1
|
Li Y, Wu Z. Effect of topical application of autologous platelet gel on sternal wound infection after cardiac surgery: A meta-analysis. Int Wound J 2024; 21:e14761. [PMID: 38420690 PMCID: PMC10902688 DOI: 10.1111/iwj.14761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 03/02/2024] Open
Abstract
Following heart operation, a severe life-threatening complication has been identified by investigators who have recently discovered that local application of platelet-rich plasma (PRP) can lower the rate of wound infection in heart surgery. Nevertheless, due to the low quality of these trials, we have tried to perform high-quality meta-analyses to prove the efficacy of PRP in heart surgery for post-operative wound infections. In this study, five randomised controlled trials (RCTs) were chosen from three databases, and there were 1005 studies to analyse the data. Among 181 cases, PRP was applied to the surgical site, and 205 in the control group. Both the CI and the OR or the average difference (MD) were computed with either a fixed or random-effect model. A meta-analysis of the data was carried out with RevMan 5.3. The results showed that there were no statistically significant differences in the incidence of post-operative surgical site infection (SSI) in control group compared to those treated with PRP gel (OR, 0.97; 95% CI, 0.38, 2.47; p = 0.95); In the heart operation, the local application of PRP gel decreased the rate of drainage after operation (MD, -217.82; 95% CI, -335.38, -100.26; p = 0.0003); The operation time of the PRP gel was not significantly different from that of the control group (MD, 12.65; 95% CI, -2.95, 28.24; p = 0.11). Contrary to earlier research, the application of autoplatelet gel in heart surgery did not seem to decrease operative site infections after the operation, but it did decrease the amount of postoperative drainage. Nevertheless, because of the limited number of RCTs in this meta-analysis, caution should be exercised in their treatment. More high-quality randomised, large-sample trials are required to further confirm the findings.
Collapse
Affiliation(s)
- Yifan Li
- Department of Cardiovascular Surgery, West China HospitalSichuan UniversityChengduChina
| | - Zhong Wu
- Department of Cardiovascular Surgery, West China HospitalSichuan UniversityChengduChina
| |
Collapse
|
2
|
Wang TF, Sanfilippo KM, Douketis J, Falanga A, Karageorgiou J, Maraveyas A, Ortel TL, Soff G, Vedantham S, Zwicker JI. Peri-procedure management of antithrombotic agents and thrombocytopenia for common procedures in oncology: Guidance from the SSC of the ISTH. J Thromb Haemost 2022; 20:3026-3038. [PMID: 36217296 DOI: 10.1111/jth.15896] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/31/2022] [Accepted: 09/23/2022] [Indexed: 01/13/2023]
Abstract
Patients with cancer have an increased risk of thrombosis requiring anticoagulants and/or antiplatelet agents, and they can also encounter thrombocytopenia due to cancer itself or cancer therapies. They often undergo many procedures such as tissue or bone marrow biopsies, placement of central access lines, diagnostic or therapeutic draining procedures, lumbar puncture, and more. Management of antithrombotic agents or thrombocytopenia around the time of these procedures is highly variable. In this document, the Hemostasis and Malignancy Subcommittee of the International Society on Thrombosis and Haemostasis aims to provide useful practice guidance in the management of antithrombotic agents and thrombocytopenia around the time of common procedures in patients with cancer.
Collapse
Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kristen M Sanfilippo
- Division of Hematology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anna Falanga
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - John Karageorgiou
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | | | - Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University, Durham, North Carolina, USA
- Department of Pathology, Duke University, Durham, North Carolina, USA
| | - Gerald Soff
- Division of Hematology, University of Miami Health System/Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Jeffrey I Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 93] [Impact Index Per Article: 46.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
Collapse
Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| |
Collapse
|
4
|
Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis. Mayo Clin Proc Innov Qual Outcomes 2022; 6:564-573. [PMID: 36304523 PMCID: PMC9594114 DOI: 10.1016/j.mayocpiqo.2022.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To summarize the available evidence about the perioperative management of patients who are receiving long-term antiplatelet therapy and require elective surgery/procedures. METHODS This systematic review supports the development of the American College of Chest Physicians guideline on the perioperative management of antiplatelet therapy. A literature search of MEDLINE, EMBASE, Scopus and Cochrane databases was conducted from each database's inception to July 16, 2020. Meta-analyses were conducted when possible. RESULTS In patients receiving long-term antiplatelet therapy and undergoing elective noncardiac surgery, the available evidence did not show a significant difference in major bleeding between a shorter vs longer antiplatelet interruption, with low certainty of evidence (COE). Compared with patients who received placebo perioperatively, aspirin continuation was associated with increased risk of major bleeding (relative risk [RR], 1.31; 95% CI, 1.15-1.50; high COE) and lower risk of major thromboembolism (RR, 0.74; 95% CI, 0.58-0.94; moderate COE). During antiplatelet interruption, bridging with low-molecular-weight heparin was associated with increased risk of major bleeding compared with no bridging (RR, 1.86; 95% CI, 1.24-2.79; very low COE). Continuation of antiplatelets during minor dental and ophthalmologic procedures was not associated with a statistically significant difference in the risk of major bleeding (very low COE). CONCLUSION This systematic review summarizes the current evidence about the perioperative management of antiplatelet therapy and highlights the urgent need for further research, particularly with the increasing prevalence of patients taking 1 or more antiplatelet agents.
