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Eur J Cardiothorac Surg 2005;27:177
© 2005 Elsevier Science NL
Letter to the Editor |
Clinic for Cardiovascular Surgery, University Hospital (Inselspital), Berne, Switzerland
Received 26 September 2004; accepted 27 September 2004.
* Corresponding author. Tel.: +41 31 632 2375; fax: +41 31 632 4443. (E-mail: thierry.carrel{at}insel.ch).
Key Words: Clopidogrel • Antiplatelet therapy • Coronary artery bypass grafting • Blood loss • Aprotinin
As Shrivastava and Akowuah note, in our observational study [1] we only recorded clodidogrel use within three days prior to surgery indiscriminately if it was stopped 1, 2 or 3 days prior to surgery. However, onset of action can be expected within hours (especially if a loading dose is administered) and once established in therapy effects are present for the lifespan of platelets. We therefore appreciate the point if the mean time clopidogrel has been stopped before surgery in the no clopidogrel group was less than 7 days. Although this was not recorded for study purpose (which is a limitation) clinical practice allows to suggest that the majority of patients in the no clopidogrel group have had no clopidogrel at all. In both groups a comparable number of patients were on aspirin (37.3% in the clopidogrel group vs. 41.5% in the no clopidogrel group, P=ns).
A recent meta-analysis of randomized clinical trials [2] points out clearly, that concerns about perioperative myocardial infarction (early graft closure) linked to aprotinin use are limited in evidence. This is in accordance to our clinical experience. It has been recognized early that aprotinin is also efficient for the reduction of blood loss after CPB in a low-dose protocol [3]. We use it routinely in the pump-prime dose (two million KIU) also in patients who are not at an increased risk of bleeding supplemented by the high dose protocol in patients are at risk.
As a next point Shrivastava and Akowuah presume a possible bias due to different practice among the surgeons in our unit. However, this can be ruled out by the fact that in the respect of interest (stopping of clopidogrel before surgery) our surgical group is very homogenous. Additionally, the continental system of a surgical unit in a university hospital differs from the consultant-system practiced in UK.
Finally we agree that further clinical trials are welcomed in this field, especially including specific measurements of platelet function. In addition, factors reducing perioperative bleeding complications (e.g. aprotinin and other antifibrinolytics) have to be evaluated for patients operated under ongoing clopidogrel therapy.
References
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