Days Of Coronary Artery Bypass Grafting Research Articles

Mechanical Circulatory Support During Surgical Revascularization for Ischemic Cardiomyopathy

BackgroundThis study aimed to describe the use of perioperative mechanical circulatory support (MCS) and its impact on outcomes in patients with ischemic cardiomyopathy who were undergoing surgical revascularization. MethodsPatients with an ejection fraction <35% who underwent isolated coronary artery bypass grafting (CABG) from 2015 to 2021 were identified (N = 378). Patients were divided into no MCS, preoperative MCS, and postoperative MCS groups on the basis of timing of MCS initiation, which included intraaortic balloon pump, extracorporeal membrane oxygenation, or Impella device (Abiomed) use. The primary outcome of interest was operative mortality. ResultsThe median Society of Thoracic Surgeons Predicted Risk of Mortality was 2.4%. Sixty-six percent (n = 246) of patients had a previous myocardial infarction, and 61.8% of these patients were within 21 days of CABG. Twenty-one patients (5.6%) presented in cardiogenic shock. The preoperative MCS cohort consisted of 31 patients (8.2%) who underwent CABG a median of 2 days after MCS initiation. Thirty (7.9%) patients required postoperative MCS. Independent risk factors for requiring postoperative MCS included the preoperative ejection fraction (odds ratio, 0.93; P = .01 and the presence of preoperative MCS (odds ratio, 3.06; P = .02). Overall, operative mortality was 3.4%, and 3-year survival was 87.0%. Operative mortality in patients who did and did not receive preoperative MCS was 7.7% and 2.9% (P = .12) with no difference in long-term survival (P = .80), whereas patients requiring postoperative MCS had significantly increased operative (16.7%) and late mortality (63%; P <.01). ConclusionsCABG can be performed safely in patients with ischemic cardiomyopathy with selective use of perioperative MCS. Despite advanced disease severity, patients requiring preoperative MCS demonstrate acceptable short- and long-term survival. Patients requiring postoperative MCS have increased postoperative morbidity and mortality.

Center Variation in Use of Preoperative Dual Antiplatelet Therapy and Platelet Function Testing at the Time of Coronary Artery Bypass Grafting in Maryland.

Patients presenting with acute coronary syndrome are administered a P2Y 12 inhibitor and aspirin before coronary catheterization to prevent further myocardial injury from thrombosis. Guidelines recommend a standard waiting period between the time patients are administered dual antiplatelet therapy (DAPT) and elective cardiac surgery. Since 25% to 30% of the population may be considered nonresponders to clopidogrel, platelet function testing can be utilized for timing of surgery and to assess bleeding risks. The extent to which a standard waiting period or platelet function testing is used across centers is not established, representing an important opportunity to standardize practice. We conducted a retrospective cohort study from 2011 to 2020 using data from the Maryland Cardiac Surgical Quality Initiative, a consortium of all 10 hospitals in the state performing cardiac surgery. The proportion of patients administered DAPT within 5 days of surgery was examined by hospital over the time period. Mixed-effects multivariable logistic regressions were used to examine the association of preoperative DAPT with ischemic and bleeding outcomes. Centers were surveyed on use or nonuse of preoperative platelet function testing, and bleeding outcomes were compared. There was significant heterogeneity of preoperative DAPT usage across centers ranging from 2% to 54% ( P < .001). DAPT within 5 days of isolated coronary artery bypass grafting (CABG) was associated with higher odds of reoperation for bleeding (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.19-2.01; P = .001), >2 units of red blood cells (RBCs) transfused (OR, 1.62; 95% CI, 1.44-1.81; P < .001), and >2 units of non-RBCs transfused (OR, 1.79; 95% CI, 1.60-2.00; P < .001). In the 5 hospitals using preoperative platelet function testing to guide timing of surgery, there were greater odds for DAPT within 5 days (OR, 1.33; 95% CI, 1.22-1.45; P < .001), fewer RBCs >2 units transfusions (22% vs 33%; P < .001), and non-RBCs >2 units (17% vs 28%; P < .001) transfusions within DAPT patients. There is significant variability in DAPT usage within 5 days of CABG between hospital centers. Preoperative platelet function testing may allow for earlier timing of surgery for those on DAPT without increased bleeding risks.