Collapse
Key Words
- ACCP/CHEST, American College of Chest Physicians
- ASA, acetylsalicylic acid
- ATE, arterial thromboembolism
- CABG, coronary artery bypass graft
- COE, certainty of evidence
- CV, cardiovascular
- DES, drug-eluting stent
- LMWH, low-molecular-weight heparin
- MI, myocardial infarction
- PE, pulmonary embolism
- PICO, patients–interventions–comparators–outcomes
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RCT, randomized clinical trial
- RR, relative risk
Collapse
|
5
|
Misfeld M, Bannon PG, Borger MA, Yan TD. Damage control in cardiac surgery: Knowing when to come back another day. JTCVS Tech 2021; 10:362-366. [PMID: 34977755 PMCID: PMC8691789 DOI: 10.1016/j.xjtc.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/10/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Martin Misfeld
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Paul G. Bannon
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, Australia
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Michael A. Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Tristan D. Yan
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- The Collaborative Research Group (CORE), Macquarie University, Sydney, Australia
- Sydney Adventist Hospital, University of Sydney, Sydney, Australia
| |
Collapse
|
6
|
Salenger R, Mazzeffi MA. The 7 Pillars of Blood Conservation in Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:504-509. [PMID: 34821153 DOI: 10.1177/15569845211051683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rawn Salenger
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Saint Joseph Medical Center, Towson, MD, USA.,Departments of Anesthesiology and Critical Care Medicine, 43989George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Michael A Mazzeffi
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Saint Joseph Medical Center, Towson, MD, USA.,Departments of Anesthesiology and Critical Care Medicine, 43989George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| |
Collapse
|
7
|
STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:97-124. [PMID: 34194077 DOI: 10.1182/ject-2100053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 12/16/2022]
|
8
|
Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. Ann Thorac Surg 2021; 112:981-1004. [PMID: 34217505 DOI: 10.1016/j.athoracsur.2021.03.033] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
| |
Collapse
|
9
|
Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. J Cardiothorac Vasc Anesth 2021; 35:2569-2591. [PMID: 34217578 DOI: 10.1053/j.jvca.2021.03.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
| |
Collapse
|
10
|
Micovic S, Everts P, Calija B, Strugarevic E, Grubor N, Boricic M, Lesanovic J, Box H, Abazovic D. Novel autologous, high concentrated fibrin as advanced hemostatic agent for coronary surgery. Transfus Apher Sci 2021; 60:103171. [PMID: 34099403 DOI: 10.1016/j.transci.2021.103171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/09/2021] [Accepted: 05/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Variability in transfusion outcomes and excessive postoperative bleeding represents a significant problem in cardiac surgery. The effort to reduce bleeding complications and transfusion outcomes is desirable. Our study investigated the feasibility of reducing bleeding complications and transfusion requirements by applying perioperatively prepared autologous bio-regenerative fibrin sealant. METHODS A prospective, case-control study enrolled 74 patients undergoing coronary artery bypass grafting by a single surgeon. Patients in the control group (N = 43), received traditional methods of hemostasis, while patients in the experimental group (N = 31) were treated additionally with autologous bio-regenerative fibrin. RESULTS Patients were well-matched with regard to basic demographic, laboratory and procedural data. Allogeneic blood transfusion requirement in control group was 39.5 % (17 of 43 patients), compared to 6.5 % (2 of 31 patients) in treated group (p < 0,001). The lower infection rate in the experimental group was also noted. No safety issues were identified during the preparation and application process. CONCLUSION Autologous bio-regenerative fibrin can be safely prepared, with no time consuming, and was demonstrated to be a useful tool to decrease allogeneic blood transfusion requirements following elective coronary artery bypass grafting surgery. A prospective randomized trial is needed to confirm these findings.
Collapse
Affiliation(s)
- Slobodan Micovic
- Cardiovascular Institute Dedinje, Milana Tepića 1, 11000, Belgrade, Serbia.
| | - Peter Everts
- Gulf Coasts Biologics Inc, 4331 Veronica S Shoemaker Blvd, Fort Myers, FL, 33916, United States.
| | - Branko Calija
- Cardiovascular Institute Dedinje, Milana Tepića 1, 11000, Belgrade, Serbia.
| | | | - Nikola Grubor
- Clinical Centre of Serbia, Pasterova2, 11000, Belgrade, Serbia.
| | - Mladen Boricic
- Cardiovascular Institute Dedinje, Milana Tepića 1, 11000, Belgrade, Serbia.
| | - Jelena Lesanovic
- Cardiovascular Institute Dedinje, Milana Tepića 1, 11000, Belgrade, Serbia.
| | - Henk Box
- St Catherine's Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, the Netherlands.
| | - Dzihan Abazovic
- Emergency Medical Centre of Montenegro, Vaka Đurovića bb, 81110, Podgorica, Montenegro.
| |
Collapse
|
11
|
Zhang ZZP, Zhang SZ, Zhou HM, Fan YQ, Liu MH, Zhong XB, Yang DY, Guo Y, Zhuang XD, Liao XX. A systematic review of guidelines for dual antiplatelet therapy in coronary artery bypass graft. Eur J Clin Invest 2021; 51:e13405. [PMID: 32926588 DOI: 10.1111/eci.13405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND In most situations, many patients undergoing coronary artery bypass graft (CABG) are on dual antiplatelet therapy (DAPT), which is also required after CABG. The adjustment of antiplatelet strategy remains controversial. In this study, we systematically review current guidelines, seeking consensus and controversies to facilitate clinical practice. METHODS AND RESULTS Guidelines are searched in PubMed, Embase, ECRI Guidelines Trust and websites of guidelines organizations and professional society. Guidelines with recommendations of DAPT for patients undergo CABG are included. Two reviewers appraised guidelines with the Appraisal of Guidelines for Research and Evaluation II (AGREE II). Relevant recommendations are extracted and summarized. A total of 14 guidelines meeting inclusion criteria are selected, with average AGREE II scores from 44% to 86%. Most guidelines score high in domains other than 'applicability'. Many guidelines are not detailed enough in reporting considerations behind recommendations. Current guidelines are consistent on the management of antiplatelet strategy before elective CABG and using DAPT after surgery for preventing graft vessel occlusion. Evidence is still lacking in urgent CABG and resumption of the previous DAPT after surgery. CONCLUSIONS Current guidelines on DAPT in CABG are generally satisfying. Suspending P2Y12 inhibitors while aspirin continued before elective CABG is recommended, as well as 12 months of DAPT following CABG. More evidence is needed to guide antiplatelet therapy in urgent CABG and to prove the benefits of resuming previous DAPT.
