Levent ÖZDEMİR, Hasan MERCAN, Mustafa KIRMAN, Kemalettin ERDEM

Acil koroner baypas ameliyatı gereken akut koroner sendromlu hastalarda klopidogrel yükleme dozlarının ameliyat sonrası kanama üzerine etkisi

Amaç: Bu çalışmada akut koroner sendrom (AKS) tanısı ile acil koroner anjiyografi yapılan ve acil koroner arter baypas greft (KABG) cerrahisi gereken hastalarda koroner anjiyografi öncesi yüksek dozlarda verilen klopidogrelin ameliyat sonrası kanama ve diğer komplikasyonlar üzerindeki etkisi değerlendirildi. Çalışma planı: Ekim 2007 ve Ekim 2010 tarihleri arasında kliniğimizde KABG işlemi uygulanan toplam 1800 ardışık hasta geriye dönük olarak incelendi. Akut koroner sendrom nedeniyle 300 mg klopidogrel verilen (n=20) ve 600 mg klopidogrel verilen (n=20) hastalar ile klopidogrel almayan (n=21) hastalardan oluşan toplam 61 hasta (44 erkek, 17 kadın; ort. yaş, 63±10 yıl; dağılım 42-79 yıl) çalışmaya dâhil edildi. Hastaların tamamı AKS nedeniyle acil anjiyografiye alınan hastalardı. Tüm hastalar en erken iki saat, en geç 18 saat içinde KABG ameliyatına alındı. Hastalar ameliyat sonrası kanama, kanama nedeni ile tekrar ameliyat, yoğun bakım ünitesi (YBÜ) ve hastanede kalma sürelerinin erken dönem mortalite üzerine etkileri yönünden karşılaştırıldı. Bulgular: Ameliyat sonrası göğüs tüpü drenajına göre 300 mg klopidogrel tedavisi uygulanan ve uygulanmayan hastalar karşılaştırıldığında kanama miktarı açısından anlamlı bir fark gözlenmedi (sırasıyla; 450 cc, 400 cc, p>0.05). Kanama miktarı 600 mg klopidogrel uygulanan hastalarda, klopidogrel tadavisi uygulanmayanlara kıyasla, anlamlı oranda yüksekti (sırasıyla; 625 cc, 400 cc, p0.05). Yoğun bakım ve hastanede kalış süresi üç grupta da benzerdi. Sonuç: Akut koroner sendrom nedeniyle 300 mg klopidogrel yükleme dozu verilen hastalara acil anjiyografi sonrası KABG ameliyatı yapılabilir. Bu hastalarda ameliyat sonrası kanama önemli bir sorun olmamaktadır. Ancak, 600 mg klopidogrel yükleme dozu verilen hastalar, klopidogrel verilmeyen hastalarla karşılaştırıldığında, ameliyat sonrası kanama ve yüksek komplikasyon riskine sahiptir.

The effects of clopidogrel loading doses on postoperative bleed ing in patients with acute coronary syndrome requiring emergent coronary bypass surgery

Background: This study aims to evaluate the effect of high dose clopidogrel administered before coronary angiography in patients with the diagnosis of acute coronary syndromes (ACS) requiring emergent coronary angiography and emergent coronary artery bypass graft (CABG) surgery on postoperative bleeding and other complications. Methods: A total of 1800 consecutive patients who underwent CABG between October 2007 and October 2010 in our clinic were retrospectively analyzed. A total of 61 patients (44 males, 17 females; mean age 63±10 years; range 42 to 79 years) were enrolled including 21 of them without clopidogrel, 20 with clopidogrel 300 mg and 20 with clopidogrel 600 mg due to ACS. All of the patients underwent emergent angiography due to ACS. All of them underwent CABG surgery within minimum two hours and maximum 18 hours. Postoperative bleeding, reoperation due to bleeding, length of stay in the intensive care unit (ICU) and hospital and early-term mortality of the patients were compared. Results: No significant difference in the amount of bleeding was observed between the postoperative chest tube drainages of patients who received clopidogrel 300 mg compared to the patients who received no clopidogrel therapy (450cc, 400cc, respectively, p>0.05). The amount of bleeding was significantly higher in patients who received clopidogrel 600 mg compared to patients who received no clopidogrel therapy (625cc, 400cc, respectively p0.05). The length of stay in the ICU and hospital were similar in all three groups. Conclusion: Patients who received loading dose of clopidogrel 300 mg due to ACS may undergo CABG surgery after emergent angiography. Postoperative bleeding may not be a critical challenge in these patients. However patients who receive loading dose of clopidogrel 600 mg are at high risk for postoperative bleeding and complications compared to patients not receiving clopidogrel

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