Derivation and validation of predictive indices for 30-day mortality after coronary and valvular surgery in Ontario, Canada.

Background:Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (AVR) are the 2 most common cardiac surgery procedures in North America. We derived and externally validated clinical models to estimate the likelihood of death within 30 days of CABG, AVR or combined CABG + AVR.Methods:We obtained data from the CorHealth Ontario Cardiac Registry and several linked population health administrative databases from Ontario, Canada. We derived multiple logistic regression models from all adult patients who underwent CABG, AVR or combined CABG + AVR from April 2017 to March 2019, and validated them in 2 temporally distinct cohorts (April 2015 to March 2017 and April 2019 to March 2020).Results:The derivation cohorts included 13 435 patients who underwent CABG (30-d mortality 1.73%), 1970 patients who underwent AVR (30-d mortality 1.68%) and 1510 patients who underwent combined CABG + AVR (30-d mortality 3.05%). The final models for predicting 30-day mortality included 15 variables for patients undergoing CABG, 5 variables for patients undergoing AVR and 5 variables for patients undergoing combined CABG + AVR. Model discrimination was excellent for the CABG (c-statistic 0.888, optimism-corrected 0.866) AVR (c-statistic 0.850, optimism-corrected 0.762) and CABG + AVR (c-statistic 0.844, optimism-corrected 0.776) models, with similar results in the validation cohorts.Interpretation:Our models, leveraging readily available, multidimensional data sources, computed accurate risk-adjusted 30-day mortality rates for CABG, AVR and combined CABG + AVR, with discrimination comparable to more complex American and European models. The ability to accurately predict perioperative mortality rates for these procedures will be valuable for quality improvement initiatives across institutions.

Management of patients after coronary artery bypass grafting surgery: a guide for primary care practitioners.

KEY POINTS About 15 000 people in Canada undergo coronary artery bypass grafting (CABG) surgery each year.[1][1] According to the 2019 Canadian Institute for Health Information Cardiac Care Quality Indicators Report, 9.4% of these patients are urgently readmitted to hospital within 30 days of CABG

Effect of Early Rehabilitation on Physical Function in Patients Undergoing Coronary Artery Bypass Grafting: A Nationwide Inpatient Database Study.

It is unclear when to begin rehabilitation after coronary artery bypass grafting (CABG) in the intensive care unit (ICU). Using the Japanese Diagnosis Procedure Combination inpatient database from 2010 to 2018, we identified adult patients who underwent a CABG and who were admitted to the ICU for ≥3 consecutive days from the date of their CABG. Patients who started any rehabilitation program prescribed by physicians or therapists within 3 days of CABG were defined as the early rehabilitation group, and the remaining patients were defined as the usual care group. We identified 30,568 eligible patients, with 13,150 (43%) patients in the early rehabilitation group. An inverse probability of treatment weighting analyses showed that the Barthel Index score at discharge in the early rehabilitation group was significantly higher than that in the usual care group (difference: 3.2; 95% confidence interval: 1.5–4.8). The early rehabilitation group had significantly lower in-hospital mortality, total hospitalization costs, length of ICU stay, and hospital stay vs. the usual care group. Our results suggested that early rehabilitation by physicians or therapists beginning within 3 days of CABG was safe, as suggested by the low mortality and improved physical function in patients who underwent CABG.

Neurophysiological correlates of postoperative cognitive disorders

A special place among cognitive disorders in patients with cardiovascular diseases is given to postoperative cognitive dysfunction (POCD). The study aimed at investigating the patterns of beta-2 activity associated with postoperative cognitive dysfunction (POCD) in patients after coronary artery bypass grafting (CABG). The study included 60 patients who underwent neuropsychological testing 3-5 days before surgery and on the 7-10th day of CABG. A multichannel electroencephalogram of resting state with eyes closed in 62 standard leads was recorded. Statistical processing of the results was carried out using Statistica 10 (StatSoft Inc, USA) and the developed method of data clustering with a minimax criterion, a software implementation of the binary clipping and branching algorithm was used to find optimal solutions. Patients with POCD had higher pre- and postoperative high-frequency beta-2 rhythm power (20-30 Hz) compared with patients without cognitive impairment. The regression model demonstrated that POCD was associated with high values of preoperative beta-2 activity in the right frontal cortex and with low values in the left parietal areas after CABG. The clustering of beta-2 rhythm power before and after CABG revealed that the best cognitive status corresponded to a stable affiliation of patients with the selected clusters. The specific POCD correlates were established in patients after CABG. Low cognitive status was characterized by the preoperative beta-2 power increase in the right frontal areas and postoperative decrease in the left parietal cortex. The developed method for classifying patients according to the level of pre- and postoperative beta-2 rhythm power has a good discriminant ability. Stable patient affiliation with the selected clusters was associated with a higher level of cognitive status.