Collapse
Affiliation(s)
| | - Shao-Zhao Zhang
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, China
| | - Hui-Min Zhou
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, China
| | - Yong-Qiang Fan
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, China
| | - Meng-Hui Liu
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, China
| | - Xiang-Bin Zhong
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, China
| | - Da-Ya Yang
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, China
| | - Yue Guo
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, China
| | - Xiao-Dong Zhuang
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, China
| | - Xin-Xue Liao
- Cardiology Department, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, China
| |
Collapse
|
12
|
Marteinsson SA, Heimisdóttir AA, Axelsson TA, Johannesdottir H, Arnadottir LO, Gardarsdottir HR, Johnsen A, Sigurdsson MI, Helgadottir S, Gudbjartsson T. Reoperation for bleeding following coronary artery bypass surgery with special focus on long-term outcomes. SCAND CARDIOVASC J 2020; 54:265-273. [PMID: 32351135 DOI: 10.1080/14017431.2020.1751265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: We studied the incidence and risk factors of reoperation for bleeding following CABG in a nationwide cohort with focus on long-term complications and survival. Design: A retrospective study on 2060 consecutive, isolated CABG patients operated 2001-2016. Outcome of reoperated patients (n = 130) were compared to non-reoperated ones (n = 1930), including major adverse cardiac and cerebrovascular events (MACCE) and overall survival. Risk factors for reoperation were determined using multivariate logistic regression and a Cox proportional hazards model to assess prognostic factors of long-term survival. Median follow-up was 7.6 years. Results: One hundred thirty patients (6.3%) were reoperated with an annual decrease of 4.1% per year over the study period (p=.04). Major complications (18.5 vs. 9.6%) and 30-day mortality (8.5 vs. 1.9%,) were higher in the reoperation group (p<.001). The use of clopidogrel preoperatively (OR 3.62, 95% CI: 1.90-6.57) and reduced left ventricular ejection fraction (OR 2.23, 95% CI: 1.25-3.77) were the strongest predictors of reoperation, whereas off-pump surgery was associated with a lower reoperation risk (OR 0.44, 95% CI: 0.22-0.85). After exluding patients that died within 30 days postoperatively, no difference in long-term survival or freedom from MACCE was found between groups, and reoperation was not an independent risk factor for long-term mortality in multivariate analysis. Conclusions: The reoperation rate in this study was relatively high but decreased significantly over time. Reoperation was associated with twofold increased risk for major complications and fourfold 30-day mortality, but comparable long-term MACCE and survival rates. This implies that if patients survive the first 30 days following reoperation, their long-term outcome is comparable to non-reoperated patients.
Collapse
Affiliation(s)
| | | | - Tomas A Axelsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Hera Johannesdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Linda O Arnadottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Helga R Gardarsdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Arni Johnsen
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Department of Anesthesia and Intensive Care, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Solveig Helgadottir
- Department of Anesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| |
Collapse
|
13
|
Qu J, Zhang D, Zhang H, Rao C, Chen S, Zhao Y, Zheng Z. Preoperative clopidogrel and outcomes in patients with acute coronary syndrome undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg 2020; 163:1044-1052.e15. [DOI: 10.1016/j.jtcvs.2020.03.118] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/20/2020] [Accepted: 03/29/2020] [Indexed: 11/15/2022]
|
14
|
Mokhtar AT, Baghaffar A, Jackson SD, Horne D. When is the optimal time to discontinue clopidogrel before in-hospital coronary bypass surgery? A closer look at the current literature. J Card Surg 2019; 35:413-421. [PMID: 31803992 DOI: 10.1111/jocs.14371] [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: 11/28/2022]
Abstract
BACKGROUND Clopidogrel and other P2Y12 inhibitors have become the standard of care among patients presenting with acute coronary syndromes. A substantial proportion of these patients require surgical revascularization during index hospitalization. HYPOTHESIS Guidelines recommend a 5-day waiting period off clopidogrel before coronary artery bypass grafting (CABG) to reduce hemorrhagic complications. These recommendations are not routinely followed in clinical practice, while recent studies also propose shorter waiting periods off clopidogrel for patients awaiting in-hospital CABG. METHODS A preliminary PubMed search was conducted using the following MeSH terms under the publication type "Hemorrhage:" "Clopidogrel," AND "Coronary Artery Bypass." Relevant studies and guidelines were then reviewed and selected based on a predetermined criteria. Studies that formulated the current recommendations for stopping clopidogrel preoperative to CABG are discussed in detail this review. RESULTS A comprehensive review of recent evidence illustrates mixed bleeding and transfusion outcomes among CABG patients with preoperative exposure to clopidogrel in less than 5 days. CONCLUSIONS The optimal discontinuation time of clopidogrel before CABG is still poorly defined. The recommendation of a 5-day washout period for clopidogrel should be reconsidered to be on par with current clinical practice.
