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Off-pump coronary artery bypass grafting attenuates postoperative bleeding associated with preoperative clopidogrel
Y Joseph Woo1, Todd Grand, Nicholas Valettas
1Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. wooy@upbs.upenn.edu
Insights
Off-pump coronary artery bypass grafting (OPCAB) in patients taking clopidogrel showed improved outcomes with reduced bleeding and equivalent results to those not on the medication. This suggests current clopidogrel administration guidelines may not be necessary for OPCAB.
Area of Science:
- Cardiovascular Surgery
- Pharmacology
Background:
- Clopidogrel is frequently used for acute coronary syndromes and before percutaneous coronary intervention (PCI).
- Surgical revascularization in patients on clopidogrel is associated with increased postoperative bleeding, transfusion needs, and reexploration.
- Off-pump coronary artery bypass grafting (OPCAB) may mitigate bleeding risks in clopidogrel-exposed patients.
Purpose of the Study:
- To evaluate the perioperative outcomes of OPCAB in patients with immediate preoperative clopidogrel exposure.
- To compare outcomes between clopidogrel-exposed OPCAB patients and both clopidogrel-naive OPCAB patients and historical on-pump coronary bypass controls.
Main Methods:
- Retrospective analysis of 78 consecutive OPCAB patients, divided into clopidogrel-exposed (n=15) and control (n=63) groups.
- Statistical comparison of multiple perioperative parameters between the groups.
- Comparison of the clopidogrel OPCAB group with a historical control group of 59 on-pump coronary bypass patients.
Main Results:
- Clopidogrel OPCAB patients exhibited significantly less postoperative bleeding, transfusion requirements, and reexploration compared to historical on-pump controls.
- Outcomes for clopidogrel OPCAB patients were statistically equivalent to those of control OPCAB patients.
- Key perioperative parameters like bleeding, transfusion, and reexploration were favorable in the clopidogrel OPCAB group.
Conclusions:
- OPCAB in patients with immediate preoperative clopidogrel and aspirin administration yields improved outcomes compared to on-pump bypass.
- Outcomes for clopidogrel-exposed OPCAB patients are equivalent to those not exposed to clopidogrel.
- Standard recommendations for clopidogrel management, such as delaying surgery or platelet transfusion, may not be necessary for OPCAB procedures.
Background:
Clopidogrel is being increasingly administered as primary therapy for acute coronary syndromes and prior to planned percutaneous coronary intervention (PCI). In these settings, surgical revascularization results in signifi- cantly increased postoperative bleeding, transfusion, and reexploration. Off-pump coronary artery bypass grafting (OPCAB) may decrease the extent of postoperative bleeding in patients exposed to clopidogrel.
Methods:
The cases of 78 consecutive patients undergoing OPCAB by a single surgeon were retrospectively analyzed, and the patients were divided into 2 groups, those with immediately preoperative clopidogrel exposure (clopidogrel OPCAB, n = 15) and those without (control OPCAB, n = 63). Multiple perioperative parameters were statistically compared. The clopidogrel OPCAB group also was compared with a group of previously described on-pump coronary bypass patients who made up a historical control group (n = 59).
Results:
Postoperative bleeding, transfusion requirements, reexploration rates, duration of mechanical ventilation, and length of stay were markedly less for clopidogrel OPCAB patients than for historical controls and were statistically equivalent to those of control OPCAB patients.
Conclusion:
Among these 15 OPCAB patients with immediately preoperative administration of clopidogrel and aspirin, outcome was improved compared with published results for on-pump coronary bypass patients and was equivalent to results among OPCAB patients not exposed to clopidogrel. Published, recommended approaches to clopidogrel administration, such as avoidance of pre-PCI clopidogrel, delay of surgery, and platelet transfusion do not appear to be necessary with OPCAB.
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