Meta-Analysis of Perioperative Stroke and Mortality in CABG Patients With Carotid Stenosis.

Coronary artery bypass grafting (CABG) is a proven approach in the treatment of coronary heart disease, but the surgery has several complications, including stroke and death. Though it has been established that perioperative stroke is associated with higher rates of long-term mortality, the relationship between stroke and mortality in the perioperative period has not yet been systematically examined. Online databases of peer-reviewed literature were searched to retrieve articles concerning mortality and stroke after CABG in patients with carotid stenosis. Six studies (n=3786) were included for analysis. This study was conducted at a single University hospital system, University of Pittsburgh Medical Center, on patients who underwent CABG. The data obtained from peer-reviewed literature originated from several sources, primarily single institution hospitals. Consistent with current literature, the incidence of stroke in CABG patients with significant carotid stenosis was 2.1%. Data were further analyzed to generate a summary odds ratio of stroke-related mortality after CABG, which showed that patients who died within 30 days of CABG were 7.3 times more likely to have had a perioperative stroke (95% confidence interval, 4.1-13.2). The 30-day mortality rate among perioperative stroke victims was 14.4% versus 2.3% for nonstroke patients. Together, these data suggest an association between stroke and mortality in the perioperative period in patients undergoing CABG, demonstrating a need for improved monitoring, screening, and treatment of stroke before, during, and shortly after surgery.

Association of postoperative complications and outcomes following coronary artery bypass grafting

The long-term effects of postoperative complications following coronary artery bypass grafting (CABG) are unknown. Medicare-linked records from the Society of Thoracic Surgeons Adult Cardiac Surgery Database were queried for isolated CABG records from 2007 through 2012. Unadjusted and adjusted associations between individual postoperative complications and both mortality and all-cause rehospitalization were evaluated to 7 years using Cox proportional-hazards models and cumulative incidence functions. Because of nonproportional hazards, associations are presented as early (0 to 90 days) and late (90 days to 7 years). Of the 294,533 isolated CABG patients who had records linked to Medicare for long-term follow-up (median age, 73 years; 30% female), 120,721 (41%) experienced at least 1 of the complications of interest, including new-onset atrial fibrillation (30.0%), prolonged ventilation (12.3%), renal failure (4.5%), reoperation (3.5%), stroke (1.9%), and sternal wound infection (0.4%). Each of the 6 postoperative complications was associated with a significantly increased risk of mortality and rehospitalization to 7 years despite adjustment for baseline characteristics and the presence of multiple complications. Although the predominant effect of postoperative complications was observed in the first 90 days, the increased risk-adjusted hazard for death and rehospitalization continued through 7 years. Postoperative complications are associated with an increased risk of both early and late mortality and all-cause rehospitalization, particularly during the "value" window within 90 days of CABG. These findings underscore the need to develop avoidance strategies as well as cost-adjustment methods for each of these complications.

The Impact of Preoperative Clopidogrel on Outcomes After Coronary Artery Bypass Grafting

