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Antithrombotic therapy in cardiac surgery
André Vincentelli1, Brigitte Jude, Sylvain Bélisle
1Centre Hospitalier Régional Universitaire de Lille, France.
Insights
Perioperative antithrombotic therapy in cardiac surgery, especially during cardiopulmonary bypass (CPB), requires careful management. Current practices often rely on clinical experience rather than evidence-based guidelines.
Area of Science:
- Cardiovascular Surgery
- Pharmacology
- Thrombosis Management
Background:
- Antithrombotic therapy is critical in cardiac surgery, encompassing procedures with and without cardiopulmonary bypass (CPB).
- Management strategies must address anticoagulation during CPB and antiplatelet therapy post-surgery.
Purpose of the Study:
- To review the perioperative management of antithrombotic therapy in cardiac surgery.
- To examine the specific considerations for cardiopulmonary bypass (CPB) and off-pump surgery.
Main Methods:
- A comprehensive review of English literature from 1975 to 2005.
- Inclusion of international practices in antithrombotic therapy for cardiac surgery.
Main Results:
- Unfractionated heparin (UFH) is standard for anticoagulation during CPB, monitored by point-of-care (POC) tests with empirical target values.
- Antiplatelet therapy is crucial post-coronary artery bypass grafting (CABG) to prevent ischemic events and improve graft patency.
- Post-valvular surgery antithrombotic therapy requires individualized risk assessment; heparin-induced thrombocytopenia is a noted complication.
Conclusions:
- Antithrombotic therapy is integral to cardiac surgery outcomes.
- Evidence-based guidelines are lacking for much of perioperative antithrombotic management, except for antiplatelet use in CABG.
Purpose:
To review the perioperative management of antithrombotic therapy in cardiac surgery, including the management of cardiopulmonary bypass (CPB) and off-pump surgery.
Methods:
A review of the relevant English literature over the period 1975-2005 was undertaken, in addition to a review of international practices in antithrombotic therapy in cardiac surgery.
Principal Findings:
Cardiopulmonary bypass is required in most procedures and makes anticoagulation mandatory. Anticoagulation is, usually, achieved with unfractionnated heparin (UFH). Unfractionated heparin is monitored by point-of-care (POC) testing, such as the activated clotting time or the determination of heparin concentration. The target values of both tests remain empirical, with no clearly validated thresholds. The target value needs to be adjusted according to the POC test, given significant variations between devices and activators. After CABG, the need for antiplatelet therapy is well demonstrated, in order to limit the risk of postoperative death or ischemic events, and improve venous graft patency. Immediately after valvular surgery, antithrombotic therapy should take into account the specific risk carried by each patient and by each prosthetic device. The risk of venous thromboembolism, though poorly defined, is also present in the postoperative period and may require additional attention. Given the frequent exposure to UFH, occurrence of heparin-induced thrombocytopenia is not infrequent in these patients and requires careful individual management.
Conclusions:
Antithrombotic therapy is an essential component of cardiac surgery. Yet, with the exception of antiplatelet agents in CABG patients, antithrombotic therapy is often based on the clinical experience of medical teams more than on an evidence-based assessment of the literature.
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