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OPCAB: which kind of anticoagulation?

Published online by Cambridge University Press:  01 June 2007

A. Koster
A. Koster*
Affiliation:
Department of Anesthesia, Deutsches Herzzentrum Berlin, Germany
*
Correspondence to: Andreas Koster, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin. E-mail: [email protected]; Tel: +49 30 4593 2600; Fax: +49 30 4593 2700
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Summary

Background and objectives

Despite the absence of cardiopulmonary bypass, systemic anticoagulation is needed for off-pump coronary artery bypass (OPCAB) surgery. The aim of the current review is to describe the influence of OPCAB surgery on hemostatic activation and to review the literature with regard to perioperative anticoagulation protocols in OPCAB surgery.

Methods

Research of the pertinent literature with appropriate terms for anticoagulation in OPCAB surgery.

Results

While during on-pump cardiac surgery a target activated clotting time (ACT) value of 400–480 is generally accepted, to date no standardized target ACT value for OPCAB surgery has been established. However, an ACT value of > 300 seconds is accepted by approximately 80% of US/Canadian surgeons and 60% of European surgeons. Even given the large variation commercially available heparins, the inter-individual variability of the effect of heparins on the ACT, and large differences in coagulation activation and ‘clot detection’ of currently used ACT systems, this target ACT corresponds to a heparin dose of approximately 150–300 IU/kg. New anticoagulant drugs have been proposed, acting through a selective anti-Xa activity (danaparoid) or directly inhibiting thrombin (bivalirudin).

Conclusions

Anticoagulation management is performed without any internationally accepted standard and, due to this and the lack of adequately powered studies, there is scarce information about the effects of OPCAB surgery on hemostatic activation in the immediate perioperative period. Although limited to two modest studies, bivalirudin appears to be an interesting option for the future.

Keywords

Graft potencyCoronary artery bypass graftingHemostatic activation
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 24 , Issue S40 , June 2007 , pp. 77 - 82
Copyright
Copyright © European Society of Anaesthesiology 2007