This study evaluated the impact of preoperative clopidogrel exposure on outcomes of coronary artery bypass grafting (CABG). Patients undergoing isolated CABG from January 2010 to February 2018 at a single institution were included. Primary stratification was based on exposure to clopidogrel within 5 days of CABG. Primary outcomes included blood product transfusion and mediastinal reexploration for bleeding. Secondary outcomes included early and late mortality, major postoperative complications, and hospital readmissions. Multivariable Cox regression was used to evaluate the risk-adjusted impact of preoperative clopidogrel on post-CABG mortality. Isolated CABG was performed in 7048 patients, including 1240 (18%) who had received clopidogrel within 5 days. Patients who received preoperative clopidogrel had higher rates of transfusions (53.4% vs 40.3%, P < .001) and reoperation for bleeding (3.0% vs 2.0%, P= .02). Most postoperative complication rates were similar, although those exposed to clopidogrel had higher rates of postoperative stroke (2.3% vs 1.2%, P= .002) and prolonged ventilation (10.2% vs 7.1%, P < .001). Clopidogrel exposure did not impact unadjusted or risk-adjusted 30-day, 1-year, or 5-year mortality or readmission. Discontinuing clopidogrel for at least 3 days preoperatively mitigated but did not eliminate the increased risk of blood transfusions after CABG. CABG can be safely performed in patients with recent clopidogrel exposure with no increased risk of early or late mortality. However, CABG should be delayed for at least 5 days, if clinically feasible, to minimize transfusions and reoperation risk. In patients with more urgent indications, delaying CABG at least 3 days can mitigate but not eliminate the increased bleeding risk.

Myiasis of Mandible Due to Lucilia sericata, in Diabetic Woman Patient: A Case Report

Introduction: Myiasis can be defined as the infestation of living tissues of humans and animals by dipterous eggs or larval stages that can penetrate the skin and soft tissues. Case Presentation: The aim of the study was to report an uncommon case of insect infestation in human tissues, called myiasis. The patient was a 62-year-old woman, with the larval presence in the jaw, who suffered from diabetes and anemia. She was originally from the rural areas of Khuzestan province, the southwest of Iran. She had a wound on her mandible with a foul-smelling mouth before preparing for coronary artery bypass grafting (CABG) surgery. Her mandible and mouth were infested by 50 live larvae after three days of CABG. The larvae were examined in the pathology and parasitology department of the laboratory and definitely identified as Lucilia sericata. Conclusions: Myiasis can be a risk for elderly people, especially old patients. The primary control method is the prevention and repulsion of adult flies before they can cause any damage.

Postoperative Bleeding Following Preoperative Clopidogrel Administration in Patients with Haemoglobin Level Above 110 g/L Undergoing Urgent CABG.

IntroductionPatients with acute coronary syndrome usually receive dual antiplatelet therapy (DAPT) (usually clopidogrel + aspirin) prior to coronary catheterization, and approximately 10% of these patients require coronary artery bypass grafting (CABG). DAPT has favorable effects on prevention of thrombus formation, but it can have deleterious effects on surgical hemostasis. Anaemia, if present, gives additional risk to such patients. The aim of this study was to examine if DAPT affects postoperative bleeding in patients with haemoglobin levels above 110 g/L, who underwent urgent or emergent CABG, less than five days after stopping DAPT therapy.MethodsData were collected prospectively on 122 CABG patients, operated by a surgical team from March 2008 to August 2013. Patients were stratified into two groups: group 1 received DAPT within 5 days of CABG (n=65), and group 2 where DAPT was discontinued for more than 5 days prior to CABG (n=57). All patients were diagnosed with acute coronary syndrome preoperatively, and all of them had haemoglobin levels above 110 g/L. Patients who needed reoperation, combined procedures, or off-pump revascularization were excluded.ResultsThere was no hospital mortality. Mean chest tube losses after the surgical revascularization did not differ significantly, but group 1 received a higher quantity of transfused red blood cells and platelets.ConclusionUrgent and emergent surgical revascularization using extracorporeal circulation in patients with acute coronary syndrome whose preoperative haemoglobin levels are above 110 g/L is a safe and effective procedure. We suggest that, where indicative, one may perform CABG in less than 5 days after the clopidogrel discontinuation.

