[Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel antiplatelet therapy]. / Dringliche oder notfallmässige Koronarrevaskularisation unter Verwendung beider Arteria Thoracica interna nach vorheriger Thrombozytenaggregationshemmung mit Clopidogrel.

BACKGROUND: Application of clopidogrel before diagnostic or therapeutical percutaneous coronary interventions has become standard for stent-thrombosis prevention. The irreversible platelet inhibition causes increasing bleeding complications if urgent coronary artery bypass grafting becomes necessary. This study evaluates the effect on bleeding complications of clopidogrel in urgent CABG using bilateral internal thoracic artery (ITA) and saphenous veins in all patients. METHODS: We retrospectively analyzed 166 patients (operated between 1/00-12/02) with urgent or emergency CABG, using both ITAs and compared 83 patients with previous (within 5 days) clopidogrel and aspirin application to 83 patients without clopidogrel. We evaluated chest tube output, reexploration rate and necessity of blood products, ventilation time and ICU stay. RESULTS: Both groups were comparable with age, gender, number of performed anastomoses (mean 4/ patient). Chest tube output (24 h) was higher in the clopidogrel group (935 +/- 599 ml vs 754 +/- 335 ml (p = 0.018)), as well as reexploration rate with 7.2% (6 of 83) vs 0% (0 of 83) (p < 0.001). Number of blood products in the clopidogrel group for red cells was 2.41 +/- 1.88 U vs 1.84 +/- 1.47 U p = 0.03, for plateletes 0.43 +/- 0.88 U vs 0.024 +/- 0.22 p = 0.0001, for fresh frozen plasma 0.41 +/- 1.14 U vs 0.096 +/- 0.59 U p = 0.029. Mechanical ventilation time was 11.35 +/- 8.77 h vs 10.57 +/- 9.12 h p = 0.51, ICU stay 32.1 +/- 21.8 h vs. 29.8 +/- 21.1 h (p = 0.48). CONCLUSIONS: Previous application of clopidogrel in combination with aspirin before urgent CABG induces increased chest tube output, reexploration rate and necessity of blood products, especially of plateletes. Nevertheless, routine use of both ITAs in patients after clopidogrel exposure can be performed with acceptable bleeding complications.

[Simultaneous carotid endarterectomy and cardiac surgery-additional risk factor or safe procedure?]. / Thrombendarteriektomie der Arteria carotis und simultane Herzoperation. Zusätzlicher Risikofaktor oder sichere Vorgehensweise?

BACKGROUND: The occurrence of severe carotid artery disease in more than 12% of patients requiring ACB results in a discrepancy concerning the best treatment for both diseases. We reviewed the early outcome of patients with ACB and/or valve replacement and simultaneous carotid endarterectomy (TEA). METHODS: We evaluated retrospectively 244 patients operated simultaneously between 7/94 and 10/2001: 209 patients received ACB, 35 patients ACB and/or valve replacement. Mean age was 68 years. 188 patients were male. We analyzed risk factors, morbidity, incidence of neurological complications and 30 day mortality. RESULTS: Perioperative stroke with hemiplegia occurred in 3.3% (8 patients). Of these patients, 4 showed contralateral carotid artery occlusion, 2 contralateral severe stenosis. Two patients (0.8%) experienced prolonged reversible ischemic neurological deficit (PRIND), 4 patients (1.6%) transient ischemic attack (TIA). 30-day morbidity was 4.5%. Three patients died due to low cardiac output, 6 patients due to extracardial reasons, 2 patients (0.8) due to cerebral death. CONCLUSION: Simultaneous TEA and cardiac surgery can be performed with an acceptable risk for neurological complications and mortality. Occlusion of the contralateral carotid artery could be identified as an evident predictor for increased neurological complications. Compared to two-stage procedures, combined operations yield a reduction of hospital costs.

Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel antiplatelet therapy.

BACKGROUND: Clopidogrel application before diagnostic or therapeutical percutaneous coronary intervention has become the standard for stent thrombosis prevention. Irreversible platelet inhibition causes increasing bleeding complications if urgent coronary artery bypass grafting is necessary. This study evaluates the effect on bleeding complications of clopidogrel in urgent CABG using bilateral internal thoracic artery (ITA) and saphenous veins in all patients. METHODS: We retrospectively analyzed 128 patients (operated between January 2000 and September 2002) undergoing urgent or emergent CABG using both ITAs, and compared 64 patients with previous clopidogrel and aspirin application (within 5 days) to 64 patients without clopidogrel. We evaluated chest tube output, re-exploration rate and necessity of blood products, ventilation time and ICU stay. RESULTS: Both groups were comparable in age, gender, number of performed anastomoses (mean 4/patient). Chest tube output (24 h) was higher in the clopidogrel group at 977+/-628 ml vs. 788+/-389 ml (p=0.046), as was re-exploration rate with 7.81% (5 of 64) vs. 0% (0 of 64) (p<0.005). The number of blood products amounted to 2.7+/-1.9 U in the clopidogrel group vs. 1.9+/-1.6 U (p=0.013) for red cells, 0.05+/-0.9 U vs. 0.03+/-0.25 (p=0.0003) for platelets, and 0.5+/-1.3 U vs. 0.2+/-1.0 U (p=0.14) for fresh frozen plasma. Mechanical ventilation time was 11.9+/-9.7 h vs. 9.6+/-5.9 h (p=0.10), ICU stay 32.6+/-22.1 h vs. 27.8+/-18.2 h (p=0.19). CONCLUSIONS: Previous application of clopidogrel in combination with aspirin before urgent CABG induces increased chest tube output, re-exploration rate and necessity of blood products, especially platelets. Nevertheless, routine use of both ITAs in patients after clopidogrel exposure can be performed with acceptable bleeding complications.

Simultaneous carotid endarterectomy and cardiac surgery--additional risk factor or safety procedure?

BACKGROUND: The occurrence of severe carotid artery disease in more than 12 % of patients requiring CABG results in a discrepancy concerning the best treatment for both diseases. We reviewed the early outcome of patients with CABG and/or valve replacement and simultaneous carotid endarterectomy (CEA). METHODS: We evaluated retrospectively 244 patients operated simultaneously between 7/94 and 10/2001. 209 patients received CABG; 35 patients CABG and/or valve replacement. Mean age was 68 years. 188 patients were male. We analyzed risk factors, morbidity, incidence of neurological complications and 30 day mortality. RESULTS: Perioperative stroke with hemiplegia occurred in 3.3 % (8 patients). 4 of these patients showed contralateral carotid artery occlusion, 2 contralateral severe stenosis. 2 patients (0.8 %) experienced prolonged reversible ischemic neurological deficit (PRIND), 4 patients (1.6 %) transient ischemic attack (TIA). 30-day lethality was 4.5 %. 3 patients died due to low cardiac output, 6 patients due to extracardial reasons, 2 patients (0.8 %) developed a cerebral death. CONCLUSIONS: Simultaneous CEA and cardiac surgery can be performed with an acceptable risk for neurological complications and mortality. Occlusion of contralateral carotid artery could be identified as an evident predictor for increased neurological complications. Compared to two-stage procedures, combined operations yield a reduction of hospital costs.