The Impact of Preoperative Clopidogrel Therapy on Postoperative Bleeding After Robotic-Assisted Coronary Artery Bypass Surgery
William T. Daniel, Henry A. Liberman, John D. Puskas, Chandan Devireddy, Wissam Jaber, Robert A. Guyton, Michael E. Halkos.
Emory, Atlanta, GA, USA.
OBJECTIVE: Current guidelines recommend a 5-day waiting period prior to coronary artery bypass surgery (CABG) for patients on clopidogrel (CL). The purpose of this study was to determine if patients undergoing robotic-assisted CABG on CL had an increased risk of bleeding complications compared to those not on CL.
METHODS: In an intent to treat analysis from 2008-2011, 322 patients underwent off-pump, sternal-sparing, robotic-assisted CABG via a 3-4cm anterolateral thoracotomy either as an isolated robotic-assisted CABG or as part of a hybrid revascularization procedure. Patients were classified according to whether they received CL within 5 days of the procedure (CL, N=54) compared to those who never received or who had discontinued CL therapy >5 days prior to surgery (No CL, N=268). A propensity analysis using 31 preoperative variables was used to control for selection bias. In a subgroup analysis, patients undergoing simultaneous hybrid procedures (CL load 600mg in OR prior to stenting) were analyzed separately and compared to patients in the CL group. Multiple regression analysis was used to control for the propensity score on outcome variables.
RESULTS: In the CL group, the mean interval between surgery and last dose of CL was 2.1±1.5 days. Compared to the No CL group, the CL group had more 24 hour chest tube drainage (961±584ml vs. 800±533ml, p=0.02) and more blood product transfusions (40.7%, 22/54 patients vs. 20.5%, 55/268 patients, p=0.002). On logistic regression analysis, there was a trend towards higher 24 hour chest tube drainage in the CL group (+161ml, p=0.06) and a significantly higher incidence of blood transfusion (OR=2.21, p=0.02). There was no difference in re-exploration, hospital mortality, ventilator time, or intensive care or hospital length of stay between groups. In the subgroup analysis, patients undergoing simultaneous hybrid procedures (n=17) had more 24 hour chest tube drainage compared to other patients in the CL group (1262 vs. 909ml, p=0.03).
CONCLUSIONS: Patients undergoing robotic-assisted CABG on CL had more postoperative bleeding and a higher incidence of blood transfusions. Therefore, these procedures should be performed without clopidogrel when possible.
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