The Effect of Hemoperfusion on Bleeding after CABG in Patients on Preoperative Plavix: A Pilot Study
-
Alireza Jahangirifard
,
Mandana Hossein Zadeh
,
Seyed Bashir Mirtajani
,
Hamid Jamali Taraei
,
Farzad Salari
,
Mohammad Hossein Mandegar
Abstract
Background: Bleeding management during and after urgent heart surgery is always challenging in patients who are taken anticoagulants especially antiplatelet ones. The present study was conducted with the aim of investigating the role of intraoperative hemoperfusion in the active removal of Plavix in patients undergoing on-pump CABG surgery.
Methods: The present study recruited patients on Plavix who underwent urgent CABG surgery. All patients have discontinued consuming Plavix less than 36 hours before surgery. During cardiopulmonary bypass, hemoperfusion set was added to the circuit and the surgery was done according to the standard open heart surgery protocols. The patients were transferred to the intensive care unit at the end of surgery and amount of bleeding was recorded in the ICU sheet hourly and calculated after 24 hours.
Results: In our study, the average age of participating patients was 73,625 years. 5 patients out of 8 (62.5%) were male and 3 (37.5%) were female. Hypertension and blood type O were the most prevalent among the patients. The average amount of bleeding was 425 in the first day after surgery and the average units of transfused blood for patients was 0.125, which is acceptable and less than the values reported in other studies that do not use the hemoperfusion.
Conclusion: The use of hemoperfusion during urgent CABG surgery, can reduce the postoperative bleeding and blood products consumption in patients on preoperative Plavix.
[1] Capodanno D, Angiolillo DJ. Management of antiplatelet therapy in patients with coronary artery disease requiring cardiac and noncardiac surgery. Circulation. 2013; 128(25):2785-98.
[2] Savonitto S, Caracciolo M, Cattaneo M, De Servi S. Management of patients with recently implanted coronary stents on dual antiplatelet therapy who need to undergo major surgery. J Thromb Haemost. 2011; 9(11):2133-42.
[3] Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation. 2016;134(10):e123-55.
[4] Ghantous AE, Ferneini EM. Aspirin, plavix, and other antiplatelet medications: what the oral and maxillofacial surgeon needs to know. Oral Maxillofac Surg Clin North Am. 2016; 28(4):497-506.
[5] Brackbill ML, Kidd RS, Abdoo AD, Warner JG, Harralson AF. Frequency of CYP3A4, CYP3A5, CYP2C9, and CYP2C19 variant alleles in patients receiving clopidogrel that experience repeat acute coronary syndrome. Heart Vessels. 2009; 24:73-8.
[6] Braunwald E. Unstable angina and non–ST elevation myocardial infarction. Am J Respir Crit Care Med. 2012; 185(9):924-32.
[7] Basra SS, Virani SS, Paniagua D, Kar B, Jneid H. Acute Coronary Syndromes: Unstable Angina and Non-ST Elevation Myocardial Infarction. Heart Fail Clin. 2016; 12(1):31-48.
[8] Nakata S, Yokoi Y, Matsumoto R, Shirai N, Otsuka R, Sugioka K, et al. Long-term cardiovascular outcomes following ischemic heart disease in patients with and without peripheral vascular disease. Osaka City Med J. 2008; 54(1):21-30.
[9] Feehan J, Hariharan R, Buckenham T, Handley C, Bhatnagar A, Baba SP, et al. Carnosine as a potential therapeutic for the management of peripheral vascular disease. Nutr Metab Cardiovasc Dis. 2022; 32(10):2289-2296.
[10] Besser MW. Post-operative of bleeding, haemolysis and coagulation in mechanical circulatory support patients. Ann Transl Med. 2020; 8(13):832.
[11] Liu MH, Yu H, Zhou RH. Application of adsorptive blood purification techniques during cardiopulmonary bypass in cardiac surgery. Oxidat Med Cell Longev. 2022; 2022:6584631.
[12] Mendes V, Colombier S, Verdy F, Bechtold X, Schlaepfer P, Scala E, et al. CytoSorb® hemoadsorption of apixaban during emergent cardio-pulmonary bypass: a case report. Perfusion. 2021; 36:873–5.
[13] Hassan K, Kannmacher J, Wohlmuth P, Budde U, Schmoeckel M, Geidel S. Cytosorb adsorption during emergency cardiac operations in patients at high risk of bleeding. Ann Thorac Surg. 2019; 108:45–51.
[14] Gao F, Shen H, Wang ZJ, Yang SW, Liu XL, Zhou YJ. Rationale and design of the RT-AF study: combination of rivaroxaban and ticagrelor in patients with atrial fibrillation and coronary artery disease undergoing percutaneous coronary intervention. Contemporary clinical trials. 2015; 43:129-32.
