Comparison of the in-vivo effect of two tranexamic acid doses on fibrinolysis parameters in adults undergoing valvular cardiac surgery with cardiopulmonary bypass - a pilot investigation

Zhen-Feng Zhou, Wen Zhai, Li-Na Yu, Kai Sun, Li-Hong Sun, Xiu-Fang Xing, Min Yan, Zhen-Feng Zhou, Wen Zhai, Li-Na Yu, Kai Sun, Li-Hong Sun, Xiu-Fang Xing, Min Yan

Abstract

Background: The blood saving efficacy of TXA in cardiac surgery has been proved in several studies, but TXA dosing regimens were varied in those studies. Therefore, we performed this study to investigate if there is a dose dependent in-vivo effect of TXA on fibrinolysis parameters by measurement of fibrinolysis markers in adults undergoing cardiac surgery with CPB.

Methods: A double-blind, randomized, controlled prospective trial was conducted from February 11, 2017 to May 05, 2017. Thirty patients undergoing cardiac valve surgery were identified and randomly divided into a placebo group, low-dose group and high-dose group by 1: 1: 1. Fibrinolysis parameters were measured by plasma levels of D-Dimers, plasminogen activator inhibitor-1 (PAI-1), thrombin activatable fibrinolysis inhibitor (TAFI), plasmin-antiplasmin complex (PAP), tissue plasminogen activator (tPA) and thrombomodulin (TM). Those proteins were measured at five different sample times: preoperatively before the TXA injection (T1), 5 min after the TXA bolus (T2), 5 min after the initiation of CPB (T3), 5 min before the end of CPB (T4) and 5 min after the protamine administration (T5). A Thrombelastography (TEG) and standard coagulation test were also performed.

Results: Compared with the control group, the level of the D-Dimers decreased in the low-dose and high-dose groups when the patients arrived at the ICU and on the first postoperative morning. Over time, the concentrations of PAI-1, TAFI, and TM, but not PAP and tPA, showed significant differences between the three groups (P < 0.05). Compared with the placebo group, the plasma concentrations of PAI-1 and TAFI decreased significantly at the T3 and T4 (P < 0.05); TAFI concentrations also decreased at the T5 in low-dose group (P < 0.05). Compared with the low-dose group, the concentration of TM increased significantly at the T4 in high-dose group.

Conclusions: The in-vivo effect of low dose TXA is equivalent to high dose TXA on fibrinolysis parameters in adults with a low bleeding risk undergoing valvular cardiac surgery with cardiopulmonary bypass, and a low dose TXA regimen might be equivalent to high dose TXA for those patients.

Trial registration: ChiCTR-IPR-17010303 , Principal investigator: Zhen-feng ZHOU, Date of registration: January 1, 2017.

Keywords: Cardiac surger; Fibrinolysis; Tissue plasminogen activator; Tranexamic acid.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Study flowchart Study population recruitment summary
Fig. 2
Fig. 2
Concentration curves of Coagulation proteins at different sample points between the three groups. PAI-1: plasminogen activator inhibitor-1, TAFI: thrombin activatable fibrinolysis inhibitor, PAP: plasmin-antiplasmin complex, tPA: tissue plasminogen activator, TM: thrombomodulin. T1: per-operatively before TXA injection (baseline); T2: 5 min after TXA bolus administration (bolus); T3: 5 min after the onset of CPB (CPB); T4: 5 min before the end of CPB (End of CPB); T5: 5 min after protamine injection (protamine). *: Low-dose group compared with placebo group; §: High-dose group compared with Low-dose group

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