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Udelsman BV, Soni M, Madariaga ML, Fintelmann FJ, Best TD, Li SSY, Chang DC, Gaissert HA. Incidence, aetiology and outcomes of major postoperative haemorrhage after pulmonary lobectomy. Eur J Cardiothorac Surg 2021; 57:462-470. [PMID: 31562514 DOI: 10.1093/ejcts/ezz266] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/19/2019] [Accepted: 08/30/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Post-lobectomy bleeding is uncommon and rarely studied. In this study, we aimed to determine the incidence of post-lobectomy haemorrhage and compare the outcomes of reoperation and non-operative management. METHODS We conducted a single-institution review of lobectomy cases from 2009 to 2018. The patients were divided into two groups based on the treatment for postoperative bleeding: reoperation or transfusion of packed red blood cells with observation. Transfusion correcting intraoperative blood loss was excluded. One or more criteria defined postoperative bleeding: (i) drop in haematocrit ≥10 or (ii) frank, sustained chest tube bleeding with or without associated hypotension. Covariates included demographics, comorbidities and operative characteristics. Outcomes were operative mortality, complications, length of hospital stay and readmission within 30 days. RESULTS Following 1960 lobectomies (92% malignant disease, 8% non-malignant), haemorrhage occurred in 42 cases (2.1%), leading to reoperation in 27 (1.4%), and non-operative management in 15 (0.8%). The median time to reoperation was 17 h. No source of bleeding was identified in 44% of re-explorations. Patients with postoperative haemorrhage were more often male (64.3% vs 41.2%; P < 0.01) and more likely to have preoperative anaemia (45.2% vs 26.5%; P = 0.01), prior median sternotomy (14.3% vs 6.0%; P = 0.04), an infectious indication (7.1% vs 1.8%; P = 0.01) and operative adhesiolysis (45.2% vs 25.8%; P = 0.01). Compared with non-operative management, reoperation was associated with fewer units of packed red blood cells transfusion (0.4 vs 1.9; P < 0.001), while complication rates were similar and 30-day mortality was absent in either group. CONCLUSIONS Haemorrhage after lobectomy is associated with multiple risk factors. Reoperation may avoid transfusion. A prospective study should optimize timing and selection of operative and non-operative management.
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Affiliation(s)
- Brooks V Udelsman
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA.,Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, MA, USA
| | - Monica Soni
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA.,Georgetown University School of Medicine, Washington, DC, USA
| | | | | | - Till D Best
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.,Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Selena Shi-Yao Li
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David C Chang
- Codman Center for Clinical Effectiveness, Massachusetts General Hospital, Boston, MA, USA
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Sakai T, Aokage K, Katsumata S, Tane K, Miyoshi T, Tsuboi M. Continuation of aspirin perioperatively for lung resection: a propensity matched analysis. Surg Today 2021; 51:1054-1060. [PMID: 33389188 DOI: 10.1007/s00595-020-02202-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To clarify the safety and effectiveness of continuing aspirin during the perioperative period of lung resection. METHODS We analyzed, retrospectively, consecutive patients who underwent lung resection between 2008 and 2017. To investigate the safety of aspirin continuation, patients who continued taking aspirin perioperatively (Group C) were matched to other patients (Group O), using a propensity score, and bleeding outcomes were compared. To assess the effect of aspirin interruption, Group C was matched to a group of patients whose aspirin regimen was interrupted (Group I), and the postoperative complications related to thromboembolism were compared. RESULTS Among 3393 patients, 52 continued on aspirin (Group C) perioperatively, whereas 184 had their aspirin discontinued (Group I). Comparing the matched cohorts extracted from Group C and Group O (n = 45), there were no significant differences in bleeding outcomes. Comparing the matched cohorts extracted from Group C and Group I (n = 40), group C had fewer postoperative complications related to thromboembolism (0% vs. 7.5%, p = 0.039). CONCLUSION Bleeding complications did not increase by continuing aspirin, but thromboembolic complications increased when the aspirin regimen was interrupted during the perioperative period of lung resection. Thus, in the absence of a prohibitive bleeding risk, the continuation of aspirin during the perioperative period of lung resection appears to be desirable.
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Affiliation(s)
- Takashi Sakai
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Keiju Aokage
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Shinya Katsumata
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Kenta Tane
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Tomohiro Miyoshi
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masahiro Tsuboi
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
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Huang W, Qi K, Chen Z, Li J. [Perioperative Outcomes of Patients Undergoing Pulmonary Resection for Lung Cancer after Coronary Stenting]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2020; 23:36-40. [PMID: 31948536 PMCID: PMC7007396 DOI: 10.3779/j.issn.1009-3419.2020.01.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
背景与目的 肺癌患者合并有冠心病是很常见的一种情况,部分患者既往植入冠脉支架并接受抗血小板治疗。对于带有冠脉支架需要行肺切除手术的肺癌患者,围手术期是否停用抗血小板药物仍然存在争议。本研究通过回顾我院的数据来明确这部分特殊人群的围手术期结局。 方法 回顾性分析了2013年1月-2019年9月冠脉支架术后在北京大学第一医院胸外科行肺切除手术的肺癌患者的临床数据。所有患者术前暂停口服抗血小板药物至少5 d。主要研究终点是院内的心血管并发症和死亡。 结果 本研究共纳入111例患者。支架放置和肺癌手术间隔的时间在1个月-3个月、3个月-12个月、超过12个月的患者分别为6.3%、13.5%和80.2%。亚肺叶切除、肺叶切除、联合肺叶切除、全肺切除以及肺叶袖式切除的患者分别为10.8%、71.2%、9.0%、2.7%和6.3%。总的心血管并发症发生率为11.6%,包括不稳定心绞痛(n=1, 0.9%)、低血压(n=1, 0.9%)、充血性心力衰竭(n=2, 1.8%)和新发心房纤颤(n=10, 9.0%)。本组病例无围手术期死亡,无主要不良心血管事件(major adverse cardiac events, MACE)。 结论 术前暂停口服抗血小板药物是安全的,围手术期未发生MACE和死亡。
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Affiliation(s)
- Weiming Huang
- Department of Thoracic Surgery, Peking University First Hospital, Beijing 100034, China
| | - Kang Qi
- Department of Thoracic Surgery, Peking University First Hospital, Beijing 100034, China
| | - Zhimao Chen
- Department of Thoracic Surgery, Peking University First Hospital, Beijing 100034, China
| | - Jian Li
- Department of Thoracic Surgery, Peking University First Hospital, Beijing 100034, China
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Yu WS, Lee CY. Safety of perioperative low dose aspirin therapy in major lung resection. J Thorac Dis 2019; 11:S1897-S1899. [PMID: 31632779 DOI: 10.21037/jtd.2019.08.43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Woo Sik Yu
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Chang Young Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Yonsei University, Seoul, Republic of Korea
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5
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EBUS-TBNA on Patients Receiving Antiplatelet Therapy: Are We Throwing Caution to the Wind? J Bronchology Interv Pulmonol 2019; 26:1-3. [PMID: 30562278 DOI: 10.1097/lbr.0000000000000549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Effect of Routine Clopidogrel Use on Bleeding Complications After Endobronchial Ultrasound-guided Fine Needle Aspiration. J Bronchology Interv Pulmonol 2019; 26:10-14. [PMID: 29664760 DOI: 10.1097/lbr.0000000000000493] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endobronchial ultrasonography has proven to be highly sensitive and specific in the diagnoses of patients with mediastinal and hilar adenopathy. Many of these patients are on a combination of clopidogrel (a compound that inhibits adenosine diphosphate-induced platelet aggregation) and aspirin due to neurological and/or cardiac-related comorbidities, and stopping anticoagulation may place these patients at high risk for potential complications. Our group has previously showed that thoracentesis with an 8-french catheter is safe in patients receiving clopidogrel and aspirin with low risk of complications. In this manuscript, we report the outcomes of the largest prospective multicenter series of patients undergoing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) while receiving clopidogrel. METHODS Patients presenting to our institutions with mediastinal/hilar adenopathy, requiring EBUS-TBNA, and actively taking clopidogrel and aspirin were included in the study. If the medication could be held for 5 to 7 days before the procedure, the patient was excluded. EBUS-TBNA was performed by an interventional pulmonology faculty on a total of 42 patients. All patients received total intravenous anesthesia, and a total of 92 nodes were sampled. First, 3 passes were performed with a 22-G needle. If no complications were encountered, we followed with additional 3 passes with a 21 G. Rapid onsite evaluation was performed in all patients. Bleeding at the puncture site was considered significant if it required cold saline, topical sympathomimetic, or balloon tamponade for hemostasis. Bleeding was considered nonsignificant if no interventions were required to achieve hemostasis. RESULTS We were able to perform all procedures successfully using both the 21 and 22-G needles. One patient required 30 mL cold saline installation to accomplish hemostasis with the 21 and 22-G needles. Our yield was comparable with the current literature. No statistically significant complications occurred during the procedure. All patients were contacted within 24 hours, and none reported bloody sputum. CONCLUSION We suggest that EBUS-TBNA, using 22 and 21-G needles, is safe with high yields in patients with mediastinal/hilar adenopathy, actively taking clopidogrel and aspirin, and are at high risk for thrombotic complications if the medication is discontinued.
