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

Shim, Jæ Kwang; Choi, Yong Seon; Oh, Young Jun; Bang, Sou Ouk; Yoo, Koo Han; Kwak, Young Lan

doi:10.1016/j.jtcvs.2007.03.013

Cited by 57 publications

(29 citation statements)

References 31 publications

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“…7-9 Indeed, OPCAB has been safely performed without an increased risk of transfusion requirement in patients with recent exposure to clopidogrel. 25 Thus, an increased number of patients has continued antiplatelet agent therapy before OPCAB, notwithstanding the guideline recommending discontinuation of antiplatelet agents at least 5 days before surgery. 4 Although the pharmacokinetic properties of HES 130/0.4 produced minimal disturbances in hemostasis, hemodilution per se causes lower platelet availability, which may pose the additional risk of increased bleeding in patients in need of continued antiplatelet therapy perioperatively.…”

Section: Discussionmentioning

confidence: 99%

Effect of Hydroxyethyl Starch 130/0.4 on Blood Loss and Coagulation in Patients With Recent Exposure to Dual Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Graft Surgery

Lee

Ahn

Song

et al. 2011

Circ J

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Background: Hydroxyethyl starch (HES) solutions are often used for maintaining intravascular volume and improving microperfusion, while a large amount of HES can cause adverse effects on coagulation. As the indications for clopidogrel expand, an increasing number of patients undergoing off-pump coronary artery bypass surgery (OPCAB) are also undergoing dual antiplatelet therapy (DAPT), with its higher risk of bleeding complications. The aim of the present study was to determine whether a moderate dose of 6% HES 130/0.4 significantly increases perioperative blood loss in patients with continued DAPT within 5 days of OPCAB. Methods and Results:Patients who received clopidogrel and aspirin within 5 days of OPCAB were randomly allocated to receive HES 130/0.4 (≤30 ml/kg) followed by crystalloid infusion (HES group, n=53), or crystalloid only (crystalloid group, n=53) perioperatively. The amount of perioperative blood loss (sum of bleeding during the intraoperative and postoperative 24-h period), transfusion requirements, modified thromboelastography and coagulation variables, hemodynamic parameters, and fluid balance were recorded. Perioperative blood loss and coagulation profiles were similar between the groups, but the postoperative hemoglobin level was higher in the crystalloid group.Conclusions: Up to 30 ml · kg -1 · day -1 of 6% HES 130/0.4 did not increase the perioperative blood loss compared to crystalloid in patients with recent exposure to DAPT undergoing OPCAB. HES 130/0.4 caused a similar degree and duration of coagulation impairment as observed when only crystalloid was given. (Circ J 2011; 75: 2397 - 2402

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Section: Discussionmentioning

confidence: 99%

Effect of Hydroxyethyl Starch 130/0.4 on Blood Loss and Coagulation in Patients With Recent Exposure to Dual Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Graft Surgery

Lee

Ahn

Song

et al. 2011

Circ J

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“…2 In contrast to many previous reports, we recently found that preoperative clopidogrel and aspirin exposure did not increase perioperative blood loss and blood transfusion requirements in patients undergoing elective OPCAB. 18 Almost all cardiac surgeons may be concerned about clopidogrel-induced hemorrhagic complications, especially in patients who need urgent or emergency surgery due to acute coronary syndrome. One study found that, in patients with acute coronary syndrome necessitating urgent surgical revascularization, failure to stop clopidogrel at least 7 days before surgery resulted in unacceptable rates of transfusion and reexploration for bleeding, regardless of whether on-or off-pump surgery was used.…”

Section: Discussionmentioning

confidence: 99%

“…Our colleagues recently reported favorable outcomes of the continuous use of clopidogrel in patients undergoing elective surgery for isolated OPCAB, but that study excluded patients with acute coronary syndrome. 18 Consequently, the present study was conducted to ascertain the effect of preoperative continuous administration of clopidogrel and aspirin on the incidence of reexploration as a result of hemorrhage, perioperative transfusion requirements, morbidity and mortality in patients undergoing OPCAB, especially due to acute coronary syndrome.…”

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confidence: 99%

Effects of Continuous Administration of Clopidogrel Before Off-Pump Coronary Artery Bypass Grafting in Patients With Acute Coronary Syndrome A Propensity Score Analysis

Song

Youn

et al. 2007

Circ J

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Background Clopidogrel has become standard treatment after urgent percutaneous coronary revascularization. Due to its enhanced and irreversible platelet inhibition, patients undergoing urgent surgical revascularization have a higher risk of bleeding complications and transfusions. Therefore, the effect of preoperative continuous administration of clopidogrel on the incidence of hemorrhagic complications in patients undergoing off-pump coronary artery bypass surgery with acute coronary syndrome was evaluated. Methods and ResultsFrom March 2004 to September 2006, 172 patients with acute coronary syndrome underwent isolated off-pump coronary artery bypass surgery; 70 (40.7%) and 102 (59.3%) of these patients did or did not take clopidogrel before surgery respectively. Seventy patients in each group were matched using propensity scores and associations between preoperative continuous administration of clopidogrel and postoperative bleeding, hemostatic reoperation, blood products received, the need for multiple transfusions and early graft patency by coronary computed tomography were assessed. Univariate analysis showed the continuous clopidogrel group had similar levels of postoperative bleeding for 24 h (601.4±312.6 ml vs 637.2±452.4 ml, p=0.616) and rates of reexploration (1.4% vs 1.4%), perioperative blood transfusion (33.3% vs 34.3%, p>0.05) and platelet transfusion (2.9% vs 7.1%, p=0.44) compared with the non-continuous group. Conclusions Preoperative continuous administration of clopidogrel did not increase the risk of hemorrhagic complications in patients with acute coronary syndrome undergoing isolated off-pump coronary artery bypass surgery. These findings indicate that surgery after clopidogrel treatment in patients with acute coronary syndrome should not be delayed until platelet function returns to normal because they may have a higher risk of recurrent myocardial ischemic events. (Circ J 2008; 72: 626 -632)

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“…(Shim et al 2007) Other data, however, document a 5-fold increase in reexploration for bleeding and a a b 2.5-fold increase in platelet administration in OPCAB patients receiving clopidogrel prior to surgery. (Kapetanakis et al 2006) Nevertheless, OPCAB was not an option in our patients since concomitant on-pump surgery was required.…”

Section: Discussionmentioning

confidence: 99%

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

Ailawadi

Kern

Peeler

et al. 2007

Clinical medicine. Cardiology

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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...

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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

Abstract: Preoperative clopidogrel and aspirin exposure even within 2 days of surgery does not increase perioperative blood loss and blood transfusion requirements in patients undergoing elective off-pump coronary artery bypass grafting.

Cited by 57 publications

References 31 publications

Effect of Hydroxyethyl Starch 130/0.4 on Blood Loss and Coagulation in Patients With Recent Exposure to Dual Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Graft Surgery

Effect of Hydroxyethyl Starch 130/0.4 on Blood Loss and Coagulation in Patients With Recent Exposure to Dual Antiplatelet Therapy Undergoing Off-Pump Coronary Artery Bypass Graft Surgery

Effects of Continuous Administration of Clopidogrel Before Off-Pump Coronary Artery Bypass Grafting in Patients With Acute Coronary Syndrome A Propensity Score Analysis

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

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