Review Article

Journal of Anesthesia

, Volume 24, Issue 1, pp 96-106

First online:

Lessons from the aprotinin saga: current perspective on antifibrinolytic therapy in cardiac surgery

  • Masahiro IdeAffiliated withKobe Anesthesia Associates
  • , Daniel BolligerAffiliated withDepartment of Anesthesiology, Emory University School of Medicine
  • , Taro TaketomiAffiliated withDepartment of Anesthesiology, Emory University School of Medicine
  • , Kenichi A. TanakaAffiliated withDepartment of Anesthesiology, Emory University School of Medicine Email author 

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Antifibrinolytic agents have been prophylactically administered to patients undergoing cardiopulmonary bypass (CPB) to reduce postoperative bleeding due to plasmin-mediated coagulation disturbances. After the recent market withdrawal of aprotinin, a potent bovine-derived plasmin inhibitor, two lysine analogs, ε-aminocaproic acid and tranexamic acid are currently available for clinical use. Although the use of aprotinin recently raised major concerns about postoperative thrombosis and organ dysfunctions, there is a paucity of information on the potential complications related to lysine analogs. Using the available preclinical and clinical data, we present current perspectives on the hemostatic mechanism and potential harms of antifbirnolytic therapy related to cardiac surgery. Fibrin formation is the critical step for hemostasis at the site of vascular injury, and localized fibrinolytic activity counterbalances excess fibrin formation which might result in vascular occlusion. Inhibition of the endogenous fibrinolytic system may be associated with thrombotic complications in susceptible organs. It is thus important to understand CPB-related changes in endogenous fibrinolytic proteins (e.g., tissue plasminogen activator (tPA), plasminogen) and antifibrinolytic proteins (e.g., α2-antiplasmin).


Antifibrinolytic therapy Complications Aprotinin ε-Aminocaproic acid Tranexamic acid