Collapse
Affiliation(s)
- Ahmed T Mokhtar
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdullah Baghaffar
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Simon D Jackson
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Horne
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| |
Collapse
|
15
|
Dual antiplatelet therapy up to the time of non-elective coronary artery bypass grafting with prophylactic platelet transfusion: is it safe? J Cardiothorac Surg 2019; 14:202. [PMID: 31775803 PMCID: PMC6880414 DOI: 10.1186/s13019-019-1028-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 11/18/2019] [Indexed: 01/17/2023] Open
Abstract
Background Guidelines suggest that patients discontinue Clopidogrel at least 5 days prior to coronary artery bypass grafting (CABG). Those with acute coronary syndrome (ACS) are at high risk for myocardial infarction (MI) if not treated with dual antiplatelet therapy (DAPT). We sought to assess pre and post-operative outcomes of patients maintained on Clopidogrel and aspirin up to the time of surgery and compare them with those on aspirin alone. Methods From the cardiac surgery database, 240 patients were retrospectively registered between January and May 2017. There were 126 patients with ACS who underwent CABG on DAPT (Clopidogrel group [CG]) and 114 patients who underwent elective CABG on aspirin alone (control). The CG received intraoperative prophylactic platelet transfusion (PPT). Demographics, comorbidities, and laboratory data were prospectively entered at the time of surgery and were subsequently retrieved for analysis. Per and postoperative findings were identified and compared between both groups. Results The cohort consisted of 240 patients (mean age 61 years, 81.3% were male, SD ± 9.58). Patients in the CG were younger (Median 57 vs. 63, P-value 0.001), and with male predominance (86% versus 75%, P-value 0.028). In addition, they had less prevalence for diabetes and renal failure as compared to control (P-values 0.003, and 0.005, respectively). There were no significant differences between both groups in number of vessels grafts, duration of on-pump and aortic clamp. Hematologic laboratory data had also similar baseline values. The CG had similar bleeding rate, redo surgery and in-hospital death (P-values non-significant), however more infection and total hospital stay as compared to control (p-values 0.048 and 0.001). Conclusion Patients who are at increased risk for MI can be maintained on DAPT up to the time of CABG because surgery is safe when patients are offered PPT.
Collapse
|
16
|
van Valen R, van Gameren M, Mokhles MM, Takkenberg JJM, Ter Horst M, Hofland J, Bogers AJJC. Effectiveness of adherence to a preoperative antiplatelet and anticoagulation cessation protocol in cardiac surgery. Interact Cardiovasc Thorac Surg 2019; 26:820-825. [PMID: 29309597 DOI: 10.1093/icvts/ivx401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/19/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Reduction of blood loss after cardiac surgery remains challenging. The effectiveness of adherence to a protocol on cessation of anticoagulants and platelet-inhibiting medications was investigated together with the influence of protocol violations on blood loss after surgery, use of blood products, surgical re-explorations and 30-day mortality. METHODS Between 2009 and 2013, data were collected prospectively for all elective cardiac surgery procedures in adult patients (n = 1637). Two groups were distinguished: Group 1 adhered to the protocol for cessation or continuation of medication (n = 1287, 79%) and Group 2 violated the protocol (n = 350, 21%). RESULTS Median blood loss was 300 ml (interquartile range 175-500 ml). Eighty patients underwent re-exploration due to blood loss (5%). Thirty-day mortality was 2% (n = 27). Protocol violation was associated with increased blood loss [median 275 ml (175-475 ml) vs 350 ml (250-612); P ≤ 0.001] and with increased average use of fresh frozen plasma (226 ml vs 139 ml; P << 0.00001), red blood cell transfusion (115 ml vs 87 ml; P = 0.081) and thrombocyte transfusions (52 ml vs 37 ml; P = 0.0082). The number of re-explorations (4% vs 6%; P = 0.39) and mortality risk (1% vs 2%; P = 0.72) did not differ. CONCLUSIONS Balancing the benefit of continuing platelet inhibitors or anticoagulants versus cessation before surgery remains challenging. Adherence to the protocol will lead to lower blood loss and in a lower consumption of blood products although the decision to go for re-exploration and 30-day mortality does not differ compared with the protocol violation. Stopping medication does not lead to thromboembolic events.
Collapse
Affiliation(s)
- Richard van Valen
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | | | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| | | | | | - Jan Hofland
- Department of Anesthesiology, Radboud UMC, Nijmegen, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, Netherlands
| |
Collapse
|
17
|
Goggs R, Blais MC, Brainard BM, Chan DL, deLaforcade AM, Rozanski E, Sharp CR. American College of Veterinary Emergency and Critical Care (ACVECC) Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE) guidelines: Small animal. J Vet Emerg Crit Care (San Antonio) 2019; 29:12-36. [PMID: 30654421 DOI: 10.1111/vec.12801] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/12/2018] [Accepted: 12/07/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To systematically review available evidence and establish guidelines related to the risk of developing thrombosis and the management of small animals with antithrombotics. DESIGN Standardized, systematic evaluation of the literature (identified by searching Medline via PubMed and CAB abstracts) was carried out in 5 domains (Defining populations at risk; Defining rational therapeutic use; Defining evidence-based protocols; Refining and monitoring antithrombotic therapies; and Discontinuing antithrombotic therapies). Evidence evaluation was carried out using Population, Intervention, Comparison, Outcome generated within each domain questions to address specific aims. This was followed by categorization of relevant articles according to level of evidence and quality (Good, Fair, or Poor). Synthesis of these data led to the development of a series of statements. Consensus on the final guidelines was achieved via Delphi-style surveys. Draft recommendations were presented at 2 international veterinary conferences and made available for community assessment, review, and comment prior to final revisions and publication. SETTINGS Academic and referral veterinary medical centers. RESULTS Over 500 studies were reviewed in detail. Worksheets from all 5 domains generated 59 statements with 83 guideline recommendations that were refined during 3 rounds of Delphi surveys. A high degree of consensus was reached across all guideline recommendations. CONCLUSIONS Overall, systematic evidence evaluations yielded more than 80 recommendations for the treatment of small animals with or at risk of developing thrombosis. Numerous significant knowledge gaps were highlighted by the evidence reviews undertaken, indicating the need for substantial additional research in this field.
