Topical Use of Tranexamic Acid in Cardiac Surgery: A Meta-Analysis.

BACKGROUND: This meta-analysis was conducted to investigate the evidence for the efficacy and safety of intrapericardial tranexamic acid (TXA) in cardiac surgery. METHODS: We searched MEDLINE from 2000 to 2017 for randomized controlled trials that compared intrapericardial TXA to placebo. We performed a meta-analysis for the eligible trials that focused on chest tube drainage measured during the first 24 hours after surgery as a primary outcome. We also examined the secondary outcome measures of these trials such as the incidence of transfusion requirements following surgery and the evidence for any increase in complication rates. RESULTS: A total of seven randomized controlled trials (six on-pump and one off-pump) comparing topical application of TXA to placebo in 692 patients were eligible for the blood loss outcome data. These trials randomized 372 patients to receive TXA and 320 patients as controls. The use of intrapericardial TXA was associated with a considerable reduction in 24-hour blood loss in all seven studies and a weighted mean difference of -343.56 mL (95% confidence interval: -316.41, -370.72) significantly differed from zero (p = 0.005) with a heterogeneity of I 2 = 0%. The incidence of packed RBC transfusion in TXA patients was significantly lower in one study and was not significant but with trend in favor of TXA in five out of the six studies in which it was reported. In one trial, TXA was not detected in any patient and in another the studied groups were similar in postoperative complications, such as graft patency, myocardial infarction, cerebral infarction, atrial fibrillation, seizures, and infections. CONCLUSIONS: Findings from this meta-analysis suggest that intrapericardial use of TXA in patients undergoing cardiac surgery can decrease postoperative bleeding without increasing the risk of postoperative seizures. Future large randomized, double-blind, controlled clinical trials are needed to confirm these promising findings.

Decreasing Postoperative Blood Loss by Topical vs. Intravenous Tranexamic Acid in Open Cardiac Surgery (DEPOSITION) study: Results of a pilot study.

BACKGROUND: Cardiac surgery patients are at high risk for postoperative bleeding. Intravenous (IV) tranexamic acid (TxA) is a commonly used antifibrinolytic drug, but is associated with postoperative seizures. We conducted this pilot randomized controlled trial (RCT) to determine the feasibility of a larger trial that will be designed to investigate the impact of TxA administration route, intrapericardial (IP) vs IV, on postoperative bleeding and seizures. METHODS: In this single-center, double-blinded, pilot RCT we enrolled adult patients undergoing nonemergent on-pump cardiac operations through a median sternotomy. Participants were randomized to IP or IV TxA groups. The primary outcomes were cumulative chest tube drainage, transfusion requirements, and incidence of postoperative seizures. RESULTS: A total of 97 participants were randomized to the intervention and control groups. Baseline characteristics were similar in both groups. Most participants underwent a CABG and/or aortic valve replacement. There was no statistical difference. The IP TxA group was found to have a tendency for less chest tube drainage in comparison to the IV TxA group, 500.5 (370.0-700.0) and 540.0 (420.0-700.0) mL, respectively, which was not statistically significant (P = 0.2854). Fewer participants in the IP TxA group with cardiac tamponade and/or required a reoperation for bleeding and fewer packed red blood cell transfusions. None of the IP TxA group developed seizure vs one from the IV TxA group. CONCLUSION: This is the first known pilot RCT to investigate the role of TxA route of administration in open cardiac surgery. Intrapericardial TxA shows promising results with decreased bleeding, transfusion requirements, reoperations, and postoperative seizures. A larger RCT is needed to confirm these results and lead to a change in practice.

Intrapericardial Amiodarone for the Prevention of Postoperative Atrial Fibrillation.

Despite probably being the most effective prophylactic drug for postoperative atrial fibrillation (POAF), amiodarone is reserved as a second-line agent because of its potential systemic side effects. Herein, we review the available experimental and clinical trials examining the effectiveness of intrapericardial (IPC) amiodarone administration in preventing POAF which, if confirmed by future studies, can have a significant impact on cardiac surgery practice.