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References

1.Al-Ruzzeh, S, Ambler, G, Asimakopoulos, G et al. . Off-pump coronary artery bypass (OPCAB) surgery reduces riskstratified morbidity and mortality. A United Kingdom multi-center comparative analysis of early clinical outcome. Circulation 2003; 108: 1–8.CrossRefGoogle ScholarPubMed
2.Sellke, FW, DiMaio, JM, Caplan, LR et al. . Comparing on-pump and off-pump coronary artery bypass grafting. Numerous studies but few conclusions. A scientific statement from the American heart association on cardiovascular surgery and anesthesia in collaboration with the interdisciplinary working group on quality of care and outcomes research. Circulation 2005; 111: 2858–2864.CrossRefGoogle Scholar
3.Parolari, A, Alamanni, F, Polvani, G et al. . Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery graft patency. Ann Thorac Surg 2005; 80: 2121–2125.CrossRefGoogle Scholar
4.Lim, E, Drain, A, Davies, W et al. . A systematic review of randomized trials comparing revascularization rate and graft patency of off-pump and conventional coronary surgery. J Thorac Cardiovasc Surg 2006; 132: 1409–1413.CrossRefGoogle ScholarPubMed
5.Merry, AF, Raudviki, PJ, Middelton, NG. Bivalirudin versus heparin and protamine in off-pump coronary artery bypass surgery. Ann Thorac Surg 2004; 77: 925–931.CrossRefGoogle ScholarPubMed
6.Dietrich, W. Cardiac surgery and the coagulation system. Curr Opin Anesthesiol 2000; 13: 27–34.CrossRefGoogle ScholarPubMed
7.Paparella, D, Brister, SJ, Buchanan, MR. Coagulation disorders of cardiopulmonary bypass: a review. Intensive Care Med 2004; 30: 1873–1881.CrossRefGoogle ScholarPubMed
8.Paparella, D, Galeone, A, Venneri, et al. . Activation of the coagulation system during coronary artery bypass grafting: comparison between on-pump and off-pump techniques. J Thorac Cardiovasc Surg 2006; 131: 290–297.CrossRefGoogle ScholarPubMed
9.Moller, CH, Steinbruchel, DA. Platelet function after coronary artery bypass grafting: is there a procoagulant activity after off-pump compared with on-pump surgery? Scand Cardiovasc J 2003; 37: 149–153.CrossRefGoogle Scholar
10.Bidstrup, BP, Scarrot, H, Luque, M. Platelet function after off pump coronary surgery. Heart Surg Forum 2003; 6: 286–287.Google ScholarPubMed
11.Mariani, MA, Gu, YJ, Boonstra, PW et al. . Procoagulant activity after off-pump coronary operation: is the current anticoagulation adequate. Ann Thorac Surg 1999; 67: 1370–1375.CrossRefGoogle ScholarPubMed
12.Engelberger, L, Immer, FF, Eckstein, FS. Off-pump coronary artery bypass grafting does not increase procoagulant and fibrinolytic activity: preliminary results. Ann Thorac Surg 2004; 77: 1560–1566.CrossRefGoogle Scholar
13.D’Ancona, G, Donias, HW, Karamanoukian, RL, Bergsland, J, Karamanoukian, HL. OPCAB therapy survey: off-pump clopidrogel, aspirin or both therapy survey. The Heart Surg Forum 2001; 4: 354–358.Google ScholarPubMed
14.Hansen, KH, Hughes, P, Steinbüchel, DA. Antithrombotic- and anticoagulation regimes in OPCAB surgery. A nordic survey. Scandinavian Cardiovascular Journal 2005; 39: 369–374.CrossRefGoogle Scholar
15.Khan, NE, DeSouza, A, Mister, R. A randomized comparison of off-pump and on-pump multivessel coronary artery bypass surgery. N Engl J Med 2004; 350: 21–28.CrossRefGoogle ScholarPubMed
16.Lingaas, PS, Hol, PK, Lundblad, R et al. . Clinical and radiological outcome of off-pump coronary surgery at 12 months follow up: a prospective randomized trial. Ann Thorac Surg 2006; 81: 2089–2895.CrossRefGoogle ScholarPubMed
17.Nathoe, HM, van Dijk, D, Jansen, EW et al. . A comparison of on-pump and off-pump coronary bypass surgery in low risk patients. N Engl J Med 2003; 348: 394–402.CrossRefGoogle ScholarPubMed
18.Puskas, JD, Williams, WH, Mahoney, EM et al. . Off-pump vs conventional coronary artery bypass grafting: early and 1 –year graft patency, cost, and quality-of-life outcome. JAMA 2004; 291: 1841–1849.CrossRefGoogle Scholar
19.Widimsky, P, Straka, Z, Stros, P et al. . One year coronary artery bypass graft patency. A randomized comparison between off-pump and on-pump surgery angiographic results of the PRAGUE-4 trail. Circulation 2004; 110: 3418–3423.CrossRefGoogle Scholar
20.Poston, R, Gu, J, Manchio, J et al. . Platelet function tests predict bleeding and thrombotic events after off-pump coronary artery bypass grafting. Eur J CardioThorac Surg 2005; 27: 584–591.CrossRefGoogle Scholar
21.Oronati, F, Olivito, S, Mastroroberto, P et al. . Perioperative patency of coronary artery bypass grafting is not influenced by off-pump technique. Ann Thorac Surg 2005; 80: 2132–2140.Google Scholar
22.Sergeant, P, Wouters, P, Meyns, B et al. . OPCAB versus early mortality and morbidity: an issue between clinical relevance and statistical significance. Eur J CardioThorac Surg 2004; 25: 779–785.CrossRefGoogle ScholarPubMed
23.El-Hamamsy, I, Cartier, R, Demers, P et al. . Long-term results after systematic off-pump coronary artery bypass graft surgery in 1000 consecutive patients. Circulation 2006; 114: 486–491.CrossRefGoogle ScholarPubMed
24.Baykut, D, Weichelt, K, Wehrle, J, Zerkowski, HR, Bernet, F. The value of heparin concentration monitoring in off-pump coronary bypass surgery. Eur J Med Res 2003; 8: 161–164.Google ScholarPubMed
25.Zehr, KJ, Handa, N, Bonilla, LF, Abel, MD, JrHolmes, DR. Pitfals and results of immediate angiography after off-pump coronary artery bypass grafting. Heart Surg Forum 2000; 3: 293–299.Google Scholar
26.Woo, YL, Atluri, P, Gand, TJ, Gardner, TJ. Should standard on-pump protamine dosing formulas be recalculated for off-pump coronary artery bypass grafting? Heart Surg Forum 2004; 7: 42–44.Google ScholarPubMed
27.Carrier, M, Robitaille, D, Perrault, LP. Heparin versus danaparoid in off-pump coronary artery bypass grafting: results of a prospective randomized trial. J Thorac Cardiovasc Surg 2003; 125: 325–329.CrossRefGoogle Scholar
28.Lincoff, AM, Bittl, JA, Harrington, RA et al. . Bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and planned glycoprotein IIb/IIIa blockade during percutaneous coronary intervention. REPLACE-2 randomized trial. JAMA 2003; 289: 853–863.CrossRefGoogle ScholarPubMed
29.Stone, GW, McLaurin, BT, Cox, DA et al. . Bivalirudin for patients with acute coronary syndrome. N Engl J Med 2006; 355: 2203–2216.CrossRefGoogle Scholar
30.Smedira, NG, Dyke, CM, Koster, A et al. . Anticoagulation with bivalirudin for off-pump coronary artery bypass grafting: The results of the EVOLUTION-OFF study. J Thorac Cardiovasc Surg 2006; 131: 686–692.CrossRefGoogle ScholarPubMed
31.Koster, A, Spiess, B, Jurmann, M et al. . Bivalirudin provides rapid, effective, and reliable anticoagulation during off-pump coronary revascularization: results of the ‘EVOLUTION OFF’ trial. Anesth Analg 2006; 103: 540–544.CrossRefGoogle ScholarPubMed
32.Halkos, ME, Cooper, WA, Peterson, R et al. . Early administration of clopidrogel is safe after off-pump coronary artery bypass surgery. Ann Thorac Surg 2006; 81: 815–819.CrossRefGoogle Scholar
33.Gurbuz, AT, Zia, AA, Vuran, AC, Cul, H, Aytac, A. Postoperative clopidrogel improves mid-term outcome after off-pump coronary artery graft surgery : a prospective study. Eur J Cardiothorac Surg 2006; 29: 190–195.CrossRefGoogle Scholar