Secondary surgical-site infection after coronary artery bypass grafting: A multi-institutional prospective cohort study

ObjectiveTo analyze patient risk factors and processes of care associated with secondary surgical-site infection (SSI) after coronary artery bypass grafting (CABG). MethodsData were collected prospectively between February and October 2010 for consenting adult patients undergoing CABG with saphenous vein graft (SVG) conduits. Patients who developed a deep or superficial SSI of the leg or groin within 65 days of CABG were compared with those who did not develop a secondary SSI. ResultsAmong 2174 patients identified, 65 (3.0%) developed a secondary SSI. Median time to diagnosis was 16 days (interquartile range 11-29) with the majority (86%) diagnosed after discharge. Gram-positive bacteria were most common. Readmission was more common in patients with a secondary SSI (34% vs 17%, P < .01). After adjustment, an open SVG harvest approach was associated with an increased risk of secondary SSI (adjusted hazard ratio [HR], 2.12; 95% confidence interval [CI], 1.28-3.48). Increased body mass index (adjusted HR, 1.08, 95% CI, 1.04-1.12) and packed red blood cell transfusions (adjusted HR, 1.13; 95% CI, 1.05-1.22) were associated with a greater risk of secondary SSI. Antibiotic type, antibiotic duration, and postoperative hyperglycemia were not associated with risk of secondary SSI. ConclusionsSecondary SSI after CABG continues to be an important source of morbidity. This serious complication often occurs after discharge and is associated with open SVG harvesting, larger body mass, and blood transfusions. Patients with a secondary SSI have longer lengths of stay and are readmitted more frequently.

RISK OF BLEEDING COMPLICATIONS IN PATIENTS TREATED WITH TICAGRELOR UNDERGOING URGENT CORONARY ARTERY BYPASS GRAFTING SURGERY: A SINGLE CENTER EXPERIENCE

Canadian guidelines recommend using ticagrelor over clopidogrel in patients with acute coronary syndrome (ACS). Because of its more potent antiplatelet effect, there are some concerns regarding the risk of bleeding complications in patients undergoing urgent coronary artery bypass grafting (CABG) surgery who received ticagrelor prior to surgery. We included all consecutive ACS patients treated with a parenteral anticoagulant who received an ADP receptor inhibitor (ADPri) within 7 days of CABG. Bleeding events, blood loss and blood transfusions were compared between patients who received ticagrelor and those who received clopidogrel. Major bleeding was defined according to the Bleeding Academic Research Consortium. Between February 2012 and February 2014, 383 patients (55 ticagrelor, 328 clopidogrel) met the inclusion criteria. Overall, there was no difference in bleeding parameters between ticagrelor and clopidogrel patients (Table). When the ADPri was stopped <48h, ticagrelor patients had a higher mean intra-operative blood loss (850cc vs 550cc;p=0.02), higher post-operative chest tube drainage at 4h (405cc vs 310cc;p=0.02), were more likely to have chest tube drainage >2L (11.5% vs 1.3%;p=0.03) and to receive blood products (platelets: 73% vs 50%,p=0.02; plasma: 50% vs 26%,p=0.02; red blood cells: 69% vs 40%,p=0.01). In patients with ADPri stopped >48h, there was no significant differences in bleeding parameters except for chest tube drainage at 4h (ticagrelor 240cc, clopidogrel 345cc; p=0.03). In this subgroup, there was a trend for less major bleeding in ticagrelor patients (0% vs 8%; p=0.1). Major bleeding was significantly less frequent when the ADPri was stopped at least 48h before surgery (ticagrelor: 23% vs 0%, p=0.01; clopidogrel: 16% vs 8%,p=0.03)(Figure). In this small study, ticagrelor, when compared to clopidogrel, was not associated with an increased risk of major bleeding in ACS patients undergoing CABG within 7 days of stopping the ADPri. In patients undergoing CABG within 48h of stopping the ADPri, there was a significant increase in the risk of bleeding in patients treated with ticagrelor. However, when ticagrelor is stopped at least 48h before surgery, the risk of bleeding is comparable to clopidogrel. Delaying CABG >48h after the last ADPri dose significantly reduces bleeding risk whether patients are pre-treated with ticagrelor or clopidogrel. Larger studies are needed to investigate the ideal timing of surgery in patients treated with ticagrelor. Postponing surgery for 48h whenever possible seems justified. Pre-treatment with ticagrelor should probably be withheld in patients with a high likelihood of urgent (<48h) CABG.View Large Image Figure ViewerDownload (PPT)

Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery.

