Early clinical outcomes of surgical myocardial revascularization in patients with preoperative platelet dysfunction

Vladimir Stojiljković; Aleksandar  Kamenov; Milan Lazarević; Mladjan Golubović; Velimir Perić; Marija Stošić; Saša Živić; Dragan Milić

doi:10.2298/VSP230306036S

Vladimir Stojiljković University Clinical Center of Niš, Department of Cardiac Surgery, Niš, Serbia
Aleksandar Kamenov University Clinical Center of Niš, Department of Cardiac Surgery, Niš, Serbia
Milan Lazarević University Clinical Center of Niš, Department of Cardiac Surgery, Niš, Serbia; University of Niš, Faculty of Medicine, Niš, Serbia
Mladjan Golubović University Clinical Center of Niš, Department of Cardiac Surgery, Niš, Serbia; University of Niš, Faculty of Medicine, Niš, Serbia
Velimir Perić University Clinical Center of Niš, Department of Cardiac Surgery, Niš, Serbia; University of Niš, Faculty of Medicine, Niš, Serbia
Marija Stošić University Clinical Center of Niš, Department of Cardiac Surgery, Niš, Serbia; University of Niš, Faculty of Medicine, Niš, Serbia
Saša Živić University Clinical Center of Niš, Department of Cardiac Surgery, Niš, Serbia
Dragan Milić University Clinical Center of Niš, Department of Cardiac Surgery, Niš, Serbia; University of Niš, Faculty of Medicine, Niš, Serbia

DOI: https://doi.org/10.2298/VSP230306036S

Keywords: coronary artery bypass, coronary disease, platelet aggregation, platelet aggregation inhibitors, treatment outcome

Abstract

Background/Aim. Coronary artery bypass grafting (CABG) is the treatment of choice for a significant number of patients with ischemic heart disease. Some of the postoperative complications are closely linked with the preoperative antiplatelet therapy (APT). The aim of this study was to compare the early clinical outcomes of CABG in patients with preserved platelet (PLT) function and patients with PLT function impaired by the residual therapeutic effect of APT. Methods. A total of 181 patients with isolated CABG were enrolled in this prospective, nonrandomized, observational study. Patients were divided into four groups: control group (arachidonic acid-dependent PLT aggregation group), with aspirin-induced platelet inhibition (ASPI) test ≥ 790 aggregation units (AU)/min; mild (M) acetylsalicylic acid (ASA) effect (MASAE) group, with ASPI test = 410–789 AU/min; pronounced (P) ASA effect (PASAE) group, with ASPI test ≤ 409 AU/min; dual (D) APT (DAPT) group, with ASPI test ≤ 789 AU/min and adenosine diphosphate (ADP) test ≤ 405 AU/min. Preoperative data, intraoperative characteristics, and postoperative outcomes were obtained and compared between the groups. Results. A significant difference was found regarding the average time of APT cessation between groups (p < 0.001). The DAPT group had a significantly higher frequency of drainage compared to the control (p = 0.004), MASAE (p = 0.001), and PASAE (p = 0.006) groups. The PASAE group had a significantly higher rate of chest reexploration compared to the MASAE group (p = 0.032). The DAPT group required significantly more packed red blood cells (PRBC) compared to the control (p < 0.001) and MASAE (p = 0.009) groups. The PASAE group received significantly more PRBC compared to the control (p < 0.001) and MASAE (p = 0.019) groups. The DAPT group required higher amounts of PLTs compared to the control (p < 0.001), MASAE (p = 0.002), and PASAE (p < 0.001) groups. The DAPT group received higher amounts of cryoprecipitate compared to the control (p = 0.002), MASAE (p = 0.009), and PASAE (p = 0.016) groups. Conclusion. Patients with a residual effect of DAPT, as well as patients with a pronounced residual effect of ASA, have a higher risk of postoperative bleeding and chest reexploration, as well as increased transfusion demands.

References

Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Co-lombo A, et al. Coronary artery bypass graft surgery versus per-cutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013; 381(9867): 629–38.

Jawitz OK, Gulack BC, Brennan JM, Thibault DP, Wang A, O'Brien SM, et al. Association of postoperative complications and outcomes following coronary artery bypass grafting. Am Heart J 2020; 222: 220‒8.

Freundlich RE, Maile MD, Hajjar MM, Habib JR, Jewell ES, Schwann T, et al. Years of life lost after complications of coro-nary artery bypass operations. Ann Thorac Surg 2017; 103(6): 1893‒9.

Demertzis S, Tiziano C, Gabriele C. Antiplatelet therapy before cardiac surgery. Cardiovasc Med 2016; 19(4): 110‒6.

Davierwala PM, Verevkin A, Leontyev S, Misfeld M, Borger MA, Mohr FW. Impact of expeditious management of perioperative myocardial ischemia in patients undergoing isolated coronary artery bypass surgery. Circulation 2013; 128(11 Suppl 1): S226‒34.

Wang TK, Stewart RA, Ramanathan T, Kang N, Gamble G, White HD. Diagnosis of MI after CABG with high-sensitivity tro-ponin T and new ECG or echocardiogram changes: relation-ship with mortality and validation of the universal definition of MI. Eur Heart J Acute Cardiovasc Care 2013; 2(4): 323‒33.

Karthik S, Grayson AD, McCarron EE, Pullan DM, Desmond MJ. Reexploration for bleeding after coronary artery bypass sur-gery: risk factors, outcomes, and the effect of time delay. Ann Thorac Surg 2004; 78(2): 527‒34; discussion 534.