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Cohen C, Pop D, Aze O, Venissac N, Mouroux J. Video-assisted mediastinoscopy is safe in patients taking antiplatelet or anticoagulant therapy. J Minim Access Surg 2018; 16:30-34. [PMID: 30178769 PMCID: PMC6945347 DOI: 10.4103/jmas.jmas_173_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: The aim of this study was to report our experience with video-assisted mediastinoscopy (VAM) in patients taking antiplatelet (AP) or anticoagulant therapies focusing on perioperative complications (especially haemorrhagic). Patients and Methods: We have done a retrospective study from a prospectively maintained database with diagnostic VAM (01/2008–06/2012). We included 54 patients with AP (41 patients – Group A) and anticoagulant (13 patients – Group B) therapies. The control group was formed by 263 patients (Group C). Data regarding the clinical records of the patients, operative time, per- and post-operative complications, total numbers of biopsies and the results of the pathologic examination were collected. We compared the groups A+B versus C, and then A versus C. Statistical differences were calculated by Chi-square test. Results: In Group A, we had two minor complications: cardiac arrhythmia and peroperative minor haemorrhage. The mean operative time was 29 min and the mean post-operative stay was 1.08 days. In Group B, we had one minor complication: Peroperative minor haemorrhage. The mean operative time was 35 min and the mean post-operative stay was 1.07 days. In Group C, the mean operative time was 28 min. One death occurred (mortality rate of 0.38%) because of cardiac arrest at the induction of anaesthesia. One major complication occurred (severe respiratory insufficiency needing re-intubation) and eight minor complications. Morbidity rate was 2.28%. Mean post-operative stay was 1.14 days. No statistical difference was noted between groups. Conclusion: VAM can be safely performed in patients receiving AP or anticoagulant treatments. There is no increase in peroperative bleeding or post-operative compressive cervico-mediastinal haematoma.
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Affiliation(s)
- Charlotte Cohen
- Department of Thoracic Surgery, Pasteur Hospital, Nice, France
| | - Daniel Pop
- Department of Thoracic Surgery, Pasteur Hospital, Nice, France
| | - Olivier Aze
- Department of Thoracic Surgery, Pasteur Hospital, Nice, France
| | | | - Jérôme Mouroux
- Department of Thoracic Surgery, Pasteur Hospital, Nice, France
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Sierra P, Gómez-Luque A, Llau JV, Ferrandis R, Cassinello C, Hidalgo F. Recommendations for perioperative antiplatelet treatment in non-cardiac surgery. Working Group of the Spanish Society of Anaesthesiology-Resuscitation and Pain Therapy, Division of Haemostasis, Transfusion Medicine, and Perioperative Fluid Therapy. Update of the Clinical practice guide 2018. ACTA ACUST UNITED AC 2018; 66:18-36. [PMID: 30166124 DOI: 10.1016/j.redar.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 12/24/2022]
Affiliation(s)
- P Sierra
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Fundación Puigvert (IUNA), Barcelona, España.
| | - A Gómez-Luque
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, España
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Dr. Peset, Universitat de València, Valencia, España
| | - R Ferrandis
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hopital Clínic i Universitari La Fe, Universitat de València, Valencia, España
| | - C Cassinello
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - F Hidalgo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Clínica Universidad de Navarra, Pamplona, España
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Linder K, Epelbaum O. Percutaneous pleural drainage in patients taking clopidogrel: real danger or phantom fear? J Thorac Dis 2018; 10:5162-5169. [PMID: 30233893 DOI: 10.21037/jtd.2018.04.161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Despite being categorized as a procedure associated with a low risk of iatrogenic hemorrhage, percutaneous pleural drainage in patients taking the ubiquitous antiplatelet agent clopidogrel is still commonly perceived as a risky proposition. There is mounting evidence, however, in support of the safety of percutaneous needle procedures in persons receiving this medication. Establishing that these pleural interventions can be performed safely without clopidogrel interruption would be of great clinical significance, especially in those taking it for recent cardiac stenting and therefore in danger of stent thrombosis should antiplatelet therapy (APT) be withheld. The purpose of the present review is to summarize the available data from published studies and series of thoracentesis and chest tube insertion in patients exposed to clopidogrel. Also incorporated into this review are relevant investigations from the thoracic surgery and interventional radiology experience, which contribute indirect evidence and help shape the context for interpreting the safety data reported in the pleural literature. At the end, an attempt is made to synthesize the current knowledge on this topic into conclusions for guiding practice.
