[HSF] Plavix, Drug Eluting Stents, Stent Thrombosis and Redo CABG

Mon Dec 4 19:42:36 EST 2006

Ben, we are all waiting on you to save the known world (except for Hal, of course). I'm not laughing at you, Mike. Just our local expert, Ben. (This is a dangerous group in which to be an expert.) Of course I am also interested in Ben's opinion but would set the hook more enigmatically.
Tea(se)

----- Original Message ----
From: "Crittenden, Michael" <Michael.Crittenden at va.gov>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, December 4, 2006 7:52:33 PM
Subject: RE: [HSF] Plavix, Drug Eluting Stents, Stent Thrombosis and Redo CABG

It had been my impression from reading the literature a few years ago
that "rescue" aprotinin did not work very well.  Maybe Ben Bidstrup
could comment?

-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Tea Acuff
Sent: Monday, December 04, 2006 8:46 PM
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Plavix, Drug Eluting Stents, Stent Thrombosis and
Redo CABG

When is aprotonin too late? If you are going to wait, and especially if
you are not using the pump, what is the difference? Is it like abx and
need a blood level before the process starts? Why not wait until the
(nearly) end? Or is this (timing) another unknown variable?
Tea

----- Original Message ----
From: Donald Ross <donross at bigpond.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, December 4, 2006 3:24:13 PM
Subject: Re: [HSF] Plavix, Drug Eluting Stents, Stent Thrombosis and
Redo CABG

Cardiologists, they are hard to respect. They just love to tell  
surgeons how to operate. One of my colleagues once lost a referring  
cardiologist by telling him: "He wasn't his f....ing sewing machine."
Operating with ASA and clopidogrel is usually safe but just  
occasionally it can result in a dangerous coagulopathy but it is not  
possible to predict this despite all the clever tests.
I would inform the patient and the cards of this fact and recommend a  
prolonged trial of medical management . The single vessel coronary  
disease is not, after all, life threatening like the surgery.
All the advice on how to tackle surgery if inevitable is good. I  
would plan opcab without stopping the drugs and only use aprotinin if  
the bleeding looked coagulopathic prior to heparinisation.
Don
On 05/12/2006, at 1:01 AM, Crittenden, Michael wrote:

> I have been asked to operate on a 54 year old man who had an AVR
> (bioprosthetic valve); mitral repair underwent and a single vein  
> bypass
> to the OM in 2002 at another institution.  He did well for 12  
> months but
> then experienced a return of his anginal symptoms and DOE.  In  
> September
> 2006, the patient was again seen at CMC, where he was admitted with CP
> and dyspnea. Adenosine - MIBI MPI was notable for a fixed antero- 
> apical
> defect and reversible defect involving the inferior wall.  Based upon
> that test result, he underwent CATH, which revealed a L-dominant  
> system
> with a total occlusion of the LAD (distal vessel fills via L-L and R-L
> collaterals); a patent SVG to the OM and serial stenoses of the mid  
> LCX
> proximal to a Left PDA. Based upon these nuclear and angiographic
> findings, a decision was made to proceed with PCI of the LCX -- 2  
> Taxus
> stents were placed in the mid and distal LCX proximal to the L-PDA.
> Unfortunately, despite this intervention, the patient has had  
> persistent
> dyspnea and chest discomfort.
>
>
>
> Re cath here, LCx and stents open.  OM graft still patent.  There is
> ersistent poor antegrade flow down a reasonable looking LAD.  I have
> been asked to revascularize the LAD with the LIMA.  THE CARDIOLOGISTS
> DON'T WANT TO STOP THE ASA AND CLOPIDOGREL.  I have asked them to  
> do so
> for 48-72 hours.  With all the "noise" about stent thromboses now they
> do not want to stop the drugs at all.
>
>
>
> I would be curious to see what opinions there are about how we should
> handle his current antithrombotic regimen and what we should do
> intraoperatively.  Our group has espoused EACA, low dose heparin and
> heparin bonded circuits.  So far we have not had to use Aprotinin  
> and so
> far have not regretted it.  Our cardiologists now want us to use
> it!!??!!
>
>
>
> Mike Crittenden
>
>
>
>
>
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