Coronary artery bypass grafting (CABG)-related bleeding complications and perioperative coronary events are strongly influenced by the management of antithrombotic therapy before and after CABG. Bleeding but also blood products transfusion increase the risk of death and compromise the long-term benefits of CABG.1 The use of new P2Y12 inhibitors, increasing pre-CABG percutaneous coronary interventions (PCI) with drug eluting stents (DES) requiring specific antiplatelet regimens, and advances in surgical technique has prompted the ESC Working Group on Cardiovascular Surgery and the ESC Working Group on Thrombosis to review the evidence of peri-CABG recommendations on antithrombotic management. Due to the paucity of randomized trials, most of the evidence is still derived from observational studies and expert consensus, further reinforcing the importance of a multidisciplinary consultation for optimal decision making. ### Benefits of preoperative aspirin Aspirin (acetylsalicylic acid, ASA) is recommended as secondary prevention therapy for all patients with proven coronary artery disease (CAD) and without contraindications. Its indication is even stronger for post-CABG patients (recommendation IA).2 The general consensus is that ASA treatment withdrawal has ominous prognostic implications in patients with CAD, especially in those with intracoronary stents, and should be advocated only when the bleeding risk clearly outweighs that of atherothrombotic events.3 The benefits of continuing ASA until the day of CABG (‘preoperative ASA’) are less clear and may explain the wide variability in the management of ASA therapy in the perioperative period and differences between guidelines endorsed by different professional and scientific societies (Supplementary material online, Table S1 ). This was based on the demonstration that ASA started the day before surgery was no more effective than ASA started 6 h after surgery at improving early (7- to 10-day) graft patency, but was associated with increased bleeding complications.4 More recent evidence suggests, however, that ASA use within 5–7 days prior to CABG …

Beta-thromboglobulin as a marker of perioperative myocardial infarction in patients undergoing coronary artery bypass grafting following aspirin discontinuation

Perioperative myocardial infarction (PMI) following coronary artery bypass grafting (CABG) is associated with significant morbidity and mortality. The aim of this study was to assess platelet activation and oxidative stress in the setting of PMI in patients undergoing CABG. We studied 108 consecutive patients who stopped taking low-dose aspirin 7–10 days prior to elective isolated on- or off-pump CABG. β-thromboglobulin (β-TG), thromboxane B2 (TXB2) and 8-iso-prostaglandin F2α (8-iso-PGF2α), a marker of oxidative stress, were measured at the baseline and 5–7 days postoperatively. Aspirin (150 mg/d) was administered every morning since 12 hours after CABG. Mean baseline β-TG was 58.5 ± 10.3 IU/ml, TXB2 was 143.6 ± 28.5 ng/ml and 8-iso-PGF2α was 355.2 ± 40.7 pg/ml. Postoperatively, after administration of 4–6 doses of aspirin, β-TG increased by 16.7% and 8-iso-PGF2α increased by 17.2% 5–7 days after surgery (p = 0.005 and p < 0.001, respectively). TXB2 decreased by 99.7% to 410.3 ± 52.1 pg/ml (p < 0.001). Nine patients (8.3%) developed PMI. Baseline β-TG and TXB2, together with postoperative β-TG and 8-iso-PGF2α were higher in PMI patients than in the remaining subjects (all, p < 0.05). Multivariate analysis showed that baseline β-TG (OR: 1.28; 95% CI: 1.05–1.57, p = 0.015) was the only independent predictor of PMI. In conclusion, we demonstrated that increased platelet activation and thromboxane production, observed in patients not taking aspirin till the day of CABG, contribute to the occurrence of PMI in early postoperative period.

Editorial Comment: The end of all our exploring ...

Editorial Comment: The end of all our exploring ...