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Affiliation(s)
- Katherine Linder
- Department of Internal Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Oleg Epelbaum
- Division of Pulmonary, Critical Care, and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
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10
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Childers CP, Maggard-Gibbons M, Ulloa JG, MacQueen IT, Miake-Lye IM, Shanman R, Mak S, Beroes JM, Shekelle PG. Perioperative management of antiplatelet therapy in patients undergoing non-cardiac surgery following coronary stent placement: a systematic review. Syst Rev 2018; 7:4. [PMID: 29321066 PMCID: PMC5763575 DOI: 10.1186/s13643-017-0635-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/23/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The correct perioperative management of antiplatelet therapy (APT) in patients undergoing non-cardiac surgery (NCS) is often debated by clinicians. American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend postponing elective NCS at least 3 months after stent implantation. Regardless of the timing of surgery, ACC/AHA guidelines recommend continuing at least ASA throughout the perioperative period and ideally continuing dual APT (DAPT) therapy "unless surgery demands discontinuation." The objective of this review was to ascertain the risks and benefits of APT in the perioperative period, to assess how these risks and benefits vary by APT management, and the significance of length of time since stent implantation before operative intervention. METHODS PubMed, Web of Science, and Scopus were searched from inception through October 2017. Articles were included if patients were post PCI with stent placement (bare metal [BMS] or drug eluting [DES]), underwent elective NCS, and had rates of major adverse cardiac events (MACE) or bleeding events associated with pre and perioperative APT therapy. RESULTS Of 4882 screened articles, we included 16 studies in the review (1 randomized controlled trial and 15 observational studies). Studies were small (< 50: n = 5, 51-150: n = 5, >150: n = 6). All studies included DES with 7 of 16 also including BMS. Average time from stent to NCS was variable (< 6 months: n = 3, 6-12 months: n = 1, > 12 months: n = 6). At least six different APT strategies were described. Six studies further utilized bridging protocols using three different pharmacologic agents. Studies typically included multiple surgical fields with varying degrees of invasiveness. Across all APT strategies, rates of MACE/bleeding ranged from 0 to 21% and 0 to 22%. There was no visible trend in MACE/bleeding rates within a given APT strategy. Stratifying the articles by type of surgery, timing of discontinuation of APT therapy, bridging vs. no bridging, and time since stent placement did not help explain the heterogeneity. CONCLUSIONS Evidence regarding perioperative APT management in patients with cardiac stents undergoing NCS is insufficient to guide practice. Other clinical factors may have a greater impact than perioperative APT management on MACE and bleeding events. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016036607.
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Affiliation(s)
- Christopher P Childers
- Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., CHS 72-247, Los Angeles, CA, 90095, USA. .,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
| | - Melinda Maggard-Gibbons
- Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., CHS 72-247, Los Angeles, CA, 90095, USA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Jesus G Ulloa
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Surgery, UCSF School of Medicine, San Francisco, CA, USA
| | - Ian T MacQueen
- Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., CHS 72-247, Los Angeles, CA, 90095, USA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Isomi M Miake-Lye
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | - Selene Mak
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Jessica M Beroes
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Paul G Shekelle
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Atay SM, Correa AM, Hofstetter WL, Mehran RJ, Rice DC, Roth JA, Sepesi B, Swisher SG, Vaporciyan AA, Walsh G, Antonoff MB. Perioperative Outcomes of Patients Undergoing Lobectomy on Clopidogrel. Ann Thorac Surg 2017; 104:1821-1828. [DOI: 10.1016/j.athoracsur.2017.05.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 04/25/2017] [Accepted: 05/08/2017] [Indexed: 10/18/2022]
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12
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Pathak V, Allender JE, Grant MW. Management of anticoagulant and antiplatelet therapy in patients undergoing interventional pulmonary procedures. Eur Respir Rev 2017; 26:26/145/170020. [PMID: 28724563 PMCID: PMC9488580 DOI: 10.1183/16000617.0020-2017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 05/05/2017] [Indexed: 12/25/2022] Open
Abstract
There has been great progress in antithrombotic therapy over the past several years. Its use has increased with the advent of novel anticoagulants, as these medications do not require frequent blood tests for monitoring. Antithrombotic therapy is aimed at reducing the risk of thromboembolic events in patients with atrial fibrillation, coronary artery disease, deep vein thrombosis, valvular heart disease and pulmonary embolism. These patients are often critically ill and frequently undergo urgent interventions requiring discontinuation of anticoagulant or antiplatelet therapy which can increase the risk of thrombosis; however, continuing these agents can lead to increased risk of haemorrhage. The purpose of this article is to summarise the literature surrounding the safety of using antiplatelet and anticoagulant therapies in patients undergoing interventional pulmonary procedures. Available studies suggest some antithrombotic agents may be used in interventional pulmonary procedureshttp://ow.ly/vSF030bRqjt
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Affiliation(s)
- Vikas Pathak
- Dept of Pulmonary Disease and Critical Care Medicine, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - J Erin Allender
- Dept of Pharmacy, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Mollie W Grant
- Dept of Pharmacy, WakeMed Health and Hospitals, Raleigh, NC, USA
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13
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Safety of Continued Clopidogrel Use in the Preoperative Course of Gastrointestinal Surgery: A Retrospective Cohort Study. Ann Surg 2017; 265:370-378. [PMID: 27049768 DOI: 10.1097/sla.0000000000001726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Our study aimed to estimate postoperative bleeding risk in older adults taking clopidogrel before gastrointestinal (GI) surgery, to aid surgeons in decisions regarding clopigogrel cessation. SUMMARY BACKGROUND DATA Balancing risks of postoperative bleeding associated with continued clopidogrel use and those associated with cessation is difficult for GI surgeons. METHODS Using 100% Texas Medicare Claims Data from 2006 to 2011, we identified patients undergoing emergent GI surgery. We propensity score matched patients on clopidogrel before surgery to patients not on clopidogrel. Using conditional logistic regression, we compared risks of bleeding events at 1-month postdischarge between groups, adjusting for bleeding risk factors. RESULTS In total, 1240 patients undergoing emergent GI surgery while treated with clopidogrel were matched to emergency GI surgery patients not treated with clopidogrel. The only significant preoperative differences between groups were higher percent of clopidogrel-treated patients with congestive heart failure, cholecystectomy, and lower percent of clopidogrel-treated patients with colectomy. Mean age was 76.91 (±7.06) and 76.70 (±7.05) years (P = 0.47), and 63.84% and 59.41% of operations were cholecystectomy, in the clopidogrel and nonclopidogrel groups (P = 0.18). In multivariable analyses adjusting for Elixhauser index, hyperlipidemia, confounding drugs, and surgery type, odds ratio for bleeding within 30 days of discharge in those exposed to clopidogrel compared with those not exposed was 1.60 (95% confidence interval, 1.08-2.38), with raw rates of bleeding 6.85% and 4.84%. CONCLUSIONS Clopidogrel use in older adults through the preoperative period of GI surgery does not significantly increase bleeding events in the month after surgery.
