Cardiac Surgery in Patients with Drug Eluting Stents: The Risk of Stopping Clopidogrel

Abstract

Abstract:Recommendations for the duration of clopidogrel (Plavix ® , Bristol Meyers Squibb, New York, NY) therapy following drug eluting stent (DES) insertion have been subject to recent criticism. Suggested recommendations for the continuation of clopidogrel have been extended to one year following DES insertion. However, patients with a previously inserted DES who now require cardiac surgery are requested to stop clopidogrel perioperatively. The safety of this practice is unclear. We report two cases of elective cardiac surgical intervention after the insertion of DES complicated by perioperative or intraoperative acute coronary ischemia attributed to DES closure.Keywords: clopidogrel, cardiac surgery, coronary artery bypass, coronary disease, stents, thrombosis Clinical Summary Patient 1A 65 year-old male presented with an NSTEMI. On cardiac catheterization, he was found to have threevessel coronary disease (Fig. 1a,b), a 5 cm ascending aortic aneurysm (Fig. 1c), and a normal ejection fraction. Two Cypher ® (Johnson and Johnson, New Brunswick, NJ) DES were inserted in the right coronary and left circumfl ex arteries. The 90% lesion in the left anterior descending (LAD) artery was then determined to be unamenable to percutaneous intervention (Fig. 1b). Due to continued intermittent chest pain, the patient was referred by his cardiologist for surgical intervention one month following DES insertion. Clodiprogel was discontinued fi ve days prior to surgery. No other antiplatelet agent was used in the interim.Ascending aortic aneurysm repair and left-internal-mammary-artery (LIMA) to LAD bypass was performed without incident. Aspirin was initiated on postoperative day one. Clopidogrel therapy (75 mg daily) was reinstituted on postoperative day two. On postoperative day three, the patient acutely deteriorated after noting acute chest pain with ST elevation in the lateral leads. Transthoracic echocardiography demonstrated a hypokinetic lateral wall. Prior to reaching the cardiac catheterization laboratory, the patient sustained a cardiopulmonary arrest and expired. The cause of death was from acute infarction of the lateral wall due to presumed DES thrombosis. Patient 2A 53-year-old male underwent a bioprosthetic aortic valve replacement two years previously at another institution. He was referred to us with dyspnea and found to have severe aortic stenosis (peak gradient = 70 mmHg, mean gradient = 40 mmHg) secondary to prosthetic valve degeneration. A cardiac catheterization performed seven months previously demonstrated left dominant normal coronary system but was complicated by an acute dissection of the circumfl ex and ramus arteries (Fig. 2a). The coronary artery dissection was treated with the insertion of several Taxus ® DES (Boston Scientifi c, Natick, MA, Fig. 2b) with good result.Seven months after DES insertion, the patient underwent a reoperative aortic valve replacement. Clopidogrel had been initiated after DES insertion but was discontinued four days prior to surgery. At the start of the operation, ST d...