Collapse
Affiliation(s)
- Robert Goggs
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, NY
| | - Marie-Claude Blais
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montreal, Saint-Hyacinthe, QC, Canada
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, University of Georgia, Athens, GA
| | - Daniel L Chan
- Department Clinical Science and Services, The Royal Veterinary College, London, United Kingdom
| | - Armelle M deLaforcade
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | - Elizabeth Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA
| | - Claire R Sharp
- School of Veterinary and Life Sciences, College of Veterinary Medicine, Murdoch University, Murdoch, WA, Australia
| |
Collapse
|
18
|
Brainard BM, Buriko Y, Good J, Ralph AG, Rozanski EA. Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 5-Discontinuation of anticoagulant therapy in small animals. J Vet Emerg Crit Care (San Antonio) 2019; 29:88-97. [PMID: 30654425 DOI: 10.1111/vec.12796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 12/10/2018] [Accepted: 12/08/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To systematically evaluate the evidence supporting the timing and mechanisms of permanent or temporary discontinuation of antiplatelet or anticoagulant medications in small animals DESIGN: Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality (poor, fair, or good), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice. SETTINGS Academic and referral veterinary medical centers. RESULTS Databases searched included Medline via PubMed and CAB abstracts. Two specific courses of inquiry were pursued, one focused on appropriate approaches to use for small animal patients receiving antiplatelet or anticoagulant drugs and requiring temporary discontinuation of this therapy for the purposes of invasive procedures (eg, surgery), and the other aimed at decision-making for the complete discontinuation of anticoagulant medications. In addition, the most appropriate methodology for discontinuation of heparins was addressed. CONCLUSIONS To better define specific patient groups, a risk stratification characterization was developed. It is recommended to continue anticoagulant therapy through invasive procedures in patients at high risk for thrombosis that are receiving anticoagulant therapy, while consideration for discontinuation in patients with low to moderate risk of thrombosis is reasonable. In patients with thrombosis in whom the underlying cause for thrombosis has resolved, indefinite treatment with anticoagulant medication is not recommended. If the underlying cause is unknown or untreatable, anticoagulant medication should be continued indefinitely. Unfractionated heparin therapy should be slowly tapered rather than discontinued abruptly.
Collapse
Affiliation(s)
- Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA
| | - Yekaterina Buriko
- Department of Clinical Studies, Philadelphia, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jennifer Good
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA
| | | | - Elizabeth A Rozanski
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA
| |
Collapse
|
19
|
Van Tuyl JS, Newsome AS, Hollis IB. Perioperative Bridging With Glycoprotein IIb/IIIa Inhibitors Versus Cangrelor: Balancing Efficacy and Safety. Ann Pharmacother 2019; 53:726-737. [PMID: 30646761 DOI: 10.1177/1060028018824640] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review the efficacy and safety of perioperative administration of intravenous (IV) antiplatelet agents as a substitute for oral P2Y12 inhibitors and to provide clinicians guidance on optimal and cost-effective use of these medications. DATA SOURCES A MEDLINE literature search (1950 to November 2018) was performed using the key search terms abciximab, bridging, cangrelor, cardiac surgery, coronary artery bypass surgery, eptifibatide, intravenous antiplatelet agent, and tirofiban. Additional references were identified from a review of literature citations. STUDY SELECTION AND DATA EXTRACTION In all, 18 original research reports and case reports/series were included in the review. DATA SYNTHESIS Prevention of postoperative bleeding is critical to decrease morbidity and mortality after cardiac surgery. IV antiplatelet medications have short half-lives and are frequently used to substitute for oral P2Y12 inhibitors to allow platelet function recovery before procedures. Functional recovery of platelets is delayed after abciximab discontinuation and increases postoperative bleeding risk. Eptifibatide and tirofiban have similar pharmacokinetic/pharmacodynamic properties and comparable efficacy and safety in the setting of perioperative bridging. Cangrelor may be considered in patients with renal insufficiency as decreased clearance of eptifibatide or tirofiban may increase the risk of postoperative bleeding. Relevance to Patient Care and Clinical Practice: Comparative studies of IV antiplatelet medications have not been published. Appropriate use of IV antiplatelet medications can prevent perioperative ischemic events and bleeding. CONCLUSIONS Eptifibatide, tirofiban, and cangrelor are preferred over abciximab as a perioperative bridge. The choice of agent should be tailored to clinical characteristics of the patient and institutional acquisition costs.