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Omar HR, Socias SM, Powless RA, Sprenker C, Karlnoski R, Mangar D, Camporesi EM. Clopidogrel is not associated with increased bleeding complications after full-mouth extraction: A retrospective study. J Am Dent Assoc 2016; 146:303-9. [PMID: 25925522 DOI: 10.1016/j.adaj.2015.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 01/02/2015] [Accepted: 01/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND To the authors' knowledge, the effect of clopidogrel on bleeding complications during full-mouth extraction has not been studied. The authors aimed to determine the safety of continued use of clopidogrel during full-mouth extraction. METHODS The authors performed a retrospective study of consecutive patients undergoing full-mouth extraction who were taking aspirin, clopidogrel, a combination of aspirin and clopidogrel, or neither. The main study outcomes in the 4 study groups were estimated blood loss, transfusion requirements, and complications. The authors also examined the correlation between the number of teeth extracted and estimated blood loss in various groups. RESULTS Seventy-one patients underwent full-mouth extraction with removal of an average of 19 teeth. The authors excluded 3 patients owing to lack of data regarding blood loss. Of the remaining 68 patients, 25 were using aspirin, 12 were using clopidogrel, 9 were using both aspirin and clopidogrel, and 22 had discontinued the use of antiplatelets. There was no significant difference in the number of teeth extracted (P = .283) and estimated blood loss (P = .111) among the 4 groups. The authors found a significant moderate correlation between the number of teeth extracted and estimated blood loss in the group using aspirin (r = 0.537; P = .006) and in the group using clopidogrel, whether alone or in combination with aspirin (r = 0.535; P = .012), but not in the group who discontinued the use of antiplatelets. There was no need for blood transfusion in any patient. CONCLUSIONS The results of this study provide limited evidence to suggest that continuation of clopidogrel during full-mouth extraction and preprosthetic surgery may be safe and does not appear to be associated with a significant risk of bleeding. PRACTICAL IMPLICATIONS Clopidogrel therapy during full-mouth extraction is not associated with significant bleeding complications and may be continued in patients who have a high risk of experiencing a cardiac event.
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Kitamura Y, Suzuki K, Teramukai S, Sonobe M, Toyooka S, Nakagawa Y, Yokomise H, Date H. Feasibility of Pulmonary Resection for Lung Cancer in Patients With Coronary Artery Disease or Atrial Fibrillation. Ann Thorac Surg 2016; 103:432-440. [PMID: 27793400 DOI: 10.1016/j.athoracsur.2016.08.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 08/15/2016] [Accepted: 08/22/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to clarify the outcomes of lung resection for lung cancer in patients with cardiac disease, especially coronary artery disease, in a large-scale multi-institutional cohort. METHODS We retrospectively analyzed the data on 1,254 patients who underwent major lung resection for lung cancer and had been diagnosed with coronary stenosis, atrial fibrillation, or both, in 58 institutions in Japan between January 2009 and December 2011. The primary outcome was 90-day postoperative mortality or in-hospital death. RESULTS Among the 1,254 patients, 902 (71.9%) and 452 patients (36.0%) were preoperatively diagnosed with coronary stenosis and atrial fibrillation, respectively, and 951 patients (75.8%) received antiplatelet therapy. Among the patients with coronary stents (n = 532; 42.4%), 204 (16.3%) received drug-eluting stents. The 90-mortality or in-hospital death rate was 2.6% (n = 32), including stent thrombosis (n = 1), thromboembolic events without stent thrombosis (n = 2), and bleeding events (n = 2). In the multivariate analyses, blood transfusion, history of cerebrovascular disease, amount of bleeding, and history of congestive heart failure were associated with a higher independent risk of 90-day mortality or in-hospital death (odds ratio, 9.400, 3.574, 2.827, and 2.945, respectively). Preoperative discontinuation of antiplatelet therapy was not associated with an independent risk of 90-day mortality or in-hospital death on univariate analysis. CONCLUSIONS Major lung resection for lung cancer in patients with coronary artery disease is feasible. Our study suggests that discontinuation of antiplatelet therapy may not increase postoperative complications in patients with coronary artery disease.
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Affiliation(s)
- Yoshitaka Kitamura
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Kenji Suzuki
- Department of General Thoracic Surgery, Juntendo University School of Medicine, Tokyo, Japan.
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Makoto Sonobe
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Shinichi Toyooka
- Department of General Thoracic Surgery, Okayama University Hospital, Okayama, Japan
| | | | - Hiroyasu Yokomise
- Department of General Thoracic, Breast and Endocrinological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
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16
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Strosberg DS, Corbey T, Henry JC, Starr JE. Preoperative antiplatelet use does not increase incidence of bleeding after major operations. Surgery 2016; 160:968-976. [DOI: 10.1016/j.surg.2016.05.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 04/26/2016] [Accepted: 05/19/2016] [Indexed: 11/28/2022]
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Schweer D, Carmouche JJ, Jupiter D, Ball T, Clements JR. Evaluating Blood Loss and the Effect of Antiplatelet Treatment in Foot and Ankle Amputations. J Foot Ankle Surg 2016; 55:1210-1215. [PMID: 27614827 DOI: 10.1053/j.jfas.2016.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Indexed: 02/03/2023]
Abstract
The interrelationship between diabetes mellitus and cardiovascular disease is well-documented, and, secondary to the latter, is the use of antiplatelet therapy. Although diabetes and the associated vascular manifestations are driving forces behind lower extremity amputations, few data are available on the risks of perioperative antiplatelet therapy with foot and ankle amputations. The goal of the present study was to address the surgical effect of continuing or discontinuing antiplatelet therapy before foot and/or ankle amputation. The following data were retrospectively collected: blood loss, pre- and postoperative hematocrit and hemoglobin, operative time, amputation type, age, diabetic status, antiplatelet treatment, and number of transfusions during the perioperative period. Perioperative antiplatelet therapy was defined as exposure to aspirin or clopidogrel within 3 days before surgery. To compare the outcomes between groups, the following factors were analyzed using bivariate analyses and then multivariate regression models: (1) the need for transfusions, (2) high blood loss (>20 mL), (3) volume of blood loss, and (4) operative time. The noninferiority of continued antiplatelet use was assessed in terms of operative time and blood loss, using a noninferiority margin of 10 minutes or 10 mL, respectively. Antiplatelet therapy was not a statistically significant risk factor for any of the studied outcomes on multivariate analysis. Equivalence testing revealed that continuing antiplatelet therapy is not inferior to discontinuing perioperative therapy in terms of blood loss and operative time. Multivariate analysis of the data suggested that antiplatelet therapy has no statistically significant impact on blood loss, transfusion rate, or operative time.
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Affiliation(s)
- David Schweer
- Department of Orthopaedics, Carilion Clinic, Musculoskeletal Education and Research Center, Virginia Tech-Carilion School of Medicine and Research Institute, Roanoke, VA
| | - Jonathon J Carmouche
- Department of Orthopaedics, Carilion Clinic, Musculoskeletal Education and Research Center, Virginia Tech-Carilion School of Medicine and Research Institute, Roanoke, VA
| | - Daniel Jupiter
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Timothy Ball
- Department of Cardiology, Carilion Clinic, Virginia Tech-Carilion School of Medicine and Research Institute, Roanoke, VA
| | - J Randolph Clements
- Department of Orthopaedics, Carilion Clinic, Musculoskeletal Education and Research Center, Virginia Tech-Carilion School of Medicine and Research Institute, Roanoke, VA.
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Bablekos GD, Analitis A, Michaelides SA, Charalabopoulos KA, Tzonou A. Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:213. [PMID: 27386487 DOI: 10.21037/atm.2016.06.02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients. METHODS Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses. RESULTS The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95] (first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second meta-analysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled three- and five- year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability. CONCLUSIONS Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.
