COAGULATION, BLEEDING, AND TRANSFUSION IN URGENT AND EMERGENCY CORONARY SURGERY VALTER CASATI, M.D. DIVISION OF CARDIOVASCULAR ANESTHESIA AND INTENSIVE CARE CLINICA S. GAUDENZIO NOVARA (ITALY)
ANTIPLATELET DRUGS, PCI AND CORONARY SURGERY -ASPIRIN -THIENOPYRIDINE (TICLOPIDINE, CLOPIDOGREL, NEW DRUGS: PRASUGREL) -GpIIb/IIIa INHIBITORS (Abciximab; Eptifibatide;Tirofiban)
ASPIRIN Cyclooxygenase (COX-1) expression (vascular endothelium) COX-1 induces TXA 2 release from stimulated platelets TXA 2 activates TP-receptor on platelet surface membrane, inducing aggregation Aspirin binds to COX-1, inhibiting irreversibly TXA 2 formation
ASPIRIN ACTION Following a single 100 mg dose of aspirin, the ability of whole blood to generate TXA recovers in 2 parallel with the appearance of new platelets and achieves pretreatment levels at 8-10 days.
ASPIRIN CESSATION ACC/AHA Guidelines: 7-10 DAYS BEFORE ELECTIVE CABG -Prolonged wound closure time -Four-fold increase in early operation for bleeding excess -Increased risk for transfusions
ASPIRIN CESSATION STS Recommendation: Cessation of aspirin in purely elective patients without acute coronary syndrome at least 2-3 days before surgery in the expectation that rates of blood transfusion will be reduced
NO ASPIRIN CESSATION ACC/AHA Guidelines: Patients who may have an acute coronary syndrome, and where the benefits of interruption may outweigh risks: -UNSTABLE ANGINA -CRITICAL LEFT MAIN CORONARY DISEASE -SEVERE THREE VESSELS CORONARY DISEASE
CLOPIDOGREL THIENOPYRIDINE WHICH WORKS THROUGH A NON-COMPETITIVE INHIBITION OF THE PLATELET ADP P2Y 12 RECEPTOR, REDUCING PLATELET AGGREGATION
CLOPIDOGREL CESSATION
CLOPIDOGREL IN HIGH RISK PATIENTS Does clopidogrel cause an increase in bleeding complications and their sequelae? Does withholding clopidogrel expose to an increase in thrombotic complications prior to surgery?
CLOPIDOGREL AND URGENT SURGERY Mean increase in blood loss of 30-100% A 2-5 times increase in the need for re-exploration Increase in adverse events (allogeneic transfusions) and intubation time NO differences in hospital length of stay NO differences in mortality
CLOPIDOGREL CESSATION
CLOPIDOGREL CESSATION PCI-CURE STUDY The mean wait for PCI was 6 days The incidence of a myocardial infarction is about 1% lower in patients treated with clopidogrel respect to placebo
CLOPIDOGREL CESSATION
CLOPIDOGREL CESSATION AHA GUIDELINES Patients requiring urgent coronary arterial bypass grafting should have their clopidogrel omitted for 5-7 days prior to their surgery if their clinical condition allows. The benefits in terms of reduction in peri-operative blood loss, reduced risk of re-exploration and reduction of blood product usage is at the expense of a 1% increase in the risk of MI while awaiting surgery
NEW THIENOPYRIDINES
POSITIVE RESULTS OF TRITON-TIMI 38 STUDY Compared to Clopidogrel, Prasugrel (60 mg) induces a lower rate of myocardial infarction and stent thrombosis early, and also after 15 months. -
NEGATIVE RESULTS OF TRITON-TIMI 38 STUDY Major bleeding after urgent CABG surgery about 7 times greater (2.7 vs 18.8%) -
GpIIb/IIIa INHIBITORS EFFECTS ABCIXIMAB: prolonged half-life EPTIFIBATIDE short half-life TIROFIBAN short half-life
GpIIb/IIIa INHIBITORS CESSATION ABCIXIMAB 12 HOURS EPTIFIBATIDE 2 HOURS TIROFIBAN 2 HOURS
OPERATIVE STRATEGIES Off-pump surgery Anti-hemorrhagic drugs Platelet Transfusion
OPCABG Is there a real advantage to perform coronary surgery without cardiopulmonary bypass in patients preoperative treated with anti-platelet drugs?
OPCABG
OPCABG
OPCABG
OPCAB AND ANTI-PLATELET DRUGS -Clopidogrel is associated with an increased risk of peri-operative bleeding even in OPCAB surgery. -The interruption of anti-platelet drugs must follow the same indications as for on-pump surgery
ANTI-HEMORRHAGIC DRUGS -APROTININ -SYNTHETIC ANTI-FIBRINOLYTIC DRUGS (Tranexamic acid, E-aminocaproic acid)
APROTININ Natural derivative product from the bovine lung, which acts through: -Serine protease inhibition -Antifibrinolytic effect -Preservation of the platelet function during CPB
APROTININ
APROTININ
APROTININ
COMPARISON OF TRANEXAMIC ACID AND APROTININ
TRANEXAMIC ACID: OUR EXPERIENCE
CONCLUSIONS (1) The management of patients treated with anti-platelet drugs requires a thorough balance between the risk of major bleeding, and the risk of ischemic myocardial events.
CONCLUSIONS (2) THE ART OF CLINICAL DECISION MAKING HAS NEVER BEEN MORE ESSENTIAL