[15] Jackson R, Trus RM, El-Diasty M. Hemadsorption for removal of ticagrelor and direct oral anticoagulants in cardiac surgery. Expert Rev Cardiovasc Ther. 2022; 20(2):141-150.
[16] Mair H, Jilek C, Haas B, Lamm P. Ticagrelor and rivaroxaban elimination with CytoSorb adsorber before urgent off-pump coronary bypass. Ann Thorac Surg. 2020; 110(5):e369-70.
[17] Tripathi R, Morales J, Lee V, Gibson CM, Mack MJ, Schneider DJ, et al. Antithrombotic drug removal from whole blood using haemoadsorption with a porous polymer bead sorbent. Eur Heart J Cardiovasc Pharmacother. 2022; 8(8):847-56.
[18] Hassan K, Geidel S, Zamvar V, Tanaka K, Knezevic-Woods Z, Wendt D, et al. Intraoperative ticagrelor removal via hemoadsorption during on-pump coronary artery bypass grafting. JTCVS Open. 2023; 15:190-196.
[19] Jackson R, Trus RM, El-Diasty M. Hemadsorption for removal of ticagrelor and direct oral anticoagulants in cardiac surgery. Expert Rev Cardiovasc Ther. 2022; 20(2):141-150.
[20] Straus S, Haxhibeqiri-Karabdic I, Grabovica SG, Granov N. A difference in bleeding and use of blood and blood products in patients who were preoperatively on aspirin or dual antiplatelet therapy before coronary artery bypass grafting. Medical Archives. 2018; 72(1):31.
[21] Kapetanakis EI, Medlam DA, Boyce SW, Haile E, Hill PC, Dullum MK, et al. Clopidogrel administration prior to coronary artery bypass grafting surgery: the cardiologist's panacea or the surgeon's headache?. Eur Heart J. 2005; 26(6):576-83.
[22] Kim JH, Newby LK, Clare RM, Shaw LK, Lodge AJ, Smith PK, et al. Clopidogrel use and bleeding after coronary artery bypass graft surgery. Am Heart J. 2008; 156(5):886-92.
[23] Kang W, Theman TE, Reed III JF, Stoltzfus J, Weger N. The effect of preoperative clopidogrel on bleeding after coronary artery bypass surgery. J Surg Educ. 2007; 64(2):88-92.
[24] Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to update the 1999 guidelines for coronary artery bypass graft surgery). Circulation. 2004; 110(14):e340-437.
[25] Leong JY, Baker RA, Shah PJ, Cherian VK, Knight JL. Clopidogrel and bleeding after coronary artery bypass graft surgery. Ann Thorac Surg. 2005; 80(3):928-33.
[26] Li C, Hirsh J, Xie C, Johnston MA, Eikelboom JW. Reversal of the anti‐platelet effects of aspirin and clopidogrel. J Thromb Haemost. 2012; 10(4):521-8.
[27] Estcourt LJ, Malouf R, Doree C, Trivella M, Hopewell S, Birchall J. Prophylactic platelet transfusions prior to surgery for people with a low platelet count. Cochrane Database of Systematic Reviews. 2018; 9(9):CD012779.
[2] Savonitto S, Caracciolo M, Cattaneo M, De Servi S. Management of patients with recently implanted coronary stents on dual antiplatelet therapy who need to undergo major surgery. J Thromb Haemost. 2011; 9(11):2133-42.
[3] Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation. 2016;134(10):e123-55.
[4] Ghantous AE, Ferneini EM. Aspirin, plavix, and other antiplatelet medications: what the oral and maxillofacial surgeon needs to know. Oral Maxillofac Surg Clin North Am. 2016; 28(4):497-506.
[5] Brackbill ML, Kidd RS, Abdoo AD, Warner JG, Harralson AF. Frequency of CYP3A4, CYP3A5, CYP2C9, and CYP2C19 variant alleles in patients receiving clopidogrel that experience repeat acute coronary syndrome. Heart Vessels. 2009; 24:73-8.
[6] Braunwald E. Unstable angina and non–ST elevation myocardial infarction. Am J Respir Crit Care Med. 2012; 185(9):924-32.
[7] Basra SS, Virani SS, Paniagua D, Kar B, Jneid H. Acute Coronary Syndromes: Unstable Angina and Non-ST Elevation Myocardial Infarction. Heart Fail Clin. 2016; 12(1):31-48.
[8] Nakata S, Yokoi Y, Matsumoto R, Shirai N, Otsuka R, Sugioka K, et al. Long-term cardiovascular outcomes following ischemic heart disease in patients with and without peripheral vascular disease. Osaka City Med J. 2008; 54(1):21-30.
[9] Feehan J, Hariharan R, Buckenham T, Handley C, Bhatnagar A, Baba SP, et al. Carnosine as a potential therapeutic for the management of peripheral vascular disease. Nutr Metab Cardiovasc Dis. 2022; 32(10):2289-2296.