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Affiliation(s)
- George D Bablekos
- 1 Technological Educational Institute of Athens, Faculty of Health and Caring Professions, Agiou Spyridonos, 12243, Egaleo, Athens, Greece ; 2 Department of Physiology, Medical School, Democritus University of Thrace, Dragana 68100, Alexandroupolis, Greece ; 3 Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527, Goudi, Athens, Greece ; 4 Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio" General Hospital, 15126, Maroussi, Athens, Greece
| | - Antonis Analitis
- 1 Technological Educational Institute of Athens, Faculty of Health and Caring Professions, Agiou Spyridonos, 12243, Egaleo, Athens, Greece ; 2 Department of Physiology, Medical School, Democritus University of Thrace, Dragana 68100, Alexandroupolis, Greece ; 3 Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527, Goudi, Athens, Greece ; 4 Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio" General Hospital, 15126, Maroussi, Athens, Greece
| | - Stylianos A Michaelides
- 1 Technological Educational Institute of Athens, Faculty of Health and Caring Professions, Agiou Spyridonos, 12243, Egaleo, Athens, Greece ; 2 Department of Physiology, Medical School, Democritus University of Thrace, Dragana 68100, Alexandroupolis, Greece ; 3 Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527, Goudi, Athens, Greece ; 4 Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio" General Hospital, 15126, Maroussi, Athens, Greece
| | - Konstantinos A Charalabopoulos
- 1 Technological Educational Institute of Athens, Faculty of Health and Caring Professions, Agiou Spyridonos, 12243, Egaleo, Athens, Greece ; 2 Department of Physiology, Medical School, Democritus University of Thrace, Dragana 68100, Alexandroupolis, Greece ; 3 Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527, Goudi, Athens, Greece ; 4 Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio" General Hospital, 15126, Maroussi, Athens, Greece
| | - Anastasia Tzonou
- 1 Technological Educational Institute of Athens, Faculty of Health and Caring Professions, Agiou Spyridonos, 12243, Egaleo, Athens, Greece ; 2 Department of Physiology, Medical School, Democritus University of Thrace, Dragana 68100, Alexandroupolis, Greece ; 3 Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 11527, Goudi, Athens, Greece ; 4 Department of Occupational Lung Diseases and Tuberculosis, "Sismanogleio" General Hospital, 15126, Maroussi, Athens, Greece
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19
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Yu WS, Jung HS, Lee JG, Kim DJ, Chung KY, Lee CY. Safety of thoracoscopic surgery for lung cancer without interruption of anti-platelet agents. J Thorac Dis 2015; 7:2024-32. [PMID: 26716042 DOI: 10.3978/j.issn.2072-1439.2015.11.40] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Perioperative bleeding concerns have led to the general recommendation that antiplatelet agents (APAs) be discontinued 7-10 days preoperatively, but this could increase the risk of perioperative cardiovascular events. This retrospective study aimed to evaluate the safety of APA continuation during thoracoscopic surgery for lung cancer. METHODS Between January 2009 and February 2015, 164 patients taking APAs underwent curative resection. Comparisons were conducted between two groups: preoperatively interrupted APA administration (group I, n=106) and continued APA administration (group N, n=58). RESULTS Group N had a significantly higher revised cardiac risk index (rCRI) (P=0.001). Lobectomy was performed in the majority of patients [95 (89.6%) in group I; 52 (89.7%) in group N]. There were no significant differences in intraoperative outcomes, such as the thoracotomy conversion rate, operating time, intraoperative transfusion, and amount of blood loss during the operation, or postoperative outcomes, such as postoperative bleeding and thrombotic complications, postoperative transfusions, and operative mortality. Within group N, the patients taking aspirin + clopidogrel (n=11) had significantly greater postoperative bleeding (P=0.005), and more postoperative transfusions (P=0.003) and chest tube drainage over a 3-day period (P=0.049) compared with other antiplatelet regimens. CONCLUSIONS Continued use of APAs during thoracoscopic surgery for lung cancer could be safely done in patients at high risk of cardiac or thrombotic events. However, in patients administered aspirin + clopidogrel, it may be the best to continue aspirin only because of an increased risk of postoperative bleeding and transfusion requirements.
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Affiliation(s)
- Woo Sik Yu
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Suk Jung
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Gu Lee
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae Joon Kim
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Young Chung
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Young Lee
- 1 Department of Thoracic Surgery, Armed Forces Capital Hospital, Seongnam-si, Kyunggi-do, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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20
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21
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Siller-Matula JM, Petre A, Delle-Karth G, Huber K, Ay C, Lordkipanidzé M, De Caterina R, Kolh P, Mahla E, Gersh BJ. Impact of preoperative use of P2Y12 receptor inhibitors on clinical outcomes in cardiac and non-cardiac surgery: A systematic review and meta-analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:753-770. [DOI: 10.1177/2048872615585516] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | - Alexandra Petre
- Department of Cardiology, Medical University of Vienna, Austria
| | | | - Kurt Huber
- 3rd Medical Department of Cardiology and Emergency Medicine, Wilhelminen Hospital, Vienna, Austria
| | - Cihan Ay
- Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Austria
| | - Marie Lordkipanidzé
- Faculty of Pharmacy, University of Montreal; Research Center, Montreal Heart Institute, Canada
| | - Raffaele De Caterina
- Institute of Cardiology, ‘G d’Annunzio’ University – Chieti-Pescara, Chieti, Italy
| | - Philippe Kolh
- Department of Cardiothoracic Surgery, University Hospital of Liege, Belgium
| | - Elisabeth Mahla
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Austria
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, College of Medicine Rochester, USA
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22
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Scheubel R. [Anticoagulants in thoracic surgery]. Chirurg 2015; 86:419-22. [PMID: 25648435 DOI: 10.1007/s00104-014-2864-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Many patients undergoing thoracic surgery are treated with anticoagulants or platelet aggregation inhibitors because of different comorbidities. Additionally the risk of thromboembolic events is increased perioperatively; therefore, a perioperative thrombosis prophylaxis is necessary. On the other hand the risk of intraoperative or postoperative bleeding is increased because of the volume of the thoracic cavity and the partially negative intrathoracic pressure. OBJECTIVES This article gives an overview of the perioperative management of anticoagulant therapy in thoracic surgery and presents an appropriate approach in cases of severe bleeding. MATERIAL AND METHODS A literature search was carried out regarding currently used anticoagulants. RESULTS AND CONCLUSION For the correct perioperative application of vitamin K antagonists, platelet aggregation inhibitors, new oral anticoagulants and drugs for thrombosis prophylaxis, it is of major importance to conceive an individual risk profile of thoracic surgery patients. However, there are not enough evidence-based data referring to the correct perioperative management for new oral anticoagulants.
