Mehmet EZELSOY, Ayten SARACOĞLU, Kemal Tolga SARACOĞLU

Antitrombotik Ajanların Preoperatif Kesilmesinin Tromboz ve Kanama Riski Üzerine Etkileri

GİRİŞ ve AMAÇ: Amacımız açık kalp ameliyatı geçiren hastalarda preoperatif antikoagülanların kesilmesi ile ilişkili olabilecek trombotik komplikasyonların insidansını belirlemektir.YÖNTEM ve GEREÇLER: Elektif açık kalp ameliyatı geçiren 512 erişkin hastanın verileri değerlendirildi. İkili antiplatelet tedavisi alan hastalar dahil edildi ve iki gruba ayrıldı. Grup 1’deki hastalar (n = 255) cerrahi öncesi aspirin tedavilerini askıya almış olup, Grup 2'deki hastalarda (n = 257) askıya alınmamıştır. Demografik özellikler, kalp rezervleri, preoperatif ve postoperatif Htc düzeyleri, antikoagülan türleri, kan ürünlerinin transfüzyonu, olası komplikasyonlar ve mortalite oranları kaydedildi.BULGULAR: Demografik özellikler, ameliyat süresi, hastane ve yoğun bakımda kalış süresi, Kardiyopulmoner Bypass zamanı, mortalite oranı, re-eksplorasyon oranı, transfüzyon ihtiyacı gruplar arasında farklılık göstermedi. Antitrombotik gruptaki transfüze edilen trombosit süspansiyonu miktarı, antitrombotik ajan içermeyen gruptan anlamlı olarak daha yüksekti (p ˂ 0.05).TARTIŞMA ve SONUÇ: Aspirin tedavisindeki kardiyak hastalar için ne re-eksplorasyon ne de transfüzyon oranları farklılık göstermemiştir. Üstelik aspirin, heparinizasyon ve ekstra korporeal dolaşımın gerekli olduğu kardiyak cerrahi için postoperatif komplikasyon insidansını artırmamıştır. Aspirinin hasta sonuçları üzerinde olumsuz bir etkisi bulunmadığından, major cerrahi geçiren hastalarda kesilmemesi gerektiği kanısına varılmıştır.

Withdrawal of Antithrombotic Agents and Its Impact on Thrombosis and Bleeding in Patients Undergoing Cardiac Surgery

INTRODUCTION: Our aim is to determine the incidence of thrombotic complications that may be associated with discontinuation of preoperative anticoagulants in patients undergoing open heart surgery.METHODS: The data of 512 adult patients undergoing elective open hearth surgery were evaluated. Patients treated with dual antiplatelet therapy were included and divided into two groups. Group 1 patients (n=255) have suspended their aspirin therapy prior to surgery. Group 2 patients (n=257) have not suspended. Demographics, cardiac reserves, preoperative and postoperative Htc levels, the types of anticoagulants, the transfusion of blood products, possible complications and mortality rates were recorded.RESULTS: The demographics, the duration of surgery, hospital and internal care unit (ICU) stay, cardiopulmonary bypass (CPB) time, mortality rate, reexploration rate, the need for transfusion did not differ between groups. The amount of platelet suspension in antithrombotic group was significantly higher than in group without antithrombotic agent (p ˂ 0.05).DISCUSSION AND CONCLUSION: Neither reexploration nor transfusion rates were different for cardiac patients on aspirin therapy. Therefore, aspirin did not increase the incidence of postoperative complications even for cardiac surgery, where heparinization and extra corporeal circulation are necessary. As aspirin has not a negative effect on patient outcomes, should not be discontinued in patients undergoing major surgery.

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1. Le Manach Y, Kahn D, Bachelot-Loza C, Le Sache F, Smadja DM, Remones V, et al. Impact of aspirin and clopidogrel interruption on platelet function in patients undergoing majorvascular surgery. PLoS One 2014; 9: e104491. doi: 10.1371/journal.pone.0104491.
2. Gulbins H, Malkoc A, Ennker IC, Ennker J. Preoperative platelet inhibition with ASA does not influence postoperative blood loss following coronary artery bypass grafting. Thorac Cardiovasc Surg 2009; 57: 18-21. doi: 10.1055/s-2008-1038791.
3. Bybee KA, Powell BD, Valeti U, Thomas RJ, Kopecky SL, Mullany CJ, et al. Preoperative aspirin therapy is associated with improved postoperative outcomes in patients undergoing coronary artery bypass grafting. Circulation 2005; 112: 286-92.
4. Biondi-Zoccai G, Lotrionte M, Agostoni P, Abbate A, Fusaro M, Burzotta F, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50 279 patients at risk for coronary artery disease. Eur Heart J 2006; 27: 2667-74.
5. Berg K, Langaas M, Ericsson M, Pleym H, Basu S, Nordrum IS, et al. Acetylsalicylic acid treatment until surgery reduces oxidative stress and inflammation in patientsundergoing coronary artery bypass grafting. Eur J Cardiothorac Surg 2013; 43: 1154-63. doi: 10.1093/ejcts/ezs591.
6. Jacob M, Smedira N, Blackstone E, Williams S, Cho L. Effect of timing of chronic preoperative aspirin discontinuation on morbidity and mortality in coronary artery bypass surgery. Circulation 2011;123:577-83. doi: 10.1161/CIRCULATIONAHA.110.957373.
7. Dhir A. Antifibrinolytics in cardiac surgery. Ann Card Anaesth 2013; 16: 117-25.
8. Sniecinski RM, Chandler WL. Activation of the hemostatic system during cardiopulmonary bypass. Anesth Analg 2011; 113: 1319‑33. doi: 10.1213/ANE.0b013e3182354b7e.
9. Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC guideline for the management of patients with non-ST elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation 2014; 130: 2354-94. doi: 10.1161/CIR.0000000000000133.
10. Mahla E, Suarez TA, Bliden KP, Rehak P, Metzler H, Sequeira AJ, et al. Platelet function measurement-based strategy to reduce bleeding and waiting time in clopidogrel-treated patients undergoing coronary artery bypass graft surgery: the timing based on platelet function strategy to reduce clopidogrel-associated bleeding related to CABG (TARGET-CABG) study. Circ Cardiovasc Interv 2012; 5: 261-9. doi: 10.1161/CIRCINTERVENTIONS.111.967208.
11. Kozek-Langenecker SA, Ahmed AB, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: First update 2016. Eur J Anaesthesiol 2017; 34: 332-95. doi: 10.1097/EJA.0000000000000630.
12. Hansson EC, Jidéus L, Åberg B, Bjursten H, Dreifaldt M, Holmgren A, et al. Coronary artery bypass grafting-related bleeding complications in patients treated with ticagreloror clopidogrel: a nationwide study. Eur Heart J 2016; 37: 189-97. doi: 10.1093/eurheartj/ehv381.