[10] Besser MW. Post-operative of bleeding, haemolysis and coagulation in mechanical circulatory support patients. Ann Transl Med. 2020; 8(13):832.
[11] Liu MH, Yu H, Zhou RH. Application of adsorptive blood purification techniques during cardiopulmonary bypass in cardiac surgery. Oxidat Med Cell Longev. 2022; 2022:6584631.
[12] Mendes V, Colombier S, Verdy F, Bechtold X, Schlaepfer P, Scala E, et al. CytoSorb® hemoadsorption of apixaban during emergent cardio-pulmonary bypass: a case report. Perfusion. 2021; 36:873–5.
[13] Hassan K, Kannmacher J, Wohlmuth P, Budde U, Schmoeckel M, Geidel S. Cytosorb adsorption during emergency cardiac operations in patients at high risk of bleeding. Ann Thorac Surg. 2019; 108:45–51.
[14] Gao F, Shen H, Wang ZJ, Yang SW, Liu XL, Zhou YJ. Rationale and design of the RT-AF study: combination of rivaroxaban and ticagrelor in patients with atrial fibrillation and coronary artery disease undergoing percutaneous coronary intervention. Contemporary clinical trials. 2015; 43:129-32.
[15] Jackson R, Trus RM, El-Diasty M. Hemadsorption for removal of ticagrelor and direct oral anticoagulants in cardiac surgery. Expert Rev Cardiovasc Ther. 2022; 20(2):141-150.
[16] Mair H, Jilek C, Haas B, Lamm P. Ticagrelor and rivaroxaban elimination with CytoSorb adsorber before urgent off-pump coronary bypass. Ann Thorac Surg. 2020; 110(5):e369-70.
[17] Tripathi R, Morales J, Lee V, Gibson CM, Mack MJ, Schneider DJ, et al. Antithrombotic drug removal from whole blood using haemoadsorption with a porous polymer bead sorbent. Eur Heart J Cardiovasc Pharmacother. 2022; 8(8):847-56.
[18] Hassan K, Geidel S, Zamvar V, Tanaka K, Knezevic-Woods Z, Wendt D, et al. Intraoperative ticagrelor removal via hemoadsorption during on-pump coronary artery bypass grafting. JTCVS Open. 2023; 15:190-196.
[19] Jackson R, Trus RM, El-Diasty M. Hemadsorption for removal of ticagrelor and direct oral anticoagulants in cardiac surgery. Expert Rev Cardiovasc Ther. 2022; 20(2):141-150.
[20] Straus S, Haxhibeqiri-Karabdic I, Grabovica SG, Granov N. A difference in bleeding and use of blood and blood products in patients who were preoperatively on aspirin or dual antiplatelet therapy before coronary artery bypass grafting. Medical Archives. 2018; 72(1):31.
[21] Kapetanakis EI, Medlam DA, Boyce SW, Haile E, Hill PC, Dullum MK, et al. Clopidogrel administration prior to coronary artery bypass grafting surgery: the cardiologist's panacea or the surgeon's headache?. Eur Heart J. 2005; 26(6):576-83.
[22] Kim JH, Newby LK, Clare RM, Shaw LK, Lodge AJ, Smith PK, et al. Clopidogrel use and bleeding after coronary artery bypass graft surgery. Am Heart J. 2008; 156(5):886-92.
[23] Kang W, Theman TE, Reed III JF, Stoltzfus J, Weger N. The effect of preoperative clopidogrel on bleeding after coronary artery bypass surgery. J Surg Educ. 2007; 64(2):88-92.
[24] Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to update the 1999 guidelines for coronary artery bypass graft surgery). Circulation. 2004; 110(14):e340-437.
[25] Leong JY, Baker RA, Shah PJ, Cherian VK, Knight JL. Clopidogrel and bleeding after coronary artery bypass graft surgery. Ann Thorac Surg. 2005; 80(3):928-33.
[26] Li C, Hirsh J, Xie C, Johnston MA, Eikelboom JW. Reversal of the anti‐platelet effects of aspirin and clopidogrel. J Thromb Haemost. 2012; 10(4):521-8.
[27] Estcourt LJ, Malouf R, Doree C, Trivella M, Hopewell S, Birchall J. Prophylactic platelet transfusions prior to surgery for people with a low platelet count. Cochrane Database of Systematic Reviews. 2018; 9(9):CD012779.
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How to Cite
1.
Jahangirifard A, Hossein Zadeh M, Mirtajani S, Jamali Taraei H, Salari F, Mandegar MH. The Effect of Hemoperfusion on Bleeding after CABG in Patients on Preoperative Plavix: A Pilot Study. Arch Anesth & Crit Care. 2024;.