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Affiliation(s)
- R Scheubel
- Thoraxchirurgische Klinik, Fachkliniken Wangen, Am Vogelherd 14, 88239, Wangen/Allgäu, Deutschland,
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23
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D'Andrilli A, Cavaliere I, Maurizi G, Andreetti C, Ciccone AM, Ibrahim M, Baldini R, Venuta F, Rendina EA. Evaluation of the efficacy of a haemostatic matrix for control of intraoperative and postoperative bleeding in major lung surgery: a prospective randomized study. Eur J Cardiothorac Surg 2014; 48:679-83. [PMID: 25543176 DOI: 10.1093/ejcts/ezu484] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 11/25/2014] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES This prospective randomized study was designed to assess the safety and efficacy of a haemostatic matrix in intraoperative bleeding control and prevention of postoperative bleeding after major lung surgery. METHODS One hundred and twenty patients undergoing major lung resection and presenting with intraoperative persistent active bleeding have been prospectively enrolled and randomly assigned to receive [Floseal® group (FG)] or not (control group) the application of Floseal® to the bleeding site and to the site of the hilar dissection. To evaluate the efficacy of the product, several intraoperative and postoperative data were compared between the two groups. RESULTS No adverse event related to the haemostatic matrix application occurred. The intraoperative haemostasis rate at 3 (primary end-point), 6 and 10 min was significantly higher and the mean time to haemostasis was significantly shorter in the FG. The quantity of chest drain fluids did not show significant differences at 24, 48 and 72 h between the two groups. Postoperative haemoglobin-level variation was significantly lower in patients of the FG (-0.7 ± 0.66 vs -2.3 ± 5.87 g/dl; P = 0.04). Similarly, haematocrit variation was lower in the haemostatic group (-2.6 ± 2.19 vs -4.2 ± 3.71; P = 0.006). The chest drain duration resulted significantly shorter in the FG (10.3 ± 5.05 vs 13.3 ± 6.28 days; P = 0.005). In-hospital stay was shorter in the FG (6.4 ± 2.9 vs 8.1 ± 5.42 days; P = 0.044). CONCLUSIONS In conclusion, the application of Floseal® in major lung resections proved safe and effective in increasing the intraoperative successful haemostasis rate and in reducing postoperative variation in haemoglobin and haematocrit levels. The sealant use was also related with a significantly shorter chest drain duration and hospitalization.
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Affiliation(s)
- Antonio D'Andrilli
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Ilenia Cavaliere
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University, Rome, Italy University of Pisa, Pisa, Italy
| | - Giulio Maurizi
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Claudio Andreetti
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Anna Maria Ciccone
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Mohsen Ibrahim
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | | | - Federico Venuta
- Department of Thoracic Surgery, Policlinico Umberto I, Sapienza University, Rome, Italy Lorillard Spencer Cenci Foundation, Rome, Italy
| | - Erino A Rendina
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University, Rome, Italy Lorillard Spencer Cenci Foundation, Rome, Italy
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Anderson K, Jupiter DC, Abernathy SW, Frazee RC. Should clopidogrel be discontinued before laparoscopic cholecystectomy? Am J Surg 2014; 208:926-31; discussion 930-1. [PMID: 25435299 DOI: 10.1016/j.amjsurg.2014.08.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/21/2014] [Accepted: 08/25/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND The perioperative management of clopidogrel remains an area of controversy. METHODS An institutional review board-approved retrospective review of patients undergoing a laparoscopic cholecystectomy while on clopidogrel from 2008 to 2012 was performed. These patients were then matched with a nonclopidogrel cohort based on American Society of Anesthesiologists score and emergent or elective surgery. Intraoperative estimated blood loss, operative time, length of stay, and 30-day morbidity were compared. RESULTS Thirty-six clopidogrel and 36 control patient records were analyzed. There were no significant differences in age, body mass index, sex, or incidence of coronary artery disease, diabetes, hyperlipidemia, and congestive heart failure. Estimated blood loss averaged 50 mL in the clopidogrel group and 47 mL in the control group (P = nonsignificant). There were no significant differences in operative time, 30-day morbidity, or length of stay between the 2 groups. CONCLUSIONS Laparoscopic cholecystectomy performed on patients maintained on clopidogrel during the perioperative period did not produce an increase in blood loss, operative time, 30-day morbidity, or length of stay.
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Affiliation(s)
- Katherine Anderson
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA
| | - Daniel C Jupiter
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA
| | | | - Richard C Frazee
- Baylor Scott & White Health, 2401 South 31st Street, Temple, TX 76508, USA.
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Spyratos D, Zarogoulidis P, Porpodis K, Angelis N, Papaiwannou A, Kioumis I, Pitsiou G, Pataka A, Tsakiridis K, Mpakas A, Arikas S, Katsikogiannis N, Kougioumtzi I, Tsiouda T, Machairiotis N, Siminelakis S, Argyriou M, Kotsakou M, Kessis G, Kolettas A, Beleveslis T, Zarogoulidis K. Preoperative evaluation for lung cancer resection. J Thorac Dis 2014; 6 Suppl 1:S162-6. [PMID: 24672690 DOI: 10.3978/j.issn.2072-1439.2014.03.06] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 03/07/2014] [Indexed: 12/25/2022]
Abstract
During the last decades lung cancer is the leading cause of death worldwide for both sexes. Even though cigarette smoking has been proved to be the main causative factor, many other agents (e.g., occupational exposure to asbestos or heavy metals, indoor exposure to radon gas radiation, particulate air pollution) have been associated with its development. Recently screening programs proved to reduce mortality among heavy-smokers although establishment of such strategies in everyday clinical practice is much more difficult and unknown if it is cost effective compared to other neoplasms (e.g., breast or prostate cancer). Adding severe comorbidities (coronary heart disease, COPD) to the above reasons as cigarette smoking is a common causative factor, we could explain the low surgical resection rates (approximately 20-30%) for lung cancer patients. Three clinical guidelines reports of different associations have been published (American College of Chest Physisians, British Thoracic Society and European Respiratory Society/European Society of Thoracic Surgery) providing detailed algorithms for preoperative assessment. In the current mini review, we will comment on the preoperative evaluation of lung cancer patients.
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Affiliation(s)
- Dionysios Spyratos
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Paul Zarogoulidis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Konstantinos Porpodis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Nikolaos Angelis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Antonios Papaiwannou
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Ioannis Kioumis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Georgia Pitsiou
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Athanasia Pataka
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Kosmas Tsakiridis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Andreas Mpakas
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Stamatis Arikas
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Nikolaos Katsikogiannis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Ioanna Kougioumtzi
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Theodora Tsiouda
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Nikolaos Machairiotis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Stavros Siminelakis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Michael Argyriou
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Maria Kotsakou
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - George Kessis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Alexander Kolettas
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Thomas Beleveslis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
| | - Konstantinos Zarogoulidis
- 1 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 3 Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece ; 4 Internal Medicine Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece ; 5 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 6 2nd Cardiac Surgery Department, "Evangelismos" General Hospital, Athens, Greece ; 7 Electrophysiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 8 Oncology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 9 Anesthisiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece ; 10 Cardiology Department, "Saint Luke" Private Clinic, Thessaloniki, Panorama, Greece
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Rossini R, Musumeci G, Visconti LO, Bramucci E, Castiglioni B, De Servi S, Lettieri C, Lettino M, Piccaluga E, Savonitto S, Trabattoni D, Capodanno D, Buffoli F, Parolari A, Dionigi G, Boni L, Biglioli F, Valdatta L, Droghetti A, Bozzani A, Setacci C, Ravelli P, Crescini C, Staurenghi G, Scarone P, Francetti L, D’Angelo F, Gadda F, Comel A, Salvi L, Lorini L, Antonelli M, Bovenzi F, Cremonesi A, Angiolillo DJ, Guagliumi G. Perioperative management of antiplatelet therapy in patients with coronary stents undergoing cardiac and non-cardiac surgery: a consensus document from Italian cardiological, surgical and anaesthesiological societies. EUROINTERVENTION 2014; 10:38-46. [DOI: 10.4244/eijv10i1a8] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
BACKGROUND Thoracentesis is commonly performed to evaluate pleural effusions. Many medications (warfarin, heparin, clopidogrel) or physiological factors (elevated International Normalized Ratio [INR], thrombocytopenia, uremia) increase the risk for bleeding. Frequently these medications are withheld or transfusions are performed to normalize physiological parameters before a procedure. The safety of performing thoracentesis without correction of these bleeding risks has not been prospectively evaluated. METHODS This prospective observational cohort study enrolled 312 patients who underwent thoracentesis. All patients were evaluated for the presence of risk factors for bleeding. Hematocrit levels were obtained pre- and postprocedure, and the occurrence of postprocedural hemothorax was evaluated. MEASUREMENTS AND MAIN RESULTS Thoracenteses were performed in 312 patients, 42% of whom had a risk for bleeding. Elevated INR, secondary to liver disease or warfarin, and renal disease were the two most common etiologies for bleeding risk, although many patients had multiple potential bleeding risks. There was no significant difference in pre- and postprocedural hematocrit levels in patients with a bleeding risk when compared with patients with no bleeding risk. No patient developed a hemothorax as a result of the thoracentesis. CONCLUSIONS This single-center, observational study suggests that thoracentesis may be safely performed without prior correction of coagulopathy, thrombocytopenia, or medication-induced bleeding risk. This may reduce the morbidity associated with transfusions or withholding of medications.
