Emergency coronary bypass grafting for failed percutaneous coronary artery stenting: increased costs and platelet transfusion requirements after the use of abciximab

Abstract

The adjunctive use of abciximab (ReoPro), a platelet glycoprotein IIb/IIIa receptor antagonist, with aspirin as pretreatment for percutaneous coronary artery stenting (PTCS) has risen dramatically. 2 Reports on the outcomes of patients who require emergency coronary bypass grafting (CABG) for unsuccessful PTCS are scarce. This report documents three cases. Table I outlines cardiopulmonary bypass (CPB), hematologic, and coagulation assays. All patients had received aspirin (300 mg) and abciximab (0.25 mg/kg/5 min bolus and 9 mg/500 ml normal saline solution at 10 mg/min intravenous infusion) before the operation. All had a profound bleeding diathesis evident from skin incision and persisting for 4 to 5 hours after the operation. Patients PATIENT 1. A 38-year-old man had acute stent thrombosis 14 days after PTCS to the left anterior descending coronary artery. Cardiogenic shock ensued, necessitating emergency CABG. Ticlopidine (Ticlid) at 250 mg twice a day had been continued since the original PTCS. CABG with a left internal thoracic artery graft to the left anterior descending coronary artery and a saphenous vein graft to a first diagonal was performed. After reversal of heparinization, 5 units of platelets were given and the chest was closed. By 60 minutes, the mediastinal blood loss was 1500 ml. At resternotomy, no specific surgical source was evident. A 1.5 mg dose of 1-deamino-8-Darginine vasopressin (Minirim) and a 4 3 10 kallikrein activation unit (KIU) dose of aprotinin (Trasylol) were given intravenously. An additional 1900 ml blood loss occurred during the next 24 hours. The patient was discharged on postoperative day 10. PATIENT 2. A 73-year-old man in cardiogenic shock with intraaortic balloon pump support was referred for operation with a postinfarct inferior ventricular septal rupture; PTCS to the proximal right coronary artery had been performed. The operation entailed polyethylene terephthalate (Dacron) patch closure of the ventricular septal defect and placement of four venous coronary bypass grafts. Because of the previous experience, intravenous aprotinin (“high” Hammersmith dose [7 3 10 KIU]) was given at induction, and after CPB 10 units of platelets were given. This patient died of low cardiac output syndrome 96 hours after the operation. PATIENT 3. A 39-year-old woman, in cardiogenic shock from an evolving anterolateral acute myocardial infarction after PTCS to the circumflex coronary artery required emergency CABG. A left internal thoracic artery graft to the left anterior descending coronary artery and two additional venous bypass grafts were performed. “High” Hammersmith dose aprotinin was used (total 5 3 10 KIU); after CPB, 10 units of platelets were also given. The patient was discharged home 6 days after the operation. Discussion. This limited experience focuses attention on the potential impact of abciximab on patients undergoing emergency CABG; the message is sharp. In all three cases, results of history, physical examination, and hematologic and coagulation assays were normal before the operation, yet perioperative blood loss was in excess of what was expected. Aprotinin in the “high” Hammersmith dose and immediate, repeated platelet transfusions after CPB appear necessary and effective in reducing mediastinal blood loss. Abciximab use is based on the reduction in the 30-day primary end point (death, acute myocardial infarction, revascularization) reported by the EPIC (placebo 12.8% vs treated 8.5%), EPILOG (placebo 11.7% vs treated 5.2%), and CAPTURE (placebo 15.9% vs treated 11.3%) trials. 2 Only the EPIC trial reported on patients requir-