Is Preoperative Clopidogrel Resistance a Predictor of Bleeding and Risks in Patients Undergoing Emergency CABG Surgery?

Kizilay, Mehmet; Aslan, Zeynep; Vural, Unsal; Balci, Ahmet Yavuz; Aglar, Ahmet Arif; Yilmaz, Sahin

doi:10.21470/1678-9741-2018-0005

Mehmet Kizilay Correspondence Address: Mehmet Kizilay, Department of Cardiovascular Surgery Dr. Siyami Ersek Training and Research Hospital, University of Health Sciences, Tibbiye Cad Selimiye, Uskudar, İstanbul, Turkey, Zip code: 34668. E-mail: kzlay@yahoo.com

MD

Department of Cardiovascular Surgery, Dr. Siyami Ersek Training and Research Hospital, University of Health Sciences, İstanbul, Turkey.

Zeynep Aslan

MD

Department of Cardiovascular Surgery, Derince Training and Research Hospital, University of Health Sciences, Derince, Kocaeli, Turkey.

Unsal Vural

MD

Department of Cardiovascular Surgery, Dr. Siyami Ersek Training and Research Hospital, University of Health Sciences, İstanbul, Turkey.

Ahmet Yavuz Balci

MD

Department of Cardiovascular Surgery, Dr. Siyami Ersek Training and Research Hospital, University of Health Sciences, İstanbul, Turkey.

Ahmet Arif Aglar

MD

Department of Cardiovascular Surgery, Dr. Siyami Ersek Training and Research Hospital, University of Health Sciences, İstanbul, Turkey.

Sahin Yilmaz

MD

Department of Anesthesiology, Dr. Siyami Ersek Training and Research Hospital, University of Health Sciences, İstanbul, Turkey.

Correspondence Address: Mehmet Kizilay, Department of Cardiovascular Surgery Dr. Siyami Ersek Training and Research Hospital, University of Health Sciences, Tibbiye Cad Selimiye, Uskudar, İstanbul, Turkey, Zip code: 34668. E-mail: kzlay@yahoo.com

No conflict of interest.

Figures (1)
Tables (5)

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Fig. 1
Clopidogrel resistance/cross-clamping time relationship.

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Abbreviations, acronyms & symbols ACS = Acute coronary syndrome ERT = Electrophoresis release test ADP = Adenosine diphosphate FFP = Fresh-frozen plasma ASA = Acetylsalicylic acid Hb = Hemoglobin AUC = Area under the aggregation curve HT = Hypertension BARC = Bleeding Academic Research Consortium ICU = Intensive care unit CABG = Coronary artery bypass graft INR = International Normalized Ratio CPB = Cardiopulmonary bypass IQR = Interquartile range CURE = Clopidogrel in Unstable angina to prevent Recurrent LIMA = Left internal mammary artery ischemic Events MI = Myocardial infarction DAPT = Dual anti-platelet therapy PCI = Percutaneous coronary intervention DM = Diabetes mellitus RIMA = Right internal mammary artery EF = Ejection fraction STEMI = ST-elevation myocardial infarction

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Table 1
Statistical analysis of preoperative demographic characteristics of the cases.

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Table 2
Analysis of postoperative clinical data according to use of clopidogrel.

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Table 3
The effect of presence or absence of clopidogrel resistance in the patients on postoperative events and clinical medications.

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Authors' roles & responsibilities MK Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval ZA Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval UV Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval AYB Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval AAA Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval SY Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval

Abbreviations, acronyms & symbols
ACS	= Acute coronary syndrome	ERT	= Electrophoresis release test
ADP	= Adenosine diphosphate	FFP	= Fresh-frozen plasma
ASA	= Acetylsalicylic acid	Hb	= Hemoglobin
AUC	= Area under the aggregation curve	HT	= Hypertension
BARC	= Bleeding Academic Research Consortium	ICU	= Intensive care unit
CABG	= Coronary artery bypass graft	INR	= International Normalized Ratio
CPB	= Cardiopulmonary bypass	IQR	= Interquartile range
CURE	= Clopidogrel in Unstable angina to prevent Recurrent	LIMA	= Left internal mammary artery
	ischemic Events	MI	= Myocardial infarction
DAPT	= Dual anti-platelet therapy	PCI	= Percutaneous coronary intervention
DM	= Diabetes mellitus	RIMA	= Right internal mammary artery
EF	= Ejection fraction	STEMI	= ST-elevation myocardial infarction