Clopidogrel loading dose and bleeding outcomes in patients undergoing urgent coronary artery bypass grafting

Coronary artery bypass grafting (CABG) performed within 5 days of clopidogrel administration is associated with increased bleeding. The impact of clopidogrel loading dose is unknown. We examined the effect of clopidogrel loading dose on bleeding outcomes in patients undergoing urgent CABG. Clinical outcomes were examined retrospectively for 196 consecutive patients undergoing urgent CABG within 5 days of a clopidogrel loading dose between January 2003 and June 2009. Major bleeding was defined as a fall in hemoglobin > 5 g/dL, fatal or intracranial bleeding, or cardiac tamponade. One hundred forty-eight patients received 300 mg and 48 patients received ≥ 600 mg clopidogrel loading. Patients were predominantly male (78%) with a mean age of 66 ± 10 years. Mean duration from clopidogrel loading to CABG was 3.0 ± 1.5 and 3.0 ± 1.6 days for the 300 and 600 mg loading doses, respectively. Major bleeding occurred in 47% of patients receiving 300 mg and 73% of patients receiving ≥ 600 mg clopidogrel loading (P = .002). Compared with 300 mg, patients receiving ≥ 600 mg had greater 24-hour chest tube output (391 ± 251 vs 536 ± 354 mL, P = .01), stayed longer in surgical intensive care (4.3 ± 4.1 vs 5.0 ± 3.1 days, P = .0001), and trended toward greater reoperation for bleeding (5% vs 12%, P = .09). Following multivariate analysis, clopidogrel loading dose ≥ 600 mg (odds ratio 2.8, CI 1.2-6.6), preoperative hemoglobin (3.4, 2.7-5.0 per 1 g/dL increase), and female gender (2.9, 1.1-7.4) predicted major bleeding. Higher clopidogrel loading doses are associated with increased bleeding when administered within 5 days of CABG. The development of shorter-acting, reversible, oral antiplatelet agents may reduce perioperative bleeding in this population.

Stopping Aspirin Before Coronary Artery Surgery

Coronary artery bypass grafting (CABG) aims to reduce immediate and longer-term risks of myocardial infarction and death in patients with coronary artery disease. CABG is, however, associated with its own thrombotic risks of perioperative myocardial infarction, stroke, pulmonary embolism, and bowel infarction.1 These risks are of major concern to the patient and referring cardiologist. Although antiplatelet drugs such as aspirin and clopidogrel can reduce thrombotic events, they might add to a competing risk of excessive bleeding during and after surgery.2,3 Excessive bleeding leads to intraoperative and postoperative hypovolemia and hypotension, delayed completion of surgery, and higher rates of blood transfusion, postoperative tamponade, and reoperation for bleeding.3,–,6 The bleeding risks most often trouble the cardiac surgeon, and the traditional practice has been to stop aspirin before elective cardiac surgery. Article see p 577 How can we resolve the competing risks of bleeding complications (not uncommon, but sometimes serious and life threatening) versus thrombotic complications in the immediate preoperative and early postoperative period (far less common, but usually serious)? Is it true that efforts to minimize perioperative thrombotic risk will invariably increase bleeding complications? Cardiologists and surgeons have different perspectives and may weigh these issues differently, and it remains unclear as to how most CABG patients would perceive these risks and what their preferences may be. Cardiologists in particular will be familiar with this issue in the nonsurgical setting. The decision to commence anticoagulation for chronic atrial fibrillation must consider the likelihood of embolic stroke versus the possibility of serious bleeding complications, such as intracerebral hemorrhage.7 The latter situation is guided by numerous large-scale clinical trials. This is not the case in the CABG setting. Aspirin is associated with bleeding in both cardiac3,8,–,12 and noncardiac …

Candida albicans sternal wound infections: a chronic and recurrent complication of median sternotomy.

Eleven patients developed deep sternal wound infections due to Candida albicans after undergoing coronary artery bypass grafting (CABG) and were assessed. Six had sternal osteomyelitis, 1 had osteomyelitis and mediastinitis, and 4 had deep wound infections that probably involved bone. Seven patients experienced onset of infection within 28 days of CABG, but 4 experienced onset 48-150 days after CABG. Infections were characterized by a chronic, indolent course requiring prolonged treatment with an antifungal agent. Delay in initiating antifungal therapy was common. All patients were treated with fluconazole, and 1 also received amphotericin B. Six patients underwent incision and drainage, with or without wire removal, and 3 underwent sternectomy with placement of a muscle flap. Of 10 patients for whom follow-up data were available, 7 were cured after initial therapy (median duration of treatment, 6 months), and 3 experienced a relapse and required a second course of fluconazole.

Postoperative atrial fibrillation: An old problem crying for new solutions

J Thorac Cardiovasc Surg 2001;121:638-41