Letter by van der Linden et al Regarding Article, “Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery: Are We Forfeiting the Benefits of Reduced Hemorrhagic Sequelae?”
To the Editor:
We read with great interest the study by Kapetanakis et al,1 which confirmed that clopidogrel administration increased the risk for hemostatic reexploration and also increased transfusion rates during and after off-pump coronary surgery. They and several other groups have previously reported similar results in patients on clopidogrel undergoing on-pump coronary surgery. The present recommendation in the accompanying editorial2 is in line with the American College of Cardiology/American Heart Association 2004 guideline update for coronary artery bypass graft surgery3. “If clinical circumstances permit, clopidogrel should be withheld for 5 days before performance of [coronary artery bypass graft] surgery” (p e394). In an earlier study by Kapetanakis et al (as well as in their present study1), approximately 18% of the patients undergoing coronary surgery were treated with clopidogrel. Further, recent data indicate that up to 5% of all patients presenting for coronary surgery4 may require urgent or immediate coronary artery bypass grafting after clopidogrel administration, and delaying surgery for the return of platelet function may not even be an option.
Intraoperative administration of aprotinin in patients on clopidogrel undergoing coronary surgery reduces bleeding and the number of transfusions, however, as we have demonstrated in a randomized controlled clinical trial.5 Thus, we agree that patients on clopidogrel who are scheduled for coronary surgery should have their operation postponed for a minimum of 5 days if possible. However, fairly often, surgery cannot be delayed; in these cases, intraoperative aprotinin will reduce blood loss and transfusion requirements after coronary surgery.
Dr van der Linden has received an unrestricted research grant from Bayer Sweden. The other authors report no conflicts.
Kapetanakis EI, Medlam DA, Petro KR, Haile E, Hill PC, Dullum MKC, Bafi AS, Boyce SW, Corso PJ. Effect of clopidogrel premedication in off-pump cardiac surgery: are we forfeiting the benefits of reduced hemorrhagic sequelae? Circulation. 2006; 113: 1667–1674.
Bavry AA, Lincoff AM. Is clopidogrel cardiovascular medicine’s double-edged sword? Circulation. 2006; 113: 1638–1640.
Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, Hart JC, Herrmann HC, Hillis LD, Hutter AM Jr., Lytle BW, Marlow RA, Nugent WC, Orszulak TA. 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: e340–e437.
van der Linden J, Lindvall G, Sartipy U. Aprotinin decreases postoperative bleeding and number of transfusions in patients on clopidogrel undergoing coronary artery bypass graft surgery: a double-blind, placebo-controlled, randomized clinical trial. Circulation. 2005; 112 (suppl I): I-276–I-280.