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

Mon Dec 4 20:20:35 EST 2006

MC wrote:
"I AM SURE IN FIRST TIME CASES YOU BOTH ARE ABLE TO STAY OFF PUMP 99.9%
OF THE TIME.  IS THIS TRUE IN REDO'S AS WELL?"
Don't trust anyone who SAYS they do off pump 99.9% of the time, or rather don't let them operate on you. Even if they do (it could happen annually every so often for a good off pump surgeon), they are more concerned with technique than results or individual problems. Those that do 100% on pump, well maybe they don't (or can't) have other techniques. (On pump surgeons can contort their needs (and the patient's dilemna) for technique as much as the off pump surgeon.) Redos really only vary the numbers maybe a sigma, but probably much less less, unless you are an "a priori" surgeon. (EG all redos need a valve replacement not a repair regardless of the problem.)
Tea

"ANOTHER QUESTION CAME UP DURING OUR CONFERENCE TODAY--WOULD YOU REPLACE
HIS "NORMAL" PORCINE VALVE WITH A MECHANICAL VALVE NOW TO PREVENT A 3RD
STERNOTOMY?"

Hard to image doing this, unless you are a 99.9%er. How about a (cor matrix ) pericardial patch instead.

Tea
Why did the meds send him home if he needed an operation day or nite?

----- Original Message ----
From: "Crittenden, Michael" <Michael.Crittenden at va.gov>
To: OpenHeart-L at lists.hsforum.com
Sent: Monday, December 4, 2006 7:46:24 PM
Subject: RE: [HSF] Plavix, Drug Eluting Stents, Stent Thrombosis and Redo CABG

Thanks to everyone who took the time to reply.

While I was doing a different redo CABG today on a patient without
Plavix, I was called by the Medical Service saying that they were going
to send the patient home.  How do you like that?

My responses are as follows:

(1) TO RSOOVA at COMCAST.NET WHO WROTE:
>I have used IIBIIIA inhibitors while the platelet inhibitors are
stopped >wait a few days then proceed with surgery, used intra-op
Aprotinin full >dose, re-start ASA Plavix post-op. Has worked well w/o
complications and >is now our standard approach for these scenarios.
>RSB

I had proposed this solution to them last week.  It sounded plausible to
me however "...there is no data" to support this treatment plan.  The
"no data" answer was supported by the editor-in-chief of a major (you
all know it) cardiology journal whom I personally know is pretty damn
smart...maybe not always right but pretty smart.  Their alternative
suggestion was to use Aprotinin with references detailing results in 99%
of first time cases.

(2) TO CHAND WHO WROTE:
>Well... they can't have the cake and eat it too. What is their c/o's
about >Aprotinin (is it patient care and Liability)? They should be more
worried >about placing DES in every one when it is not indicated. 
>I agree with Ani, we now routinely do our cases on Plavix but use
Aprotinin.
Chand

To be fair, it was our group's reservations about using Aprotinin that
has kept us from using it.  With the technique I described earlier, we
have very little bleeding issues whether it's a long or a short case;
redo or first time.  For first time cases we have begun to relax our
total insistence on stopping Plavix on NON-EMERGENT cases.  If we were
able to wait a day (more like overnight) or two without Plavix, then we
would operate on them within 24-48 hours.  Of course for emergent cases
we "bite the bullet" and do it.  Much to my surprise, it does not seem
to be as bad as advertised.  This is the first, NON-EMERGENT redo in
whom the request to stop or hold Plavix was not heeded.

(3) TO PRASSANA, BEN AND ANI WHO WROTE:
>You are lucky Ani. Clopidogrel has a varying responsiveness in
different >patients and I have seen patients simply exsanguinate after
Clopidogrel 
>+ CPB. The new platelets given have just got inhibited by circulating
>Clopidogrel and it has been horrible. It isn't that all patients bleed
like >this but when they do it is terrible.
>Prasanna

>There are enormous variation sin the response of the human organism to
>clopidogrel. Hence the increased loading dose being used more and more.
>There is evidence coming out of polymorphism of the expression of the
ADP >receptor.  Similar with ASA Platelet mapping....

>We use aprotinin for all such cases...if abnormal or if bleeding we
give >platelets.  The few cases I have seen seem not to bleed more than
other >reops and somehow I feel the (adverse) effect of clopidogrel on
surgery is >overstated.
>Ani

My experience has been that almost regardless of loading dose or not,
length of treatment (long or short), at least for first time cases, the
magnitude of "non-surgical bleeding" is quite variable.  The very first
time I operated on a patient WITHOUT STOPPING PLAVIX he bled very badly.
I took him back to surgery and did not find a true surgical bleed.  Most
see to either dry up in the OR as if there had not even seen the drug or
some will bleed more than most but will stop right when you have to
decide whether or not to call the OR team back in.

(4) TO DON ROSS, MICHAEL FIRSTENBERG AND TOMAS SALERNO WHO WROTE:
>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

>Do the case off pump, and when finished, remain in the operating room
after >packing the chest, then clear the wound again and wait another
half an >hour. Only leave the OR when the chest is absolutely dry. By
doing this, I >have been able to operate on patients on Plavix and ASA.
>The ones that I closed immediately were brought for bleeding.
>Tomas

>The other question is what also to graft?
>LIMA to LAD obviously, but what about the bypassing the stents?
>How bad is his function?  With the fixed defect on the antero-apical is
a >LIMA-LAD going to help?
>I dont know myself which is why I am asking (not doubting, just
unsure). >Any valvular problems?
>Something does not quiet sound right with this guy - he sounds pretty
>sick??
>when you say SOB - is that running a marathon or walking to the kitchen
to >get another beer during halftime?
>michael

Don and Michael,
At a combined cardiology-cardiac surgery conference, we discussed this
guy.  He has angina and dyspnea.  To him, his symptoms are so severe
that he would have the operation anytime day or night.  He had a
rest-redistribution Thallium study that demonstrated a viable anterior
wall with evidence of anterior wall ischemia.

After discussing the pros and cons of surgery with and without aprotinin
and elected to pursue medical management for another 3-4 months feeling
that at this point we could stop the Plavix long enough to operate on
him and then restart the Plavix the morning following surgery if all is
well.

As far as his valves--both the PORCINE aortic valve and the mitral
repair look good on echo.

Don and Tom,
I feel fairly accomplished in doing redo coronaries but I always find it
to be a little more difficult to find vessels on redo's.  LADs are
usually easier than lateral wall vessels but this is not always so in my
experience.

I AM SURE IN FIRST TIME CASES YOU BOTH ARE ABLE TO STAY OFF PUMP 99.9%
OF THE TIME.  IS THIS TRUE IN REDO'S AS WELL?

ANOTHER QUESTION CAME UP DURING OUR CONFERENCE TODAY--WOULD YOU REPLACE
HIS "NORMAL" PORCINE VALVE WITH A MECHANICAL VALVE NOW TO PREVENT A 3RD
STERNOTOMY?
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