Collapse
Affiliation(s)
- Joseph S Van Tuyl
- 1 SSM Health St Louis University Hospital, MO, USA.,2 St Louis College of Pharmacy, MO, USA
| | - Andrea Sikora Newsome
- 3 The University of Georgia College of Pharmacy, Augusta, GA, USA.,4 Augusta University Medical Center, Augusta, GA, USA
| | - Ian B Hollis
- 5 University of North Carolina Medical Center, Chapel Hill, NC, USA.,6 UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| |
Collapse
|
20
|
Vuilliomenet T, Gebhard C, Bizzozero C, Glauser S, Blum S, Buser A, Bolliger D, Grapow MTR, Siegemund M. Discontinuation of dual antiplatelet therapy and bleeding in intensive care in patients undergoing urgent coronary artery bypass grafting: a retrospective analysis. Interact Cardiovasc Thorac Surg 2018; 28:665-673. [DOI: 10.1093/icvts/ivy330] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/02/2018] [Accepted: 10/16/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Thierry Vuilliomenet
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Caroline Gebhard
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Chiara Bizzozero
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Salome Glauser
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Steffen Blum
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Department of Haematology, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital Basel, Basel, Switzerland
| | - Martin T R Grapow
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
21
|
Baumann Kreuziger L, Karkouti K, Tweddell J, Massicotte MP. Antithrombotic therapy management of adult and pediatric cardiac surgery patients. J Thromb Haemost 2018; 16:2133-2146. [PMID: 30153372 DOI: 10.1111/jth.14276] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Indexed: 12/16/2022]
Abstract
Despite the development of catheter-based interventions for ischemic and valvular heart disease, hundreds of thousands of people undergo open heart surgery annually for coronary artery bypass graft (CABG), valve replacement or cardiac assist device implantation. Cardiac surgery patients are unique because therapeutic anticoagulation is required during cardiopulmonary bypass. Developmental hemostasis and altered drug metabolism affect management in children. This narrative review summarizes the current evidence-based and consensus guidelines regarding perioperative, intraoperative and postoperative antithrombotic therapy in patients undergoing cardiac surgery. Anticoagulation preoperatively is required in the setting of cardiac arrhythmias, prior valve replacement or history of venous thromboembolism. In patients with ischemic heart disease, aspirin is continued in the perioperative period, whereas oral P2Y12 antagonists are withheld for 5-7 days to reduce the risk of perioperative bleeding. Intraoperative management of cardiopulmonary bypass in adults and children includes anticoagulation with unfractionated heparin. Variability in dose-response to heparin and influence of other medical conditions on dosing and reversal of heparin make intraoperative anticoagulation challenging. Vitamin K antagonist therapy is the standard anticoagulant after mechanical heart valve or left ventricular assist device (LVAD) implantation. Longer duration of dual antiplatelet therapy is recommended after CABG if patients undergo surgery because of acute coronary syndrome. Antiplatelet therapy after LVAD implantation includes aspirin, dipyridamole and/or clopidogrel in children and aspirin in adults. A coordinated approach between hematology, cardiology, anesthesiology, critical care and cardiothoracic surgery can assist to balance the risk of thrombosis and bleeding in patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- L Baumann Kreuziger
- BloodCenter of Wisconsin, Blood Research Institute, Milwaukee, WI, USA
- Medical College of Wisconsin, Department of Medicine, Division of Hematology and Oncology, Milwaukee, WI, USA
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - J Tweddell
- Department of Surgery and Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - M P Massicotte
- University of Alberta, Department of Pediatrics, Edmonton, Alberta, Canada
| |
Collapse
|
22
|
Gestion des agents antiplaquettaires pour une procédure invasive programmée. Propositions du Groupe d’intérêt en hémostase périopératoire (GIHP) et du Groupe français d’études sur l’hémostase et la thrombose (GFHT) en collaboration avec la Société française d’anesthésie-réanimation (SFAR). ANESTHÉSIE & RÉANIMATION 2018. [DOI: 10.1016/j.anrea.2018.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
23
|
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
| |
Collapse
|
24
|
Management of antiplatelet therapy in patients undergoing elective invasive procedures: Proposals from the French Working Group on perioperative hemostasis (GIHP) and the French Study Group on thrombosis and hemostasis (GFHT). In collaboration with the French Society for Anesthesia and Intensive Care (SFAR). Arch Cardiovasc Dis 2018; 111:210-223. [PMID: 29402671 DOI: 10.1016/j.acvd.2017.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 01/02/2023]
|
25
|
Godier A, Fontana P, Motte S, Steib A, Bonhomme F, Schlumberger S, Lecompte T, Rosencher N, Susen S, Vincentelli A, Gruel Y, Albaladejo P, Collet JP. Management of antiplatelet therapy in patients undergoing elective invasive procedures. Proposals from the French Working Group on perioperative haemostasis (GIHP) and the French Study Group on thrombosis and haemostasis (GFHT). In collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR). Anaesth Crit Care Pain Med 2018; 37:379-389. [PMID: 29309950 DOI: 10.1016/j.accpm.2017.12.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 12/28/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022]
Abstract
The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals for the management of antiplatelet therapy in patients undergoing elective invasive procedures. The proposals were discussed and validated by a vote; all proposals but one could be assigned with a high strength. The management of antiplatelet therapy is based on their indication and the procedure. The risk of bleeding related to the procedure can be divided into high, moderate and low categories depending on the possibility of performing the procedure in patients receiving antiplatelet agents (none, monotherapy and dual antiplatelet therapy respectively). If discontinuation of antiplatelet therapy is indicated before the procedure, a last intake of aspirin, clopidogrel, ticagrelor and prasugrel 3, 5, 5 and 7 days before surgery respectively is proposed. The thrombotic risk associated with discontinuation should be assessed according to each specific indication of antiplatelet therapy and is higher for patients receiving dual therapy for coronary artery disease (with further refinements based on a few well-accepted items) than for those receiving monotherapy for cardiovascular prevention, for secondary stroke prevention or for lower extremity arterial disease. These proposals also address the issue of the potential role of platelet functional tests and consider management of antiplatelet therapy for regional anaesthesia, including central neuraxial anaesthesia and peripheral nerve blocks, and for coronary artery surgery.
