Pre-operative clopidogrel exposure increases the risk of haemostatic re-operation and the requirements for blood and blood product transfusion during, and after, CABG surgery.

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Because our initial goal was to generate interest in the hemorrhagic complications caused by the use of clopidogrel in cardiac surgery patients, it was with satisfaction that we read the comments of Poston and van der Linden et al regarding our own contribution to the discussion. 1 Both Poston and van der Linden et al propose practicable solutions to deal with the problem. They primarily advocate the perioperative administration of aprotinin as a means of reducing bleeding rates and transfusion requirements in patients exposed to clopidogrel undergoing cardiac surgery. They reach this conclusion based on previously conducted and presented research. 2,3 The widespread use of aprotinin, however, is still impeded by many surgeons' concerns about its cost, associated hypersensitivity reactions, possible thrombotic complications, and endorgan damage. 4 Although we agree that aprotinin could be used in selected high-risk patients or in cases of excessive hemorrhage (current practice at our institution), we are hesitant to advocate universal application. Furthermore, evidence in the literature regarding the safety and efficacy of aprotinin in off-pump cardiac surgery is still limited.Ideally, the best approach would be to delay the administration of clopidogrel until the coronary anatomy is deemed amenable to percutaneous coronary intervention. Otherwise, in elective circumstances, we advocate waiting 5 days before surgery in those patients who have received a loading dose of clopidogrel at the time of catheterization or who have been maintained on a daily regimen. Disclosures

Background-Premedication with clopidogrel has reduced thrombotic complications after percutaneous coronary revascularization procedures. However, because of the enhanced and irreversible platelet inhibition by clopidogrel, patients requiring surgical revascularization have a higher risk of bleeding complications and transfusion requirements. A principal benefit of surgical coronary revascularization without cardiopulmonary bypass is its lower hemorrhagic sequelae. The purpose of this study was to evaluate the effect of preoperative clopidogrel administration in the incidence of hemostatic reexploration, blood product transfusion rates, morbidity, and mortality in patients undergoing off-pump coronary artery bypass graft surgery using a large patient sample and a risk-adjusted approach. Methods and Results-Two

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