Neposredni ishodi hirurške revaskularizacije miokarda kod bolesnika sa preoperativnom disfunkcijom trombocita
Sažetak
Uvod/Cilj. Hirurška revaskularizacija miokarda (coronary artery bypass grafting – CABG) kod značajnog broja bolesnika je osnovni vid lečenja ishemijske bolesti srca. Neke od postoperativnih komplikacija su blisko povezane sa preoperativnom antiagregacionom terapijom (AAT). Cilj rada bio je da se uporede neposredni ishodi CABG kod bolesnika sa očuvanom funkcijom trombocita i bolesnika kod kojih je funkcija trombocita bila narušena rezidualnim efektom AAT. Metode. Prospektivnom, opsrevacionom, nerandomizovanom studijom obuhvaćeno je 181 bolesnika sa izolovanim CABG. Bolesnici su bili podeljeni na četiri grupe: kontrolnu grupu (agregacija trombocita zavisna od arahidonske kiseline), sa aspirin-induced platelet inhibition (ASPI) testom ≥ 790 agregacionih jedinica (aggregation units – AU)/min; grupu bolesnika sa blagim efektom (BE) acetilsalicilne kiseline (ASK) (BEASK), sa ASPI testom = 410–789 AU/min; grupu bolesnika sa izraženim efektom (IE) ASK (IEASK), sa ASPI testom ≤ 409 AU/min; grupu bolesnika sa dvojnom (D) AAT (DAAT), sa ASPI testom ≤ 789 AU/min i adenozin difosfat (ADF) testom ≤ 405 AU/min. Preoperativni podaci, intraoperativne karakteristike i postoperativni ishodi upoređeni su među grupama. Rezultati. Ispitivane grupe su se značajno razlikovale u odnosu na prosečno vreme obustave AAT(p < 0,001). DAAT grupa imala je značajno češću drenažu u poređenju sa kontrolnom (p = 0,004), BEASK (p = 0,001) i IEASK (p = 0,006) grupom. Grupa IEASK imala je značajno veću učestalost reeksploracije grudnog koša u poređenju sa BEASK grupom (p = 0,032). Bolesnici iz DAAT grupe primili su značajno više koncentrovanih eritrocita u poređenju sa kontrolnom (p < 0,001) i BEASK (p = 0,009) grupom. Bolesnici iz IEASK grupe primili su značajno više koncentrovanih eritrocita u poređenju sa kontrolnom (p < 0,001) i BEASK (p = 0,019) grupom. DAAT grupa primila je značajno više trombocita u poređenju sa kontrolnom (p < 0,001), BEASK (p = 0,002) i IEASK (p < 0,001) grupom. Transfuzije krioprecipitata bile su značajno češće u DAAT grupi u poređenju sa kontrolnom (p = 0,002), BEASK (p = 0,009) i IEASK (p < 0,016) grupom. Zaključak. Bolesnici sa rezidualnim efektom DAAT, kao i bolesnici sa izraženim rezidualnim efektom ASK imaju povišen rizik od postoperativnog krvarenja i reeksploracije grudnog koša, kao i povećanu potrebu za transfuzijama.
Reference
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.