		Use of clopidogrel				P
		Absent		Present
		n	%	n	%
Gender	Female	25	66	13	34	0.032^b b Pearson's chi-square test;
Gender	Male	86	47	98	53	0.032^b b Pearson's chi-square test;
DM	Absent	59	44	76	56	0.019^b b Pearson's chi-square test;
DM	Present	52	60	35	40	0.019^b b Pearson's chi-square test;
HT	Absent	39	37	66	63	<0.001^b b Pearson's chi-square test;
HT	Present	72	62	45	38	<0.001^b b Pearson's chi-square test;
MI	Absent	89	61	58	39	<0.001^b b Pearson's chi-square test;
MI	Present	22	29	53	71	<0.001^b b Pearson's chi-square test;
Angiography	Emergency	12	28	31	72	0.001^b b Pearson's chi-square test;
Angiography	Elective	99	55	80	45	0.001^b b Pearson's chi-square test;
Surgery	Emergency	7	22	25	78	0.001^b b Pearson's chi-square test;
Surgery	Elective	104	55	86	45	0.001^b b Pearson's chi-square test;
		Median	IQR	Median	IQR
Age (year), mean±sd		60.41	9.42	58.34	9.28	0.100^c c independent samples t-test.
Preoperative EF (%)		55	45, 60	50	45, 60	0.088^a a Mann-Whitney U test;
Troponin (ug/L) (n= 135)		0.05	0.01, 0.85	0.36	0.04, 1.25	0.029^a a Mann-Whitney U test;
Preoperative Hb (g/L)		13.3	12, 14.2	13.8	12.5, 14.9	0.030^a a Mann-Whitney U test;
Preoperative Plt (thousand/µL)		238	200, 289	217	184, 283	0.175^a a Mann-Whitney U test;
Preoperative INR		1.02	0.96, 1.1	1.04	1, 1.08	0.128^a a Mann-Whitney U test;

		Clopidogrel				P
		Absent		Present
		n	%	n	%
Protamine sulfate	Absent	96	49	100	51	0.404^b b Pearson's chi-square test;
Protamine sulfate	Present	15	58	11	42	0.404^b b Pearson's chi-square test;
Tranexamic acid	Absent	92	53	81	47	0.075^b b Pearson's chi-square test;
Tranexamic acid	Present	19	39	30	61	0.075^b b Pearson's chi-square test;
Reoperation	Absent	104	50	106	50	0.553^b b Pearson's chi-square test;
Reoperation	Present	7	58	5	42	0.553^b b Pearson's chi-square test;
Pericardial effusion (n= 71)	Absent	5	20	20	80	0.566^b b Pearson's chi-square test;
Pericardial effusion (n= 71)	Present	12	26	34	74	0.566^b b Pearson's chi-square test;
Tamponade (n= 71)	Absent	15	23	51	77	0.587^d d Fisher's exact test.
Tamponade (n= 71)	Present	2	40	3	60	0.587^d d Fisher's exact test.
LIMA/RIMA (n= 211)	LIMA	102	49.5	104	50.5	0.683^d d Fisher's exact test.
LIMA/RIMA (n= 211)	RIMA	3	60	2	40	0.683^d d Fisher's exact test.
Saphenous graft	Used	103	92,8	110	99.1	0.035^a a Mann-Whitney U test; ,^d d Fisher's exact test.
	Not used	8	7,1	1	0.9
Use of platelet transfusion (unit)	Present	2	1,8	10	9.0	0.018^a a Mann-Whitney U test;
	Absent	109	98,2	101	91.0
Fresh blood replacement (unit)	Present	16	14,4	41	36.9	0.001^a a Mann-Whitney U test;
	Absent	95	85,6	70	63.1
		Median	IQR	Median	IQR
Bleeding (mL)		300	200, 500	300	200, 500	0.987^a a Mann-Whitney U test;
CPB time (minute)		97	77, 116	89	74, 110	0.248^a a Mann-Whitney U test;
Cross-clamping time		59	45. 78	53	42, 66	0.106^a a Mann-Whitney U test;
Number of bypasses		3	2, 3	3	2, 4	0.207^a a Mann-Whitney U test;
Postoperative bleeding (24h)		750	600, 1000	750	500, 1100	0.680^a a Mann-Whitney U test;
Amount of postoperative drainage		1000	700, 1350	1000	700, 1450	0.778^a a Mann-Whitney U test;
Erythrocyte (unit)		0	0, 1	0	0, 1	0.533^a a Mann-Whitney U test;
FFP (unit)		2	0, 2	2	0, 2	0.100^a a Mann-Whitney U test;
Postoperative platelet number		170	147, 208	179	143, 227	0.216^a a Mann-Whitney U test;
Postoperative EF (%) (n= 71)		50	45, 55	50	45, 60	0.160^a a Mann-Whitney U test;
Drain removal (day)		2	2, 3	2	2, 3	0.621^a a Mann-Whitney U test;
Intensive care (day)		1	1, 2	1	1, 1	0.706^a a Mann-Whitney U test;
Clinical stay (day)		6	5, 6	6	5, 6	0.429^a a Mann-Whitney U test;
Hospitalization (day)		7	6, 7	7	6, 8	0.477^a a Mann-Whitney U test;