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Abstract
Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.
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Affiliation(s)
- A D Oprea
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
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Hemorrhagic Complications of Thoracentesis and Small-Bore Chest Tube Placement in Patients Taking Clopidogrel. Ann Am Thorac Soc 2014; 11:73-9. [DOI: 10.1513/annalsats.201303-050oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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Benahmed A, Kianda M, Ghisdal L, Broeders N, Massart A, Lemy A, Mikhalski D, Hoang AD, Donckier V, Sadis C, Le Moine A, Madhoun P, Racape J, Wissing M, Abramowicz D. Ticlopidine and clopidogrel, sometimes combined with aspirin, only minimally increase the surgical risk in renal transplantation: a case-control study. Nephrol Dial Transplant 2013; 29:463-6. [DOI: 10.1093/ndt/gft385] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Oprea AD, Popescu WM. ADP-Receptor Inhibitors in the Perioperative Period: The Good, the Bad, and the Ugly. J Cardiothorac Vasc Anesth 2013; 27:779-95. [DOI: 10.1053/j.jvca.2012.11.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Indexed: 02/02/2023]
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Effect of routine clopidogrel use on bleeding complications after ultrasound-guided thoracentesis. J Bronchology Interv Pulmonol 2013. [PMID: 23207527 DOI: 10.1097/lbr.0b013e3182720428] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Thoracentesis is one of the most commonly performed medical procedures with an excellent safety profile. Clopidogrel (a compound that inhibits adenosine diphosphate-induced platelet aggregation) is often prescribed for primary or secondary prevention of cardiovascular disease and has been associated with bleeding complications in patients undergoing surgical procedures. The purpose of this study was to assess the safety of ultrasound (US)-guided thoracentesis in patients receiving clopidogrel therapy. METHODS Data were collected on 30 consecutive patients taking clopidogrel without other known underlying coagulation problems. These patients underwent 45 US-guided thoracenteses over 26 months. Clopidogrel was not discontinued before the thoracentesis in patients presenting with symptomatic pleural effusion. Thoracenteses were performed in these patients and the incidence of bleeding and other complications among patients was reported. RESULTS Between June 2009 and August 2011, there were 30 consecutive patients on clopidogrel at the time of thoracenteses. These patients presented with respiratory distress because of pleural effusion and underwent a total of 45 thoracenteses. There was no significant bleeding or other complications in this patient population. No patient required transfusion after the procedure. CONCLUSION Patients who are receiving clopidogrel and present with symptomatic pleural effusion can safely undergo US-guided thoracentesis without interrupting clopidogrel before the procedure. Larger studies are required to confirm these results.
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Rouine-Rapp K, McDermott MW. Perioperative management of a neurosurgical patient with a meningioma and recent coronary artery stent. J Clin Anesth 2013; 25:228-31. [DOI: 10.1016/j.jclinane.2012.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 10/14/2012] [Accepted: 11/11/2012] [Indexed: 11/24/2022]
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Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery. Chest 2013; 143:e166S-e190S. [DOI: 10.1378/chest.12-2395] [Citation(s) in RCA: 542] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Incremental Risk of Prior Coronary Arterial Stents for Pulmonary Resection. Ann Thorac Surg 2013; 95:1212-8; discussion 1219-20. [DOI: 10.1016/j.athoracsur.2013.01.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 01/07/2013] [Accepted: 01/11/2013] [Indexed: 11/21/2022]
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Safety of Ultrasound-guided Small-Bore Chest Tube Insertion in Patients on Clopidogrel. J Bronchology Interv Pulmonol 2013; 20:16-20. [DOI: 10.1097/lbr.0b013e31828194f9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Perioperative management of anticoagulants requires one to balance the patient's risk factors for operative bleeding, the type of operation to be performed, and the patient's risk of thromboembolism. At present, no set algorithm exists for the perioperative management of all the anticoagulants. In this article, we address the perioperative management of the most commonly used anticoagulants seen in practice today, such as warfarin, heparin, dabigatran, clopidogrel, and aspirin, for the most commonly performed general thoracic operations.
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Affiliation(s)
- Robert J Cerfolio
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 703 19th Street South, ZRB 739, Birmingham, AL 35294, USA.
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[Perioperative management of antiplatelet therapy in thoracic surgery. A survey of German hospitals]. Chirurg 2012; 83:576-82. [PMID: 22327953 DOI: 10.1007/s00104-011-2252-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND The common practice to stop therapy with acetylsalicylic acid (aspirin) and/or clopidogrel perioperatively is critically discussed in the literature. There are no generally accepted guidelines for the handling of this problem. In this article the present strategy of perioperative antiplatelet therapy applied in German thoracic surgery departments was investigated. METHODS Questionnaires were sent to the heads of thoracic surgery departments registered in the German Society of Thoracic Surgery (n = 133) inquiring about the handling of aspirin and clopidogrel before elective thoracic surgical procedures. The return ratio was 59% (n = 78). RESULTS The analysis of the survey results showed a heterogeneous approach. Of the respondents 51-53% reported stopping aspirin therapy before surgery if the patient was taking aspirin due to a bare metal stent (implantation 3 months before). An even larger number of respondents stopped aspirin therapy before surgery if the patient was taking aspirin due to an ischemic insult or due to peripheral arterial disease with infrainguinal stenting (59-63% and 59-65%, respectively). In the case of drug-eluting stent implantation (implantation 3 months before) 34-41% of the respondents completely stopped the dual antiplatelet therapy before surgery and only 6-8% of the surgeons proceeded with surgery under dual platelet inhibition. Of the thoracic surgeons questioned 28% considered the existing data sufficient to manage this problem. Those surgeons who considered the existing data concerning the management of perioperative antiplatelet therapy as adequate had a stronger tendency to continue the antiplatelet therapy perioperatively. The aspirin and clopidogrel therapy was usually stopped 5-7 days preoperatively. CONCLUSIONS The survey showed that in Germany the majority of thoracic surgeons reduce or stop antiplatelet therapy (given as secondary prophylaxis) before surgical procedures. It can be assumed that patients are therefore exposed to an increased risk of cardiovascular morbidity and mortality.
