Postoperative blood loss in patients undergoing coronary artery bypass surgery after preoperative treatment with clopidogrel. A prospective randomised controlled study.
ABSTRACT The optimal timing for discontinuation of clopidogrel before surgery remains under debate. The purpose of this study is to determine the effect of preoperative clopidogrel administration on postoperative blood loss and the total requirements of homologous blood products after coronary artery bypass grafting (CABG). We also evaluated the perioperative complications.
Consecutive patients (n=130) undergoing elective CABG were recruited and randomised between 2006 and 2007. In 38 patients (group 1), treatment with clopidogrel was discontinued 5 days prior to surgery, in 40 patients (group 2) 3 days before surgery and in 40 other patients (group 3) clopidogrel was stopped on the day of surgery.
Significantly more postoperative blood loss was observed in group 3 compared to group 1 (929+/-472 ml vs 664+/-312 ml; p=0.009). Other group comparisons were not significant. Blood loss after 12 h and at drain removal was also significantly higher in group 3. Patients in group 3 also had higher total requirements of homologous blood products (p=0.046) and a significantly higher need for fresh frozen plasma (FFP) transfusion (p=0.034). Univariable regression analyses revealed that continuing clopidogrel till the day of surgery (group 3) was predictive for postoperative blood loss (beta=0.289; p=0.007) and the total requirements of homologous blood products after surgery (beta=0.280; p=0.008). These effects remained the same in multivariable analyses.
Continuation of clopidogrel until the day of surgery induces significantly more postoperative blood loss and increases significantly the total requirements of homologous blood products and FFP transfusion after surgery. The blood loss and the use of blood products in the group that stopped at 3 days preoperatively were similar to that of the group that stopped at 5 days preoperatively.
- [Show abstract] [Hide abstract]
ABSTRACT: Objective An increasing number of patients present for urgent coronary surgery exposed to clopidogrel which constitutes a risk of bleeding and related events. Based on the wide variability in clopidogrel response and platelet function recovery after cessation, we evaluated the role of point-of-care platelet function testing to define the optimal time for off-pump coronary artery bypass graft (CABG) surgery in a case control study. Methods Three equally matched groups (300 patients in total) undergoing isolated off-pump CABG for acute coronary syndrome were compared. Group A were treated by clopidogrel and prospectively underwent a platelet function testing-guided strategy. Outcomes were compared with two propensity score matched groups: Group B underwent CABG after the currently recommended 5 days clopidogrel cessation; Group C were never exposed to clopidogrel. Results Patients in Group A displayed reduced postoperative bleeding as compared to Group B (523±202 mL vs 851±605mL, p<0.001) and a lower number of packed red blood cells (PRBCs) units transfused during the postoperative hospital stay (1.2±1.6 vs1.9±1.8,p=0.004). Postoperative bleeding and number of PRBCs units transfused were similar in Group A and Group C. There was no difference in blood derivative products and platelet consumption, mortality nor in the need for reoperation among groups. Patients in Group A waited 3.6±1.7 days for surgery. Group A strategy saved 280 days of hospital stay in total. Conclusions The platelet-function-guided strategy for off-pump CABG offers an improved guidance for optimal timing of CABG in patients treated by clopidogrel. This strategy significantly reduces postoperative bleeding, blood consumption and shorter waiting time for surgery than current clinical practice.The Journal of thoracic and cardiovascular surgery 01/2014; · 3.41 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Routine coagulation tests and bleed-scores fail to identify patients at risk of excessive postoperative drainage following coronary artery bypass grafting (CABG). We sought to investigate whether lower von Willebrand factor (VWF) and higher ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) are associated with a high postoperative drainage after CABG. In the prospective cohort study, VWF antigen (VWF:Ag), VWF ristocetin cofactor (VWF:RCO), VWF collagen-binding (VWF:CB), ADAMTS13 antigen (ADAMTS13:Ag) and ADAMTS13 activity were measured on the day of elective on-pump CABG in 232 consecutive patients without a prior history of haemorrhagic diathesis, including von Willebrand disease (95% discontinued aspirin preoperatively). Postoperative drainage and blood product use were recorded. A comparison of extreme drainage quartiles (n = 56) showed that individuals with the highest drainage volumes have mean VWF:RCO lower by 19% (P < 0.0001), median VWF:Ag lower by 19% (P < 0.0001), ADAMTS13:Ag higher by 8% (P = 0.0002), ADAMTS13 activity higher by 9% (P = 0.01) and fibrinogen lower by 14% (P = 0.03) than those with the lowest drainage. Linear regression analysis showed that preoperative VWF:RCO (b = -4.83, P = 0.002) and fibrinogen (b = -61.52, P = 0.04) are the only independent predictors of postoperative drainage. Multivariate logistic regression demonstrated that preoperative VWF:RCO in the lowest quartile and ADAMTS13:Ag levels in the highest quartile increased the risk of high (≥1000 ml) drainage (odds ratio [95% confidence interval] = 4.88 [1.83-13.02], P = 0.001 and 3.77 [1.49-9.52], P = 0.005; respectively). Patients undergoing elective CABG with lower preoperative VWF:RCO are at risk of having larger postoperative drainage, which suggests a novel contributor to increased perioperative bleeding in cardiac surgery.European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 12/2013; · 2.40 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Clopidogrel is a commonly used anti-platelet medication in patients with cardiovascular disorders. The safety of thoracentesis and small-bore chest tube placement in patients taking clopidogrel is not well established. We conducted a prospective study to assess the risk of hemothorax in patients on clopidogrel undergoing the pleural procedures. Twenty-five consecutive patients taking clopidogrel undergoing thoracentesis or small-bore (14 Fr) chest tube placement were enrolled. The control group consisted of 50 patients undergoing these pleural procedures who were not on clopidogrel. All the procedures were ultrasound-guided and performed by interventional pulmonologists or fellows under direct supervision. Hemothorax was screened by observing for a drop in hemoglobin by 2 g/dl or re-accumulation of pleural effusion within 24 hours of the procedure for patients admitted in the hospital. The patients who were not admitted were called within 2 weeks to determine if they had any symptoms suggestive of hemothorax. There was one case of hemothorax after thoracentesis in the clopidogrel group versus none in the control group (incidence 4% in clopidogrel group, p-value = 0.15). The patient with hemothorax required 2 units of packed red blood cells transfusion, a small-bore chest tube placement, and clopidogrel was held. No other complications were noted in any patient. It is safe to perform thoracentesis and small-bore chest tube placement in patients on clopidogrel using ultrasound guidance. There is a higher but statistically insignificant risk of hemothorax with clopidogrel use and patients should be informed about it when the consent is obtained.Annals of the American Thoracic Society. 10/2013;