Impact of clopidogrel in coronary artery bypass grafting
Impact of clopidogrel in coronary artery bypass grafting
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DOI：
10.1016/j.ejcts.2004.03.030
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发表时间：
2004-07-01
影响因子：
3.4
通讯作者：
Carrel, T
中科院分区：
文献类型：
--
作者：
Englberger, L;Faeh, B;Carrel, T
目的：氯吡格雷已成为预防心脏介入治疗，特别是冠状动脉内支架置入术后血栓并发症的标准护理。此外，阿司匹林不耐受患者以及颈动脉和外周血管疾病的患者也越来越多地接受氯吡格雷治疗。在需要紧急手术的氯吡格雷治疗患者中，血小板抑制可能成为止血的一个问题。方法：我们前瞻性地分析了连续505例单纯冠状动脉搭桥术患者的术中和术后转归，并比较了两组患者的术中和术后转归：术前72h氯吡格雷暴露组(n=136)和未暴露氯吡格雷组(n=369)。排除因PTCA失败和心源性休克、相关瓣膜手术、重做冠脉搭桥术而接受紧急手术的患者，以及暴露于额外的血小板IIb/IIIa受体抑制剂的患者。手术前接受阿司匹林和/或肝素治疗的患者不被排除在外。结果：接受氯吡格雷治疗的患者有更高的III或IV级心绞痛发生率(67vs39%，P<；0.01)，48h内接受血管再通的频率更高(41vs14%，P=0.02)，接受支架植入术的频率更高(57vs13%)。接受氯吡格雷治疗的患者在冠状动脉旁路移植术后24 h内胸腔引流显著增加(1485vs780ml，P=0.003)，这些患者还需要更多的血小板和新鲜冰冻血浆的输注。氯吡格雷组因出血而再次探查的总体比率显著高于对照组(5.9vs1.2%，P<；0.01)。开胸前输注血小板对止血效果有一定的保护作用。结论：冠状动脉旁路移植术前3天或更短时间应用氯吡格雷显著增加了术后出血的风险、围手术期输血的需要和再次探查的发生率。手术应该使用标准的肝素化和抗纤溶策略，但在关闭胸腔之前，需要积极纠正血小板功能障碍。(C)2004爱思唯尔B.V.保留所有权利。
Objective: Clopidogrel has become the standard of care to prevent thrombotic complications following cardiological interventions, in particular intracoronary stenting. In addition, patients with aspirin intolerance and those with carotid and peripheral vascular disease are also increasingly treated with clopidogrel. Platelet inhibition may become a concern for hemostasis in patients treated with clopidogrel who need emergency and undelayed surgery. Methods: We prospectively analyzed the intra- and postoperative outcome of 505 consecutive patients who underwent isolated CABG and compared two groups: those with clopidogrel exposure until 72 h prior to surgery (n = 136) with those without exposition to clopidogrel (n = 369). Patients undergoing emergency surgery because of failed PTCA and cardiogenic shock, associated valvular surgery, redo-CABG, and those with additional platelet IIb/IIIa receptor inhibitor exposure were excluded. Patients who received aspirin and/or heparin treatment prior to surgery were not excluded. Results: Patients who received clopidogrel had a higher prevalence of angina class III or IV (67 vs 39%, P < 0.01), received more often revascularization within 48 h (41 vs 14%, P = 0.02), and had received more frequently stenting (57 vs 13%). Chest tube drainage was significantly increased during the first 24 h following CABG in the group of patients who had clopidogrel treatment (1485 vs 780 ml, P = 0.003) These patients also required more transfusion of platelets and fresh frozen plasma. Overall re-exploration rate because of bleeding was significantly higher in the clopidogrel group (5.9 vs 1.2%, P < 0.01). Platelets transfused before chest closure had a beneficial effect on preservation of the hemostasis. Conclusions: Clopidogrel exposure 3 days or less prior to CABG surgery significantly increases the risk of postoperative bleeding, the need for perioperative transfusion and the incidence of re-exploration. Surgery should be performed using standard heparinization and anti-fibrinolytic strategies but aggressive correction of platelets dysfunction is required before chest closure. (C) 2004 Elsevier B.V. All rights reserved.