
Increased mortality, morbidity, and cost associated with red blood cell transfusion after cardiac surgery
Curr Opin Cardiol
(2008) - et al.
Tranexamic acid reduces bleeding after cardiopulmonary bypass when compared to epsilon aminocaproic acid and placebo
J Card Surg
(1997)
A randomized trial of tranexamic acid in combination with cell salvage plus a meta-analysis of randomized trials evaluating tranexamic acid in off-pump coronary artery bypass grafting
J Thorac Cardiovasc Surg
On-pump and off-pump coronary bypass surgery
Circulation
Activation of coagulation and fibrinolysis during coronary surgery: on-pump versus off-pump techniques
Anesthesiology
Tranexamic acid in patients undergoing coronary-artery surgery
N Engl J Med
Does tranexamic acid reduce blood loss in off-pump coronary artery bypass?
Asian Cardiovasc Thorac Ann
Cited by (35)
Patient Blood Management in Vascular Surgery
2022, Anesthesiology ClinicsCitation Excerpt :The 2 main antifibrinolytic agents are synthetic lysine analogs, tranexamic acid (TXA), and epsilon aminocaproic acid. TXA has been widely established to reduce bleeding and transfusion requirements for multiple surgical fields ranging from cardiac, orthopedic, spine, abdominal, trauma, plastic, and obstetrics surgeries and even epistaxis and upper gastrointestinal bleeds, without increased complications in thrombotic adverse effects.57–64 Seizure has been reported in cardiac surgery cases of high dose tranexamic acid administration in patients with chronic kidney disease.65,66
Tenets for the Proper Conduct and Use of Meta-Analyses: A Practical Guide for Neurosurgeons
2022, World NeurosurgeryCitation Excerpt :Finally, it is certainly plausible that some of the heterogeneity, especially in surgical meta-analyses, could reflect the existence of “meta”-learning curves (e.g., such as the inception of new technologies such as robotic surgery,67-69 or novel surgical approaches).70-72 Cumulative meta-analysis, ordered chronologically by publication date or perhaps the first year of patient recruitment, could potentially be used to explore this hypothesis.73-77 Systematic review methodologists have published an extensive body of literature about how meta-analyses should be reported.
Fibrinolysis and the Influence of Tranexamic Acid Dosing in Cardiac Surgery
2020, Journal of Cardiothoracic and Vascular AnesthesiaAcute Myocardial Infarction After Tranexamic Acid: Review of Published Case Reports
2020, Chinese Medical Sciences JournalCurrent Evidence and Future Directions of Tranexamic Acid Use, Efficacy, and Dosing for Major Surgical Procedures
2020, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :Several mechanisms likely contribute to this phenomenon, including less pump-associated systemic hemodilution, red-cell trauma, and heparin dose.20 Fewer clinical trials have specifically addressed the use of TXA for off-pump surgery, but they largely have revealed similar efficacious results to on-pump surgery.21-26 In 2011, Adler et al. conducted a meta-analysis using 8 clinical trials with 544 patients.26
Off-Pump Coronary Artery Bypass Grafting: Closing the Communication Gap Across the Ether Screen
2020, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :From numerous trials and large retrospective studies, it is reasonable to deduce that OPCAB reduces postoperative morbidity at the expense of higher rates of incomplete revascularization.84 It has been shown that OPCAB reduces perioperative blood transfusion,42,81 and the use of tranexamic acid has been found to reduce the need for postoperative packed red blood cell and fresh frozen plasma transfusion.85 However, several recent randomized controlled trials have reported increased 5-year mortality for OPCAB on long-term follow-up.17,83,86,87