		Clopidogrel resistance				P
		Absent		Present
		n	%	n	%
Effusion	Absent	5	20	20	80	0.566^b b Pearson's chi-square test;
Effusion	Present	12	26.1	34	73.9	0.566^b b Pearson's chi-square test;
Tamponade	Absent	15	22.7	51	77.3	0.587^d d Fisher's exact test;
Tamponade	Present	2	40	3	60	0.587^d d Fisher's exact test;
LIMA/RIMA	LIMA	15	22.1	53	77.9	^‡ ‡ No measures of association are computed. -
LIMA/RIMA	RIMA	0	0	0	0	^‡ ‡ No measures of association are computed. -
Saphenous graft	Used	45	100	26	100
Saphenous graft	Not used	-	-	-	-
Use of platelet transfusion (unit)	Present	0	0	3	5.6	0.321
Use of platelet transfusion (unit)	Absent	17	100	51	94.4	0.321
Fresh blood replacement (unit)	Present	1	5.9	23	42.6	0.005^a a Mann-Whitney U test;
Fresh blood replacement (unit)	Absent	16	94.1	31	57.4	0.005^a a Mann-Whitney U test;
		Median	IQR	Median	IQR
Troponin (ug/L)		0.36	0.01, 0.55	0.33	0.06, 1.7	0.390^a a Mann-Whitney U test;
Preoperative EF (%)		52.5	47.5, 60	50	45, 60	0.999^a a Mann-Whitney U test;
Postoperative EF (%)		50	45, 55	50	45, 60	0.160^a a Mann-Whitney U test;
Number of bypasses		3	3, 3	3	3, 4	0.485^a a Mann-Whitney U test;
Perioperative bleeding (mL)		750	500, 950	725	450, 1000	0.973^a a Mann-Whitney U test;
Bleeding (24h) (mL)		300	200, 400	300	200, 500	0.896^a a Mann-Whitney U test;
Total bleeding (mL)		1800	1300, 2300	1775	1200, 2300	0.999^a a Mann-Whitney U test;
Erythrocyte (unit)		1	0, 2	0	0, 1	0.136^a a Mann-Whitney U test;
FFP (unit)		2	0, 2	2	0, 2	0.599^a a Mann-Whitney U test;
Intensive care unit stay (day)		2	1, 4	1	1, 2	0.020^a a Mann-Whitney U test;
Drain removal time (day)		2	2, 3	2	2, 3	0.994^a a Mann-Whitney U test;
Clinical admittance (day)		6	6, 8	6	6, 7	0.370^a a Mann-Whitney U test;
Discharge period (day)		9	7, 14	7	7, 8	0.051^a a Mann-Whitney U test;
Cross-clamping time (minute)		70	51, 88	48	40, 67	0.040^a a Mann-Whitney U test;
CPB time (minute)		104	94, 113	91.5	70, 112	0.091^a a Mann-Whitney U test;

Authors' roles & responsibilities
MK	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval
ZA	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval
UV	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval
AYB	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval
AAA	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval
SY	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; final manuscript approval

[1] Correspondence Address: Mehmet Kizilay, Department of Cardiovascular Surgery Dr. Siyami Ersek Training and Research Hospital, University of Health Sciences, Tibbiye Cad Selimiye, Uskudar, İstanbul, Turkey, Zip code: 34668. E-mail: kzlay@yahoo.com

Brasil

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Is Preoperative Clopidogrel Resistance a Predictor of Bleeding and Risks in Patients Undergoing Emergency CABG Surgery?

Abstract

Objective:

Methods:

Results:

Conclusion: