What is the role of DDAVP (desmopressin) in minimizing perioperative bleeding in patients undergoing Coronary Artery Bypass Grafting (CABG)?

Role of DDAVP (Desmopressin) in Minimizing Perioperative Bleeding in CABG Patients

Desmopressin (DDAVP) is not routinely recommended for reducing perioperative bleeding in patients undergoing coronary artery bypass grafting (CABG), as it provides only a small reduction in blood loss that is unlikely to be of clinical importance. 1

Mechanism of Action and Indications

• Desmopressin is a pro-hemostatic drug that stimulates the release of von Willebrand factor (vWF) from the endothelium, which then binds platelets to collagen through GP1b receptors and to other platelets through GPIIb/IIIa receptors 1
• FDA-approved indications for desmopressin include hemophilia A with factor VIII coagulant activity >5% and von Willebrand's Disease (Type I), but not specifically for CABG-related bleeding 2
• The standard dosage for hemostatic effects is 0.3 μg/kg body weight diluted in sterile physiological saline and infused slowly over 15 to 30 minutes 2

Evidence in CABG Patients

• Recent guidelines (2025) indicate that while desmopressin may lead to a small reduction in blood loss and volume of RBCs transfused in cardiac surgery, these differences are unlikely to be of clinical importance 1
• Multiple randomized controlled trials have shown no significant difference in total blood loss between desmopressin and placebo groups in uncomplicated CABG surgery 3, 4, 5
• A 2014 review found that desmopressin does not provide a clinically significant reduction in transfusion exposure in unselected patients undergoing cardiopulmonary bypass 6

Specific Patient Subgroups

• Desmopressin may potentially benefit specific subgroups of CABG patients, including: 1, 6

  • Patients with platelet dysfunction secondary to cardiopulmonary bypass
  • Patients with recent antiplatelet therapy prior to cardiac surgery
  • Patients with CPB times exceeding 140 minutes
  • Patients with demonstrable pre- or perioperative platelet dysfunction

• However, even in patients treated with aspirin until the day before surgery, studies have shown that desmopressin does not significantly reduce postoperative bleeding 4

Preferred Hemostatic Agents for CABG

• Lysine analogues (tranexamic acid) are recommended as first-line agents for reducing perioperative blood loss and transfusion requirements in patients undergoing on-pump CABG (Level of Evidence: A) 1
• For patients on dual antiplatelet therapy requiring urgent CABG with increased bleeding risk, options include: 1
  • Preoperative platelet transfusion
  • Administering antifibrinolytic drugs such as tranexamic acid or α-aminocaproic acid
  • Avoiding aprotinin due to increased risk of thrombotic events

Practical Approach to Bleeding Management in CABG

• Implement a multimodal approach with transfusion algorithms, point-of-care testing, and a focused blood conservation strategy to limit transfusions 1
• Consider off-pump CABG techniques to reduce perioperative bleeding and allogeneic blood transfusion when appropriate 1
• For patients on antiplatelet medications:
  • Withhold clopidogrel and ticagrelor for at least 5 days before elective CABG 1
  • Withhold prasugrel for at least 7 days before elective CABG 1
  • Use tranexamic acid rather than desmopressin as the primary hemostatic agent 5

Conclusion

While desmopressin has theoretical benefits for improving platelet function, the evidence does not support its routine use in CABG patients. Tranexamic acid remains the preferred hemostatic agent with stronger evidence for reducing perioperative bleeding in cardiac surgery.