Collapse
Affiliation(s)
- Anne Godier
- Department of Anaesthesiology and Intensive Care, Fondation Rothschild, and Inserm UMR-S1140, Paris Descartes university, 75006 Paris, France.
| | - Pierre Fontana
- Division of angiology and haemostasis and Geneva Platelet Group, University hospitals of Geneva, 1205 Geneva, Switzerland
| | - Serge Motte
- Department of Vascular Diseases, Erasme University Hospital, Université Libre de Bruxelles, 1050 Brussels, Belgium
| | - Annick Steib
- Department of Anaesthesiology and Intensive Care, NHC, University Hospital-Federation de Medecine Translationnelle, 67000 Strasbourg, France
| | - Fanny Bonhomme
- Department of Anaesthesiology, Pharmacology, and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland
| | | | - Thomas Lecompte
- Geneva Platelet Group (GpG), Department of Medical Specialties, Faculty of Medicine, Geneva University Hospitals, University of Geneva, 1205 Geneva, Switzerland
| | - Nadia Rosencher
- Cochin Hospital, Paris Descartes University, AP-HP, 75014 Paris, France
| | - Sophie Susen
- U1011 - EGID, Inserm, Institute of haematology-transfusion, université de Lille, CHU de Lille, 59000 Lille, France
| | - André Vincentelli
- Department of cardiac surgery, Centre hospitalier régional universitaire de Lille, Lille, France
| | - Yves Gruel
- Department of Haematology-Haemostasis, University-Hospital of Tours, 37044 Tours cedex, France
| | - Pierre Albaladejo
- Department of Anaesthesiology and Critical Care, Grenoble-Alpes University Hospital, Grenoble, ThEMAS, TIMC, UMR CNRS 5525, Université Grenoble-Alpes, 38700 Grenoble, France
| | - Jean-Philippe Collet
- ACTION Study Group, Inserm UMR_S 1166, department of cardiology, institut de cardiologie, Pitié-Salpêtrière Hospital, Sorbonne Universités_Univ Paris 06 (UPMC), AP-HP, 75013 Paris, France
| | | |
Collapse
|
26
|
Assessing Intraoperative Bleeding Risk in Patients Undergoing Coronary Artery Bypass Grafting with Prior Exposure to Clopidogrel: Single Center Retrospective Analysis. Am J Ther 2016; 24:e648-e652. [PMID: 26825485 DOI: 10.1097/mjt.0000000000000339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In patients undergoing coronary artery bypass grafting (CABG), intraoperative and postoperative major bleeding requiring blood transfusions and surgical reexploration is associated with increased mortality and morbidity. Our study hypothesized that exposure to clopidogrel is not significantly associated with increased risk for intraoperative bleeding, even when administered less than 5 days before CABG. We also aimed to determine variables associated with intraoperative packed red blood cell (iPRBC) transfusion. Patients of both sexes aged 18 years or older who underwent CABG from July 1, 2011 to December 31, 2012 were included in the analysis. Study population consisted of 2 groups-clopidogrel arm and nonclopidogrel arm. Patients were included in clopidogrel arm if they were exposed to clopidogrel in the past (as one of their home medications or received the medication for first time during the index hospitalization), whereas patients who never received clopidogrel were included in nonclopidogrel arm. We identified a total of 303 adult patients who underwent CABG with a mean age was 64.5 years. Mortality rate in our study was 0.99% (n = 3) with increased mortality in women as compared with men (3.27% vs. 0.41%, P = 04). The mean iPRBC transfused were 1.68 units, with higher units being transfused in women as compared with men (2.23 vs. 1.49 units, respectively, P = 0.03) and no significant difference between clopidogrel and nonclopidogrel arms (1.92 vs. 1.50, respectively, P = 0.18). After multivariate analysis, age [odds ratio (OR) = 1.03, P = 0.01], female sex (OR = 2.61, P = 0.006) and hypertension (OR = 7.10, P = 0.02) predicted increased iPRBC transfusion. Clopidogrel or nonclopidogrel status was not associated with increased iPRBC transfusion (OR = 1.06, P = 0.81). iPRBC transfusion rates were similar in both arms with age, female sex, and hypertension being an independent predictor of iPRBC transfusion.
Collapse
|
27
|
Yanagawa B, Ruel M, Bonneau C, Lee MM, Chung J, Al Shouli S, Fagan A, Al Khalifa A, White CW, Yamashita MH, Currie ME, Teoh H, Mewhort HE, Verma S. Dual antiplatelet therapy use by Canadian cardiac surgeons. J Thorac Cardiovasc Surg 2015; 150:1548-54.e3. [DOI: 10.1016/j.jtcvs.2015.08.066] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 08/06/2015] [Accepted: 08/17/2015] [Indexed: 10/23/2022]
|
28
|
Verma S, Goodman SG, Mehta SR, Latter DA, Ruel M, Gupta M, Yanagawa B, Al-Omran M, Gupta N, Teoh H, Friedrich JO. Should dual antiplatelet therapy be used in patients following coronary artery bypass surgery? A meta-analysis of randomized controlled trials. BMC Surg 2015; 15:112. [PMID: 26467661 PMCID: PMC4605093 DOI: 10.1186/s12893-015-0096-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 10/01/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND We assessed the effectiveness of dual antiplatelet therapy (DAPT) post elective or urgent (i.e., post acute coronary syndrome [ACS]) coronary artery bypass graft surgery (CABG). METHODS We systematically searched MEDLINE, EMBASE, and the Cochrane Registry from inception to August 2015. Randomized controlled trials (RCTs) in adults undergoing CABG comparing either dual vs. single antiplatelet therapy or higher- vs. lower-intensity DAPT were identified. RESULTS Nine RCTs (n = 4,887) with up to 1y follow-up were included. Five RCTs enrolled patients post-elective CABG (n = 986). Two multi-centre RCTs enrolled ACS patients who subsequently underwent CABG (n = 2,155). These 7 RCTs compared clopidogrel plus aspirin to aspirin alone. Two other multi-centre RCTs reported on ACS patients who subsequently underwent CABG comparing higher intensity DAPT with either ticagrelor (n = 1,261) or prasugrel (n = 485) plus aspirin to clopidogrel plus aspirin. Post-operative anti-platelet therapy was started when chest tube bleeding was no longer significant, typically within 24-48 h. There were no differences in all-cause mortality in clopidogrel plus aspirin vs. aspirin RCTs; conversely, all-cause mortality was significantly lower in ticagrelor and prasugrel vs. clopidogrel RCTs (risk ratio[RR] 0.49, 95% confidence interval[CI] 0.33-0.71, p = 0.0002; 2 RCTs, n = 1695; I(2) = 0%; interaction p < 0.01 compared to clopidogrel plus aspirin vs aspirin RCTs). There were no differences in myocardial infarctions, strokes, or composite outcomes. Overall, major bleeding was not significantly increased (RR 1.31, 95% CI 0.81-2.10, p = 0.27; 7 RCTs, n = 4500). There was heterogeneity (I(2) = 42%) due almost entirely to higher bleeding reported for the prasugrel RCT which included mainly CABG-related major bleeding (RR 3.15, 95% CI 1.45-6.87, p = 0.004; 1 RCT, n = 437). CONCLUSIONS Most RCT data for DAPT post CABG is derived from subgroups of ACS patients in DAPT RCTs requiring CABG who resume DAPT post-operatively. Limited RCT data with heterogeneous trial designs suggest that higher intensity (prasugrel or ticagrelor) but not lower intensity (clopidogrel) DAPT is associated with an approximate 50% lower mortality in ACS patients who underwent CABG based on post-randomization subsets from single RCTs. Large prospective RCTs evaluating the use of DAPT post-CABG are warranted to provide more definitive guidance for clinicians.