Senage T, Gerrard C, Moorjani N, Jenkins DP, Ali JM. Early postoperative bleeding impacts long-term survival following first-time on-pump coronary artery bypass grafting. J Thorac Dis 2021; 13(10): 5670‒82.

Ranucci M, Baryshnikova E, Castelvecchio S, Pelissero G; Surgical and Clinical Outcome Research (SCORE) Group. Surgical and Clinical Outcome Research (SCORE) Group. Major bleeding, transfusions, and anemia: The deadly triad of cardiac surgery. Ann Thorac Surg 2013; 96(2): 478–85.

Hudzik B, Błachut A, Lesiak M, Kubica J, Wojakowski W, Gąsior M. Summary of the European Society of Cardiology guidelines on dual antiplatelet therapy in patients after percutaneous coronary interventions. Kardiol Pol 2022; 80(10): 974‒89.

Klempfner R, Barac YD, Younis A, Kopel E, Younis A, Ronen G, et al. Early referral to coronary artery bypass grafting follow-ing acute coronary syndrome, trends and outcomes from the Acute Coronary Syndrome Israeli Survey (ACSIS) 2000–2010. Heart Lung Circ 2018; 27(2): 175‒82.

Hwang D, Lee JM, Rhee TM, Kim YC, Park J, Park J, et al. The effects of preoperative aspirin on coronary artery bypass sur-gery: a systematic meta-analysis. Korean Circ J 2019; 49(6): 498‒510.

Solo K, Lavi S, Choudhury T, Martin J, Nevis IF, Kwok CS, et al. Pre-operative use of aspirin in patients undergoing coronary artery bypass grafting: a systematic review and updated meta-analysis. J Thorac Dis 2018; 10(6): 3444‒59. Erratum in: J Thorac Dis 2018; 10(12): E860.

Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, et al. 2021 ACC/AHA/SCAI guideline for coro-nary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145(3): e4–17. Erratum in: Circulation 2022; 145(11): e771.

Petricevic M, Knezevic J, Biocina B, Mikus M, Konosic L, Rasic M, et al. Association among Clopidogrel cessation, platelet func-tion, and bleeding in coronary bypass surgery: an observational trial. Thorac Cardiovasc Surg 2021; 69(7): 630‒8.

Gherli R, Mariscalco G, Dalén M, Onorati F, Perrotti A, Chocron S, et al. Safety of preoperative use of ticagrelor with or with-out aspirin compared with aspirin alone in patients with acute coronary syndromes undergoing coronary artery bypass graft-ing. JAMA Cardiol 2016; 1(8): 921‒8.

Thielmann M, Sharma V, Al-Attar N, Bulluck H, Bisleri G, Bunge JJH, et al. ESC Joint Working Groups on Cardiovascu-lar Surgery and the Cellular Biology of the Heart Position Pa-per: Perioperative myocardial injury and infarction in patients undergoing coronary artery bypass graft surgery. Eur Heart J 2017; 38(31): 2392‒407.

Nardi P, Pisano C, Turturici M, Bertoldo F, Maggio VR, Bassano C, et al. The impact of dual antiplatelet therapy administra-tion on the risk of bleeding complications during coronary ar-tery bypass surgery. Kardiochir Torakochirurgia Pol 2021; 18(3): 145‒51.

Matkovic M, Novakovic T, Bilbija I, Lazovic JM, Tutus V, Cubrilo M, et al. The routine use of platelet function tests in elective coronary artery bypass grafting: A prospective observational trial. J Card Surg 2021; 36(2): 629‒36.

Qu J, Zhang H, Rao C, Chen S, Zhao Y, Sun H, et al. Dual an-tiplatelet therapy with clopidogrel and aspirin versus aspirin monotherapy in patients undergoing coronary artery bypass graft surgery. J Am Heart Assoc 2021; 10(11): e020413.

Charif F, Hamdan R, Youness G, El Zein A, Issa M, Jassar Y, et al. Dual antiplatelet therapy up to the time of non-elective coronary artery bypass grafting with prophylactic platelet transfusion: is it safe? J Cardiothorac Surg 2019; 14(1): 202.

Kapetanakis EI, Medlam DA, Boyce SW, Haile E, Hill PC, Dul-lum MK, et al. Clopidogrel administration prior to coronary ar-tery bypass grafting surgery: the cardiologist's panacea or the surgeon's headache? Eur Heart J 2005; 26(6): 576‒83.

Cao L, Young N, Liu H, Silvestry S, Sun W, Zhao N, et al. Pre-operative aspirin use and outcomes in cardiac surgery patients. Ann Surg 2012; 255(2): 399‒404.

Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, et al. Stopping vs. continuing aspirin before coronary artery surgery. N Engl J Med 2016; 374(8): 728‒37.

Morawski W, Sanak M, Cisowski M, Szczeklik M, Szczeklik W, Dropinski J, et al. Prediction of the excessive perioperative bleeding in patients undergoing coronary artery bypass graft-ing: role of aspirin and platelet glycoprotein IIIa polymor-phism. J Thorac Cardiovasc Surg 2005; 130(3): 791‒6.

Hastings S, Myles P, McIlroy D. Aspirin and Coronary Artery Surgery: A Systematic Review and Meta-analysis. Br J Anaesth 2015; 115(3): 376‒85.

Sadeghi R, Haji Aghajani M, Miri R, Kachoueian N, Jadbabaei AN, Mahjoob MP, et al. Dual antiplatelet therapy before coro-nary artery bypass grafting in patients with myocardial infarc-tion: a prospective cohort study. BMC Surg 2021; 21(1): 449.