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Eur J Cardiothorac Surg 2004;26:232
© 2004 Elsevier Science NL

Letter to the Editor

Reply to Raja

Hasan Karabulut, Cem Alhan*

Acibadem Hospital, Tekin Sokak No:8, Acibadem, Kadiköy, 34718 stanbul, Turkey

Received 9 April 2004; accepted 13 April 2004.

* Corresponding author. Tel.: +90-216-5444124
e-mail: cemalhan{at}superonline.com

Key Words: Coronary artery bypass grafting • Clopidogrel • Bleeding • Platelet dysfunction

We thank Dr Raja for his comment, and we are very glad that the article by my colleagues and me arouses interest. We fully agree that in case of excessive postoperative chest tube output, aprotinin, desmopressin, and platelet transfusion may reduce or control bleeding. We also agree that the results of our study contradict the expected effect of clopidogrel administration. It is clear that clopidogrel, like aspirin, irreversibly inhibits platelet aggregation for their lifetime. However, the decision to discontinue aspirin preoperatively in patients undergoing coronary artery bypass grafting (CABG) is still controversial. Dacey and colleagues [1], on behalf of the Northern New England Cardiovascular Disease Study Group, have shown that preoperative aspirin use was associated with a decreased risk of mortality in CABG patients without significant increase in hemorrhage, blood product requirements, or related morbidities. It has also been shown that aspirin did not increase bleeding-related complications in either on- [2] or off-pump [3] CABG. Recently, Woo and colleagues [4] reported similar bleeding, transfusion requirements, and reexploration rates in patients exposed to clopidogrel treatment compared to the patients who did not receive clopidogrel before off-pump CABG.

The first few cases in our practice were patients requiring emergent surgery, in whom it was impossible to delay the surgery. The encouraging results of these patients influenced our clinical practice and now, we do not delay surgery in a patient exposed to clopidogrel.

It has been documented that the risk of dying while waiting for CABG is 1.3% per month making a peak in first 2 weeks [5]. It should be always remembered that to minimize the risk of the ‘death on the waiting list’, CABG must be offered within a week after diagnostic coronary angiography, even for ‘elective’ cases.

In an era in which CABG is performed with 1–2% mortality rate, it seems not to be rational to delay the surgery in patients exposed to clopidogrel.

References

  1. Dacey L.J., Munoz J.J., Johnson E.R., Leavitt B.J., Maloney C.T., Morton J.R., Olmstead E.M., Birkmeyer J.D., O'Connor G.T. Effect of preoperative aspirin use on mortality in coronary artery bypass grafting patients. Ann Thorac Surg 2000;70:1986-1990.[Abstract/Free Full Text]
  2. Vuylsteke A., Oduro A., Cardan E., Latimer R.D. Effect of aspirin in coronary artery bypass grafting. J Cardiothorac Vasc Anesth 1997;11:831-834.[CrossRef][Medline]
  3. Srinivasan A.K., Grayson A.D., Pullan D.M., Fabri B.M., Dihmis W.C. Ann Thorac Surg 2003;76:41-45.[Abstract/Free Full Text]
  4. Woo Y.J., Grand T., Valettas N. Off-pump coronary artery bypass grafting attenuates postoperative bleeding associated with preoperative clopidogrel administration. Heart Surg Forum 2003;6:282-285.[Medline]
  5. Silber S., Muhling H., Dorr R., Zindler G., Preuss A., Stumpfl A. Waiting times and death on the waiting list for coronary artery bypass operation. Experiences in Munich with over 1,000 patients. Herz 1996;21:389-396.[Medline]




This Article
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Right arrow Email this article to a friend
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Right arrow Alert me to new issues of the journal
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Right arrow Author home page(s):
Cem Alhan
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Right arrow Articles by Karabulut, H.
Right arrow Articles by Alhan, C.
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PubMed
Right arrow Articles by Karabulut, H.
Right arrow Articles by Alhan, C.
Related Collections
Right arrow Cardiac - pharmacology
Right arrow Coronary disease

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