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Bertolaccini L, Terzi A, Rizzardi G, Gorla A, Viti A, Palmisano S, Coletta G. Risk is not our business: safety of thoracic surgery in patients using antiplatelet therapy. Interact Cardiovasc Thorac Surg 2011; 14:162-6. [PMID: 22159230 DOI: 10.1093/icvts/ivr005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
American Heart Association recommendations have changed preoperative management of patients with antiplatelet therapy (APT). We assessed safety and outcomes of surgery in patients who were receiving APT. A prospective study of patients operated on while receiving APT was matched with those with no APT (ratio 1:4), using the propensity score method. Logistic regression analysis was used to identify covariates among imbalanced baseline patient variables. Both χ(2) test and Fisher's test were used to calculate the probability value for the comparison of dichotomous variables. Between January 2008 and December 2010, 38 patients who received APT at the time of surgery were matched with 141 patients who had not received APT. APT indications were a history of myocardial infarction, coronary artery by-pass graft and/or valve replacement (19), coronary artery stent (11) and severe peripheral vascular disease (8). None of the patients required re-operation for bleeding. Two patients received blood transfusions. The amount of chest tube drainage was not statistically significantly different. There were no statistically significant differences between the outcomes for the operative time, length of hospital stay, estimated blood loss or morbidity. The results show that thoracic surgical procedures can safely be performed in patients receiving APT at the time of surgery, with no increased risk of bleeding or morbidity and no differences in the operative time and the length of hospital stay.
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Affiliation(s)
- Luca Bertolaccini
- Thoracic Surgery Unit, S. Croce e Carle City Hospital, Cueno, Italy.
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Ferguson MK, Celauro AD, Vigneswaran WT. Validation of a modified scoring system for cardiovascular risk associated with major lung resection. Eur J Cardiothorac Surg 2011; 41:598-602. [PMID: 22345181 DOI: 10.1093/ejcts/ezr081] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The well-known revised cardiac risk index (RCRI) has recently been modified based on factors and outcomes specific to thoracic surgery patients (ThRCRI). We explored the accuracy of this modified scoring system in predicting cardiovascular morbidity after major lung resection. METHODS We analyzed outcomes from a prospective database of patients undergoing major lung resection 1980-2009. ThRCRI score was based on weighted factors for serum creatinine, coronary artery disease, cerebrovascular disease and extent of lung resection. Target adverse outcomes included pulmonary embolism, myocardial infarction, cardiac arrest, pulmonary edema and cardiac death. RESULTS A total of 1255 patients (mean age 61.8 years; 649 men) underwent lobectomy or bilobectomy (1070; 85%) or pneumonectomy (185; 15%) for cancer (1037; 83%) or other problems. Severe cardiovascular complications occurred in 30 patients (2.4%), an incidence similar to that in the published derivation group (3.3%). ThRCRI median scores in patients without and with severe CV complications were 0 and 1.5 (P < 0.001). Score categories yielded incremental risks of cardiovascular complications (0: 0.9%; 1-1.5: 4.5%; ≥ 2: 12.8%; P < 0.001). The Hosmer-Lemeshow test demonstrated no significant difference between expected and observed outcomes (P = 0.11). CONCLUSIONS The incidences of severe postoperative cardiovascular complications were similar in the published derivation group and the current validation group. The ThRCRI score successfully stratified risk for postoperative cardiovascular events after major lung resection in the validation group. The expected risk in the validation group was similar to the observed risk, indicating that ThRCRI accurately predicted specific risk rather than just relative risk. Further evaluation of the utility of this scoring system is warranted.
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Affiliation(s)
- Mark K Ferguson
- Department of Surgery, The University of Chicago, Chicago, IL 60637, USA.
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Ceppa DP, Welsby IJ, Wang TY, Onaitis MW, Tong BC, Harpole DH, D'Amico TA, Berry MF. Perioperative management of patients on clopidogrel (Plavix) undergoing major lung resection. Ann Thorac Surg 2011; 92:1971-6. [PMID: 21978871 DOI: 10.1016/j.athoracsur.2011.07.052] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 07/12/2011] [Accepted: 07/19/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Management of patients requiring antiplatelet therapy with clopidogrel (Plavix) and major lung resection must balance the risks of bleeding and cardiovascular events. We reviewed our experience with patients treated with clopidogrel perioperatively to examine outcomes, including results of a new strategy for high-risk patients. METHODS Patients who underwent major lung resection and received perioperative clopidogrel between January 2005 and September 2010 were reviewed. Initially, clopidogrel management consisted of discontinuation approximately 5 days before surgery and resumption immediately after surgery. After July 2010, high-risk patients (drug-eluting coronary stent placement within prior year or previous coronary event after clopidogrel discontinuation) were admitted 2 to 3 days preoperatively and bridged with the intravenous glycoprotein IIb/IIIa receptor inhibitor eptifibatide (Integrilin) according to a multidisciplinary cardiology/anesthesiology/thoracic surgery protocol. Outcomes were compared with control patients (matched for preoperative risk factors and extent of pulmonary resection) who did not receive perioperative clopidogrel. RESULTS Fifty-four patients who had major lung resection between January 2005 and September 2010 and received clopidogrel perioperatively were matched with 108 control subjects. Both groups had similar mortality, postoperative length of stay, and no differences in the rates of perioperative transfusions, reoperations for bleeding, myocardial infarctions, and strokes. Seven of the 54 clopidogrel patients were admitted preoperatively for an eptifibatide bridge. Two of these patients received perioperative transfusions, but there were no deaths, reoperations, myocardial infarctions, or stroke. CONCLUSIONS Patients taking clopidogrel can safely undergo major lung resection. Treatment with an eptifibatide bridge may minimize the risk of cardiovascular events in higher risk patients.
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Affiliation(s)
- Duykhanh P Ceppa
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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Murray AT, Sederberg JH. Intraoperative thrombosis of right coronary artery drug-eluting stent after 2 years of dual antiplatelet therapy. Semin Cardiothorac Vasc Anesth 2011; 15:40-3. [PMID: 21840879 DOI: 10.1177/1089253211411105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study presents the case of intraoperative thrombosis of a right coronary drug-eluting stent and subsequent right heart ischemia more than 2 years poststent placement and after recent withdrawal of clopidogrel therapy. Dual antiplatelet therapy had been continued uninterrupted since placement until 7 days prior to surgery when clopidogrel was stopped. This case highlights the emerging evidence that drug-eluting stents are susceptible to late occlusive thrombosis on acute withdrawal of antiplatelet therapy. Right heart ischemia resolved with rapid intraoperative management and emergent cardiac catheterization. This emphasizes the necessity of immediate availability to cardiac interventional facilities, which can influence outcomes.
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Affiliation(s)
- Aaron T Murray
- University of Colorado Denver School of Medicine, Aurora, CO, USA
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