Bridge to Operation with the GPIIb/IIIa Inhibitor Abciximab in High-Risk Coronary Patients[1]

Abstract

Background: Glycoprotein-IIb/IIIa inhibitors are now frequently used in the cardiological treatment of high-risk coronary patients even if the patient is considered suitable for surgical intervention. However, there is no consensus whether GPIIb/IIIa inhibitors should be stopped before operation because of an increased risk of bleeding or if surgery should even be delayed until the anticoagulating effect subsides. Methods: From June 2002 to August 2003 140 patients who had to undergo primary aorto-coronary bypass for ongoing myocardial ischemia were enrolled in the present study. The patients received either clopidogrel, aspirin and heparin or additionally abciximab until operation. Results: Although the intraoperative need for blood products was higher in the abciximab group, there was no significant difference in postoperative blood loss. The hemodynamic situation of the abciximab patients after the operation was better compared to the other groups. 30-day mortality was not increased when compared to the elective control group (6.7 % vs. 6.1 %). Conclusion: The GPIIb/IIIa inhibitor abciximab can be safely used as a bridge to operation and results in a better hemodynamic outcome in high-risk coronary patients while reducing the incidence of major ischemic events.

Key words

GPIIb/IIIa inhibitors - abciximab - emergency CABG - EuroSCORE

1 Presented at the Annual Meeting of the German Society of Thoracic and Cardiovascular Surgery, Hamburg 2005

References

• 1 Second International Study of Infarct Survival Collaborative Group . Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction: ISIS‐2.  Lancet. 1988;  2 349-360
• 2 Levy J H, Smith P K, LeNarz L A. et al . Group Recommendations.  Ann Thorac Surg. 2000;  70 (Suppl) 43
• 3 Seshadri N, Whitlow P L, Acharya N. et al . Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era.  Circulation. 2002;  106 2346-2350
• 4 Shubrooks Jr S J, Nesto R W, Leeman D. Urgent coronary bypass surgery for failed percutaneous coronary intervention in the stent era: Is backup still necessary?.  Am Heart J. 2001;  142 190-196
• 5 Boersma E, Harrington R A, Moliterno D J. et al . Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta analysis of all randomized controlled trials that enrolled over 1000 patients.  Lancet. 2002;  359 189-198
• 6 Vahl C F, Kayhan N, Thomas G, Bode C, Hagl S. Myocardial revascularization after pretreatment with the GPIIb/IIIa-antagonist abciximab.  Z Kardiol. 2001;  90 889-897
• 7 Nashef S AM, Roques F, Michel P. et al . European system for cardiac operative risk evaluation (EuroSCORE).  Eur J Cardio Thorac Surg. 1999;  16 9-13
• 8 Coller B S. Blockade of platelet GPIIb/IIIa receptors as an antithrombotic strategy.  Circulation. 1995;  92 2373-2380
• 9 Bidstrup B P, Royston D, Sapsford R N. et al . Reduction in blood loss and blood use after cardiopulmonary bypass with high dose aprotinin.  J Thorac Cardiovasc Surg. 1989;  97 364-372
• 10 EPISTENT Investigators . Randomised, placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein IIb/IIIa-blockade.  Lancet. 1998;  352 87-92
• 11 Breede J J, Bavinck J H, Berreklouw E. Acute myocardial ischemia and cardiogenic shock after percutaneous transluminal coronary angioplasty: risk factors for and results of emergency coronary bypass.  Eur Heart J. 1989;  10 (Suppl) 104-111
• 12 Craver J M, Weintraub W S, Jones E L. Emergency coronary artery bypass surgery after failed percutaneous coronary angioplasty: a 10 year experience.  Ann Surg. 1992;  215 425-433
• 13 EPIC Investigators . Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty.  N Engl J Med. 1994;  330 956-961
• 14 EPILOG Investigators . Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularisation.  N Engl J Med. 1997;  336 1689-1696
• 15 Boehrer J D, Kereiakes D J, Navetta F I, Califf R M, Topol E J. Effects of profound platelet inhibition with c7E3 before coronary angioplasty on complications of coronary bypass surgery.  Am J Cardiol. 1994;  74 1166-1170
• 16 Bracey A, Radovancevic R, Vaughn W, Ferguson J, Livesay J. Blood use in emergency coronary artery bypass after receipt of abciximab during angioplasty.  Transfusion. 1998;  38 (Suppl) S250
• 17 Booth J A, Patel V B, Balog C. Is bleeding risk increased in patients undergoing urgent coronary bypass surgery following abciximab?.  Circulation. 1998;  98 (Suppl) 845
• 18 Juergens C P, Yeung A C, Oesterle S N. Routine platelet transfusion in patients undergoing emergency coronary bypass surgery after receiving abciximab.  Am J Cardiol. 1997;  80 74-75
• 19 Gammie J S, Zenati M, Kormos R L. Abciximab and excessive bleeding in patients undergoing emergency cardiac operations.  Ann Thorac Surg. 1998;  65 465-469
• 20 Alvarez J M. Emergency coronary bypass grafting for failed percutaneous coronary artery stenting: increased costs and platelet transfusion requirements after the use of abciximab.  J Thorac Cardiovasc Surg. 1998;  115 472-473
• 21 Lemmer Jr J H, Metzdorff M T, Krause A H, Martin M A, Okies J E, Hill J G. Emergency coronary artery bypass surgery in abciximab-treated patients.  Ann Thorac Surg. 2000;  69 90-95

1 Presented at the Annual Meeting of the German Society of Thoracic and Cardiovascular Surgery, Hamburg 2005