Emmanouil I. Kapetanakis

Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery Are We Forfeiting the Benefits of Reduced Hemorrhagic Sequelae?

Background— Premedication with clopidogrel has reduced thrombotic complications after percutaneous coronary revascularization procedures. However, because of the enhanced and irreversible platelet inhibition by clopidogrel, patients requiring surgical revascularization have a higher risk of bleeding complications and transfusion requirements. A principal benefit of surgical coronary revascularization without cardiopulmonary bypass is its lower hemorrhagic sequelae. The purpose of this study was to evaluate the effect of preoperative clopidogrel administration in the incidence of hemostatic reexploration, blood product transfusion rates, morbidity, and mortality in patients undergoing off-pump coronary artery bypass graft surgery using a large patient sample and a risk-adjusted approach. Methods and Results— Two hundred eighty-one patients (17.9%) did and 1291 (82.1%) did not receive clopidogrel before their surgery, for a total of 1572 patients undergoing isolated off-pump coronary artery bypass graft surgery between January 2000 and June 2002. Risk-adjusted logistic regression analyses and a matched pair analyses by propensity scores were used to assess the association between clopidogrel administration and reoperation as a result of bleeding, intraoperative and postoperative blood transfusions received, and the need for multiple transfusions. Hemorrhage-related preoperative risk factors identified in the literature and those found significant in a univariate model were used. The clopidogrel group had a higher likelihood of hemostatic reoperations (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.47 to 10.47; P<0.01) and an increased need in overall packed red blood cell (OR, 2.6; 95% CI, 1.94 to 3.60; P<0.01), multiple unit (OR, 1.6; 95% CI, 1.07 to 2.48; P=0.02), and platelet (OR, 2.5; 95% CI, 1.77 to 3.66; P<0.01) transfusions. Surgical outcomes and operative mortality (1.4% versus 1.4%; P=1.00) were not statistically different. Conclusions— Clopidogrel administration in the cardiology suite increases the risk for hemostatic reoperation and the requirements for blood product transfusions during and after off-pump coronary artery bypass graft surgery.

Allogeneic blood transfusion requirements after minimally invasive versus conventional aortic valve replacement: a risk-Adjusted analysis

BACKGROUND Aortic valve replacement (AVR) through a partial sternotomy (mini-AVR) has been suggested to significantly reduce postoperative morbidity compared with conventional AVR. This study sought to investigate whether mini-AVR patients require fewer transfusions than patients who had conventional AVR. METHODS Of 511 patients who had AVR, 56 had mini-AVR and 455 had conventional AVR. A matched-case logistic regression analysis was used to adjust for these imbalances between groups. RESULTS No patient in the mini-AVR cohort required conversion to a conventional AVR. Cardiopulmonary bypass time was longer in the mini-AVR group compared with the conventional AVR group, with a median of 102 minutes (range, 78 to 119 minutes) versus 75 minutes (range, 61 to 96 minutes; p < 0.01) in the conventional AVR group. A total of 31 patients (55%) in the mini-AVR group and 336 patients (74%) in the conventional sternotomy group required transfusions during their hospital stay (p < 0.01). After adjusting for differences in preoperative risk factors, year of operation, and surgeon, by matching on propensity score, the differences were not statistically significant (odds ratio = 0.84, 95% confidence interval = 0.40 to 1.75, p = 0.63). CONCLUSIONS Mini-AVR produces better wound cosmesis and less surgical trauma but requires more time to perform. Matched-case analysis failed to show a significant difference in blood transfusion requirements after mini-AVR compared with the conventional AVR approach.

Inhaled iloprost in eight heart transplant recipients presenting with post‐bypass acute right ventricular dysfunction

Background:  During heart transplantation, weaning from cardiopulmonary bypass may be particularly laborious as a result of superimposed acute right ventricular dysfunction in the setting of pre‐existing pulmonary hypertension. Research in recent years has focused on inhaled vasodilatory treatment modalities which selectively target the pulmonary circulation.

Comparison of the quality of life after conventional versus off-pump coronary artery bypass surgery.

Abstract  Purpose: Numerous studies have focused on off‐pump coronary artery bypass graft (off‐pump CABG) morbidity and mortality outcomes, but few looked at the patients perception of the technique and its effect on postoperative quality of life (QOL). We investigated and compared postoperative QOL in patients who had undergone either conventional or off‐pump CABG myocardial revascularization. Methods: During a six‐month period, 191 patients who underwent CABG surgery were prospectively studied through preoperative and six‐month postoperative short‐form 36 (SF‐36) general health status surveys. One hundred‐sixteen (60.7%) off‐pump CABG patients and 75 (39.3%) conventional on‐pump CABG patients were enrolled. Results: Sixteen (13.8%) off‐pump patients reported improvement in physical score QOL, 84 (72.4%) reported no change, and 16 (13.8%) reported a decrease. In comparison, 20 (80.0%) patients in the on‐pump CABG group reported an improvement in QOL, 42 (56.0%) were unchanged, and 13 (17.3%) reported deterioration (p = 0.28). For postoperative change in mental score, 19 (16.4%) off‐pump patients reported an improvement, 85 (73.3%) stayed unchanged, and 12 (10.3%) reported a decrease compared with 8 (10.7%) conventional CABG patients reporting improvement, 60 (80.0%) showing no change, and 7 (9.3%), having a score decline (p = 0.52). In multivariate logistic regression analysis, hypertension (odds ratio [OR] 2.2, 95% confidence intervals [CI], 1.08 to 4.40, p = 0.03) and multivessel coronary artery disease (OR 2.1, 95% CI, 1.11 to 4.13, p = 0.02) emerged as independent predictors of worse physical score component score. Diabetes was associated with an improved physical score component score after CABG (OR 0.4, 95% CI, 0.17 to 0.76, p = 0.01), regardless of the surgical approach. Conclusion: This prospective study reveals no significant differences in the expected QOL at six months after either on‐pump or off‐pump CABG. Patients with hypertension and multivessel coronary artery disease were more likely to have worse, while patients with diabetes have improved physical score component scores six months after CABG.

Response to Letters Regarding Article, “Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery: Are We Forfeiting the Benefits of Reduced Hemorrhagic Sequelae?”

Because our initial goal was to generate interest in the hemorrhagic complications caused by the use of clopidogrel in cardiac surgery patients, it was with satisfaction that we read the comments of Poston and van der Linden et al regarding our own contribution to the discussion.1 Both Poston and …