Antithrombotic controversies in off-pump coronary bypass

Effects of preoperative aspirin and clopidogrel therapy on perioperative blood loss and blood transfusion requirements in patients undergoing off-pump coronary artery bypass graft surgery

“…24 Owing to avoidance of cardiopulmonary bypass-induced coagulation abnormalities and its association with lower rate of hemorrhagic sequelae, 25 off-pump CABG may have a role in decreasing postoperative bleeding and its sequelae, thereby eliminating the need to delay surgery in patients exposed to clopidogrel. 14,15 Indeed, there has been a limited number of studies regarding the relationship between recent clopidogrel and aspirin exposure with postoperative blood loss in off-pump CABG, and the results are contradictory. 10,16,17 Recently, there was a study evaluating the effect of preoperative clopidogrel on the incidence of hemostatic re-exploration, requirement for blood product transfusion, morbidity, and mortality in patients undergoing off-pump CABG using a large sample size of patients.…”

“…13 Therefore, it has been proposed as an alternative surgical technique to reduce postoperative bleeding in patients with coronary artery occlusive disease who have recent exposure to antiplatelet therapy. 14,15 Yet, these studies demonstrate conflicting results and were either preliminary or retrospective, lacking statistical power or risk adjustment between the groups. 10,16,17 We therefore evaluated the influence of preoperative combined aspirin and clopidogrel medication on perioperative blood loss and blood transfusion requirements in patients undergoing elective off-pump CABG in a prospective trial.…”

Heparin responsiveness during off-pump coronary artery bypass graft surgery: predictors and clinical implications

“…Based on previous studies, ACTs between 250 and 300 s during OPCAB seem to be acceptable in many institutions [22,24] , and the majority of hospitals administered 150 U/kg heparin at the beginning of graft anastomosis for a target ACT value of approximately 300 s [15] , which is similar to that for PCI. In view of the inflammation and coagulation statuses, OPCAB stands in a unique position because it is still associated with significant inflammatory responses and the activation of the coagulation and fibrinolytic systems following mid-sternotomy and cardiac manipulation, which are more pronounced in OPCAB patients than in patients undergoing PCI [2,25] . Moreover, it has been demonstrated that OPCAB is associated with a postoperative procoagulant state related to increases in prothrombin factor and von Willebrand factor and to transient platelet dysfunction compared to onpump CABG [13,14] .…”

“…Heparin inhibits thrombin generation by binding to antithrombin III (AT-III), and heparin is widely used as an anticoagulant during percutaneous coronary interventions (PCI) and coronary artery bypass graft surgery (CABG) to prevent thromboembolic complications [1][2][3] . However, large variability exits in individual heparin responsiveness [4,5] , and despite the theoretical possibility of increased periprocedural ischemic events associated with reduced heparin responsiveness (HR reduced ), clinical evidence is either contradictory or limited.…”