Yonsei Med J.  2013 Sep;54(5):1119-1126. 10.3349/ymj.2013.54.5.1119.

Optimal Anticoagulation during Off Pump Coronary Artery Bypass in Patients Recently Exposed to Clopidogrel

• Song Y
• Song JW
• Shim JK
• Kwak YL

• KMID: 1793158
• DOI: http://doi.org/10.3349/ymj.2013.54.5.1119

Abstract

PURPOSE
The aim of this study was to find an optimal range of activated clotting time (ACT) during off-pump coronary artery bypass surgery (OPCAB) yielding ischemic protection without the risk of hemorrhagic complications in patients with recent exposure to dual antiplatelet therapy.
MATERIALS AND METHODS
Three hundred and five patients who received aspirin and clopidogrel within 7 days of isolated multi-vessel OPCAB were retrospectively studied. Combined hemorrhagic and ischemic outcome was defined as the occurrence of 1 of the following: significant perioperative bleeding (>30% of estimated blood volume), transfusion of packed red blood cell (pRBC) > or =2 U, or myocardial infarction (MI). This was compared in relation to the tertile distribution of the time-weighted average ACT-212-291 sec (first tertile), 292-334 sec (second tertile), 335-485 sec (third tertile).
RESULTS
The amount of perioperative blood loss was 937+/-313 mL, 1014+/-340 mL, and 1076+/-383 mL, respectively (p=0.022). Significantly more patients in the third tertile developed MI (4%, 4%, and 12%, respectively, p=0.034). The incidence of significant perioperative blood loss and transfusion of pRBC > or =2 U were lower in the first tertile than those of other tertiles without statistical significance. In the multivariate analysis, the first tertile was associated with a 52% risk reduction of combined hemorrhagic and ischemic outcomes (95% confidence interval: 0.25-0.92, p=0.027).
CONCLUSION
A lower degree of anticoagulation with a reduced initial heparin loading dose should be carefully considered for patients undergoing OPCAB who have recently been exposed to clopidogrel.

Keyword

Clopidogrel; heparin; time weighted average activated clotting time; off-pump coronary artery bypass surgery

MeSH Terms

Age Factors
Aged
Anastomosis, Surgical
Blood Loss, Surgical/prevention & control
Blood Transfusion
*Coronary Artery Bypass, Off-Pump
Female
Heparin/administration & dosage/therapeutic use
Humans
Intraoperative Complications
Male
Middle Aged
Multivariate Analysis
Myocardial Infarction/etiology/prevention & control
Perioperative Period
Platelet Aggregation Inhibitors/administration & dosage/*therapeutic use
Premedication
Reference Values
Retrospective Studies
Sex Factors
Ticlopidine/administration & dosage/*analogs & derivatives/therapeutic use
Whole Blood Coagulation Time
Heparin
Platelet Aggregation Inhibitors
Ticlopidine

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