Response to Letters Regarding Article, “Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery: Are We Forfeiting the Benefits of Reduced Hemorrhagic Sequelae?”
Because our initial goal was to generate interest in the hemorrhagic complications caused by the use of clopidogrel in cardiac surgery patients, it was with satisfaction that we read the comments of Poston and van der Linden et al regarding our own contribution to the discussion.1 Both Poston and van der Linden et al propose practicable solutions to deal with the problem. They primarily advocate the perioperative administration of aprotinin as a means of reducing bleeding rates and transfusion requirements in patients exposed to clopidogrel undergoing cardiac surgery. They reach this conclusion based on previously conducted and presented research.2,3
The widespread use of aprotinin, however, is still impeded by many surgeons’ concerns about its cost, associated hypersensitivity reactions, possible thrombotic complications, and end-organ damage.4 Although we agree that aprotinin could be used in selected high-risk patients or in cases of excessive hemorrhage (current practice at our institution), we are hesitant to advocate universal application. Furthermore, evidence in the literature regarding the safety and efficacy of aprotinin in off-pump cardiac surgery is still limited.
Ideally, the best approach would be to delay the administration of clopidogrel until the coronary anatomy is deemed amenable to percutaneous coronary intervention. Otherwise, in elective circumstances, we advocate waiting 5 days before surgery in those patients who have received a loading dose of clopidogrel at the time of catheterization or who have been maintained on a daily regimen.
Dr Kapetanakis has a research grant from MedStar Research Institute. 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.
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.