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ICVTS on-line discussion A

Dept of Cardiothoracic Surgery, Drexel Univ. College of Medicine, Philadelphia, PA 19107, USA

Should clopidogrel be stopped prior to urgent cardiac surgery?

eComment: I agree with the authors [1]. Clopidogrel clearly increases the intraoperative and postoperative bleeding, blood product requirement and risk of reoperation for bleeding or tamponade in the patients who undergo coronary artery bypass grafting. Significant morbidity and mortality can result from postoperative bleeding and subsequent sternal reexploration [2]. Patients undergoing exploration for bleeding also consume considerable resources, including blood products, prolonged intensive care, and longer overall hospital stay [2]. Reexploration of the chest in the patients on clopidogrel usually doesn't have any specific bleeding site but general oozing from surgical sites. If a patient requires emergent or urgent CABG with recent clopidogrel administration, the patients should be notified that he or she has an increased risk of bleeding complications. The action of clopidogrel is irreversible and therefore persists for the entire lifespan of the platelet. Therefore, the American College of Cardiology recommends 5–7 days of cessation of clopidogrel prior to cardiac surgery.

In unstable patients requiring urgent or emergent CABG, surgeons must balance the risk of ischemic event against the risk of postoperative bleeding complications. Clopidogrel is the most common medication prescribed to patients who had previous percutaneous catheter intervention (PCI). Recently, a loading dose of clopidogrel, up to 900 mg, is given to patients with acute coronary syndrome who are anticipating emergent PCI [3]. If these patients undergo emergent surgery, the risk of the postoperative bleeding should be explained to the patient and blood products for transfusion should be prepared.

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1. Kunadian B, Thornley AR, Tanos M, Dunning J. Should clopidogrel be stopped prior to urgent cardiac surgery? Interact CardioVasc Thorac Surg doi:doi:10.1510/icvts.2006.140038.
2. Dacey LJ, Munoz JJ, Baribeau YR, Johnson ER, Lahey SJ, Leavitt BJ, Quinn RD, Nugent WC, Birkmeyer JD, O'Connor GT. Reexploration for hemorrhage following coronary artery bypass grafting: incidence and risk factor. Northern New England Cardiovascular Disease Study Group. Arch Surg 1998; 133:442–7.[Abstract/Free Full Text]
3. Montalescot G, Sideris G, Meuleman C, Bal-dit-Sollier C, Lellouche N, Steg G, Slama M, Milleron O, Collet JP, Patrick Henry, Beygui F. Ludovic Drouet for the ALBION Trial Investigators. A randomized comparison of high clopidogrel loading doses in patients with non-ST-segment elevation acute coronary syndromes: the ALBION (Assessment of the Best Loading Dose of Clopidogrel to Blunt Platelet Activation, Inflammation and Ongoing Necrosis). Trial. J Am Coll Cardiol doi:10.1016/j.jacc.2006.04.090.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hitoshi Hirose Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hirose, H. Search for Related Content PubMed PubMed Citation Articles by Hirose, H. Related Collections Related Article