Collapse
Affiliation(s)
- Subodh Verma
- />Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, University of Toronto, Toronto, ON M5S 2J7 Canada
- />King Saud University, Riyadh, 12372 Saudi Arabia
| | - Shaun G. Goodman
- />Division of Cardiology, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Medicine, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Medicine, University of Toronto, Toronto, ON M5S 2J7 Canada
| | - Shamir R. Mehta
- />Department of Medicine, McMaster University, Hamilton, ON L8L 2X2 Canada
- />Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON L8L 2X2 Canada
| | - David A. Latter
- />Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, University of Toronto, Toronto, ON M5S 2J7 Canada
| | - Marc Ruel
- />University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7 Canada
| | - Milan Gupta
- />Department of Medicine, University of Toronto, Toronto, ON M5S 2J7 Canada
- />Department of Medicine, McMaster University, Hamilton, ON L8L 2X2 Canada
- />Canadian Cardiovascular Research Network, Brampton, ON L6Z 4N5 Canada
| | - Bobby Yanagawa
- />Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, University of Toronto, Toronto, ON M5S 2J7 Canada
| | - Mohammed Al-Omran
- />Division of Vascular Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, University of Toronto, Toronto, ON M5S 2J7 Canada
- />King Saud University, Riyadh, 12372 Saudi Arabia
| | | | - Hwee Teoh
- />Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Division of Endocrinology & Metabolism, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Surgery, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Medicine, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
| | - Jan O. Friedrich
- />Department of Medicine, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Critical Care, St. Michael’s Hospital, Toronto, ON M5B 1W8 Canada
- />Department of Medicine, University of Toronto, Toronto, ON M5S 2J7 Canada
- />Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON M5S 2J7 Canada
| |
Collapse
|
29
|
Plicner D, Mazur P, Hymczak H, Stoliński J, Litwinowicz R, Drwiła R, Undas A. Preoperative platelet aggregation predicts perioperative blood loss and rethoracotomy for bleeding in patients receiving dual antiplatelet treatment prior to coronary surgery. Thromb Res 2015; 136:519-25. [PMID: 26003782 DOI: 10.1016/j.thromres.2015.04.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/13/2015] [Accepted: 04/28/2015] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Patients scheduled for coronary artery bypass graft surgery (CABG) are commonly treated with clopidogrel. We sought to assess the relation between preoperative platelet aggregation and bleeds in CABG patients on clopidogrel. MATERIAL AND METHODS In a case-control study, we compared 52 consecutive patients undergoing isolated CABG on aspirin and clopidogrel 75mg/d versus 50 controls on aspirin monotherapy. Platelet aggregation induced by 10μmol/l adenosine di-phosphate (ADP) in platelet-rich plasma was measured in subjects on clopidogrel within 5days prior to surgery. ADP-induced aggregation of ≥50% was used to define subjects with satisfactory inhibition of platelet reactivity. RESULTS In 29 patients with preoperative ADP-induced aggregation ≥50%, compared with 23 subjects with aggregation <50%, lower chest-tube drainage volumes (after 6h, p=0.002; and 12h, p=0.001) and fewer rethoracotomies were observed (p=0.03). The former group was characterized with lower transfusion rates of packed red blood cells (p=0.009), platelet concentrate (p=0.04) and fresh frozen plasma (p=0.001). Patients with ADP-induced aggregation ≥50% did not differ from untreated controls regarding the postoperative drainage, transfusions and rethoracotomy. The incidence of thromboembolic events and death during perioperative period were similar in all groups. Multivariate logistic regression identified ADP-induced aggregation <50% as the only independent predictor of rethoracotomy (OR=2.94 [1.12-7.75], p=0.029). CONCLUSIONS Patients on aspirin and clopidogrel <5days before CABG who had preoperative ADP-induced platelet aggregation ≥50% have bleeding risk similar to those receiving aspirin monotherapy. Reduced platelet reactivity to ADP can predict postoperative bleeding in CABG patients on dual antiplatelet therapy.
Collapse
Affiliation(s)
| | - Piotr Mazur
- John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.
| | | | | | - Radosław Litwinowicz
- John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Rafał Drwiła
- John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anetta Undas
- John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| |
Collapse
|
30
|
Wan S. Right here waiting...? J Thorac Cardiovasc Surg 2014; 148:3099-100. [PMID: 25451509 DOI: 10.1016/j.jtcvs.2014.09.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 09/25/2014] [Indexed: 11/28/2022]
|