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eComment. Is anticoagulation management more significant for patients undergoing off-pump bypass than for those after CABG
eComment. HIT in OPCAB surgery
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Efstratios Apostolakis Cardiothoracic Surgery Department of University Hospital of Patras, 22500 Rion Patras, Greece, Ioanna Koniari
stratisapostolakis{at}yahoo.gr Efstratios Apostolakis, et al.
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Interactive CardioVascular and Thoracic Surgery 2008,
doi:10.1510/icvts.2007.169086B © 2008 European Association of Cardio-Thoracic Surgery Actually, this survey confirms that there is a great variation as far as the strategy for OPCAB operations is concerned between several Cardiothoracic Departments [1]. As a result, the observed inhomogeneous practice regarding anticoagulation protocols, antiplatelet therapy, use of antifibrinolytics and the further lack of guidelines for OPCAB reflects the difficulty of even multi-Center trials to lead to reliable conclusions [2]. Besides, the fact that a cell-server -being a miniature of CPB- is used by 70% of surgeons may explain the report by several studies of comparable results between CABG and OPCAB concerning the incidence of stroke, SIRS, neuro-cognitive disorders, haemorrhage etc. [3]. The fact that 34% of surgeons consider OPCAB as an independent risk factor for the early occlusion of grafts [1], indicates that this surgical method has not yet been proved reliable. Also, it would be interesting to inform us which was the surgical experience (operations/year) of these surgeons. Moreover, the fact that two-thirds (67%) of surgeons support the postoperative administration of antiplatelet agents in combination with low-dose heparine reflects their fear of complications, not only of DVT - whose risk is relatively lower [4], but also the early thrombosis of anastomoses or grafts. In our opinion, anticoagulation therapy plays a more significant role for the patients undergoing OPCAB compared with CABG, where there is a notable decreased coagulation “status” (decreased platelets levels, hemodilution, consumption of coagulation factors, fibrinolysis, preoperative administration of antiplatelet agents and heparine, etc.) [5]. Consequently, the creation of guidelines concerning the optimal perioperative strategy during OPCAB remains an important aim to improve the early and late results. REFERENCES [1]Englberger L, Streich M, Tevaearai HT, Carrel TP. Different anticoagulation strategies in off-pump coronary artery bypass operations: a European survey Interact CardioVasc Thorac Surg, doi:10.1510/icvts.2007.169086. [2]Hansen KH, Hughes P, Steinbruchel DA. Antithrombotic-and anticoagulation regimens in OPCAB surgery. A Nordic survey. Scand Cardiovasc J 2005; 39: 369–374. [3]Racz MJ, Hannan EL, Isom W, Subramanian VA, Jones RH, Gold JP, Ryan TJ, Hartman A, Culliford AT, Bennett E, Lancey RA, Rose EA. A comparison of short- and long-term outcomes after off-pump and on-pump coronary artery bypass surgery with sternotomy. J Am Coll Cardiol 2004; 43: 557–564. [4]Cartier R, Robitaille D. Thrombotic complications in beating heart operations. J Thorac Cardiovasc Surg 2001; 121: 920–922. [5]Wheatley D: The complications of coronary surgery. In: Wheatley D (Ed):Surgery of Coronary Artery Disease, Arnold London, 2003, p. 237-238. |
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Karsten Knobloch Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover 30625, Germany, Andreas Gohritz, Marcus Spies, Peter M. Vogt
kknobi{at}yahoo.com Karsten Knobloch, et al.
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Interactive CardioVascular and Thoracic Surgery 2008,
doi:10.1510/icvts.2007.169086A © 2008 European Association of Cardio-Thoracic Surgery Given the fact that 78% of the respondent surgeons use low or high molecular weight heparin for perioperative prophylaxis of thrombosis, potential adverse effects of heparin should be considered [1]. As such, thrombocytopenia is a common problem in cardiovascular patients, and heparin-induced thrombocytopenia (HIT) is therefore frequently suspected following cardiac surgery. Currently, is it not clear whether OPCAB surgery is associated with the same or a different incidence of HIT I or HIT II in contrast to on-pump cardiac surgery. It has been suggested that both functional (platelet activation tests) and immunologic assays (antigen assays) are necessary in every patient to establish the diagnosis of HIT. Screening with thromboelastography has been proposed recently [2]. The prevalence of heparin/platelet factor 4 antibodies is currently under investigation. As far as cardiac surgery is concerned, the high prevalence of antibodies to the heparin/PF4 complex after cardiac surgery and the low rate of thromboembolic complications in this population suggest that the antibody alone does not confer an increased risk of thrombotic complications [3]. This is supported by a recent retrospective analysis [4]. The authors concluded that postoperative platelet count fall between days 5 and 10 increases diagnostic specificity for HIT, irrespective of whether this platelet count fall occurs after postoperative platelet count recovery or is superimposed upon persisting postoperative thrombocytopenia. A recent survey among 487 cardiac surgery patients with postoperative thrombocytopenia (50% drop in platelet count or absolute count < 100,000/µl) at least one enzyme-linked immunosorbent assay for HIT platelet factor 4 antibodies was performed [5]. Postoperative infections occurred more frequently in HIT+ patients, including sepsis and pneumonia. The HIT+ patients also had a higher rate of renal failure requiring hemodialysis and acute limb ischemia. Thirty-day mortality was significantly higher in the HIT+ group (24.8% versus 15.2%, p = 0.019). Postoperative HIT emerged as an independent predictor of renal failure (OR = 1.73, p < 0.001) and thromboembolic complications (OR = 2.39, p = 0.02). In conclusion, greater awareness of the potential devastating sequelae may allow earlier detection of HIT in OPCAB as well as in on-pump cardiac surgery. References [1] Englberger L, Streich M, Tevaearai HT, Carrel TP. Different anticoagulation strategies in off-pump coronary artery bypass operations: a European survey. Interact Cardiovasc Thorac Surg, doi:10.1510/icvts.2007.169086. [2] Kouerinis IA, Kourtesis A, El-Ali M, Sergentanis T, Plagou A, Argiriou M, Theakos N, Giannakopoulou A. Heparin induced thrombocytopenia diagnosis in cardiac surgery: is there a role for thromboelastography? Interact Cardiovasc Thorac Surg, doi:10.1510/icvts.2007.161679. [3] Everett BM, Yeh R, Foo SY, Criss D, Van Cott EM, Laposata M, Avery EG, Hoffman WD, Walker J, Torchiana D, Jang IK. Prevalence of heparin/platelet factor 4 antibodies before and after cardiac surgery. Ann Thorac Surg 2007;83:592-7. [4] Selleng S, Selleng K, Wollert HG, Muellejans B, Lietz T, Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia in patients requiring prolonged intensive care unit treatment after cardiopulmonary bypass. J Thromb Haemost. 2008 Mar;6(3):428-35. [5] Kerendi F, Thourani VH, Puskas JD, Kilgo PD, Osgood M, Guyton RA, Lattouf OM. Impact of heparin-induced thrombocytopenia on postoperative outcomes after cardiac surgery. Ann Thorac Surg 2007;84:1548-53. |
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