Ann Thorac Surg 2014;98:782–7
Clinical Outcomes Unit American University of Beirut Beirut, Lebanon Sean Neill, MD Department of Anesthesiology University of Michigan Ann Arbor, MI Jennifer Vance, MD Department of Anesthesiology University of Michigan Ann Arbor, MI Donald S. Likosky, PhD Department of Cardiac Surgery University of Michigan Ann Arbor, MI
References 1. Wang S-Y, Xue F-S, Li R-P, Cui X-L. Assessing independent effects of anemia and transfusion on late mortality (letter). Ann Thorac Surg 2014;98:782. 2. Pedersen AB, Baron JA, Overgaard S, Johnsen SP. Short- and long-term mortality following primary total hip replacement for osteoarthritis: a Danish nationwide epidemiological study. J Bone Joint Surg Br 2011;93:172–7. 3. Engoren M, Habib RH, Arslanian-Engoren C, Kheterpal S, Schwann TA. The effect of acute kidney injury and discharge creatinine level on mortality following cardiac surgery. Crit Care Med. In press. PMID 24810529 4. Leslie K, Myles PS, Forbes A, Chan MT. The effect of bispectral index monitoring on long-term survival in the B-aware trial. Anesth Analg 2010;110:816–22. 5. Engoren M, Schwann TA, Habib RH, Neill SN, Vance JL, Likosky DS. The independent effects of anemia and transfusion on mortality after coronary artery bypass. Ann Thorac Surg 2014;97:514–20. 6. Harlaar JJ, Gosselink MP, Hop WC, Lange JF, Busch OR, Jeekel H. Blood transfusions and prognosis in colorectal cancer: long-term results of a randomized controlled trial. Ann Surg 2012;256:681–6.
Clopidogrel After Surgical Coronary Revascularization Increases Venous Graft Patency To the Editor: I read with great interest the article by Ebrahimi and colleagues [1] regarding the effect of the combination of aspirin and clopidogrel on vein graft patency after coronary artery bypass grafting (CABG) surgery. In this observational analysis of data from the Randomized On and Off-Pump Bypass trial, the authors concluded that clopidogrel use after CABG did not significantly reduce the incidence of 1-year venous graft failure. A recent meta-analysis [2] of five randomized controlled studies investigating the effect of single versus dual antiplatelet therapy on early patency of graft conduits after CABG concluded that dual antiplatelet therapy significantly reduced the risk of venous graft occlusion. It is important to note that for vein grafts, single antiplatelet therapy was associated with a significantly increased graft failure rate (91 of 846; 10.8%) versus dual antiplatelet therapy (57 of 860; 6.6%; p ¼ 0.003). Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
783
In the latest guidelines on myocardial revascularization from the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery [3], the task force authors recommend the use of clopidogrel after CABG only in cases of aspirin intolerance because there are no randomized controlled trial comparing the efficacy of clopidogrel plus aspirin versus aspirin alone on graft patency. With the present strong and persuasive scientific evidence, this statement is now outdated. Grafts are especially vulnerable in the early postoperative period, and effective prompt postoperative antiplatelet therapy is paramount to preserve the revascularization benefit [4]. This underscores the importance of rapid identification of patients with aspirin resistance, thus allowing a timely intervention. The beneficial effect of clopidogrel is attributable to the fact that dual antiplatelet therapy overcomes single drug resistances as shown in the CRYSSA (prevention of coronary artery bypass occlusion after off-pump procedures) trial [5]. Jamil Hajj-Chahine, MD Department of Cardio-thoracic Surgery University Hospital of Poitiers 2 Rue de la Miletrie 86021 Poitiers, France e-mail: [email protected]
References 1. Ebrahimi R, Bakaeen FG, Uberoi A, et al. Effect of clopidogrel use post coronary artery bypass surgery on graft patency. Ann Thorac Surg 2014;97:15–21. 2. Nocerino AG, Achenbach S, Taylor AJ. Meta-analysis of effect of single versus dual antiplatelet therapy on early patency of bypass conduits after coronary artery bypass grafting. Am J Cardiol 2013;112:1576–9. 3. Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI), Kolh P, Wijns W, Danchin N, et al. Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2010;38(Suppl):S1–52. 4. Gluckman TJ, McLean RC, Schulman SP, et al. Effects of aspirin responsiveness and platelet reactivity on early vein graft thrombosis after coronary artery bypass graft surgery. J Am Coll Cardiol 2011;57:1069–77. 5. Mannacio VA, Di Tommaso L, Antignan A, De Amicis V, Vosa C. Aspirin plus clopidogrel for optimal platelet inhibition following off-pump coronary artery bypass surgery: results from the CRYSSA (prevention of Coronary arteRY bypass occlusion After off-pump procedures) randomised study. Heart 2012;98:1710–5.
Acute Kidney Injury and Cardiopulmonary Bypass Surgery To the Editor: In a recent issue of The Annals of Thoracic Surgery, Sickeler and colleagues [1] did not confirm any association of cardiac surgery–related acute kidney injury (AKI) risk with the cooccurrence of hypotension and anemia during cardiopulmonary bypass (CPB) relative to anemia alone. Also, they found no association between CPB hypotension (alone) and postoperative AKI. These findings are surprising. However, an important point that should be kept in mind when drawing conclusions from this study is that cerebral 0003-4975/$36.00
MISCELLANEOUS
Robert H. Habib, PhD
CORRESPONDENCE
Clinical Outcomes Unit American University of Beirut Beirut, Lebanon Sean Neill, MD Department of Anesthesiology University of Michigan Ann Arbor, MI Jennifer Vance, MD Department of Anesthesiology University of Michigan Ann Arbor, MI Donald S. Likosky, PhD Department of Cardiac Surgery University of Michigan Ann Arbor, MI
References 1. Wang S-Y, Xue F-S, Li R-P, Cui X-L. Assessing independent effects of anemia and transfusion on late mortality (letter). Ann Thorac Surg 2014;98:782. 2. Pedersen AB, Baron JA, Overgaard S, Johnsen SP. Short- and long-term mortality following primary total hip replacement for osteoarthritis: a Danish nationwide epidemiological study. J Bone Joint Surg Br 2011;93:172–7. 3. Engoren M, Habib RH, Arslanian-Engoren C, Kheterpal S, Schwann TA. The effect of acute kidney injury and discharge creatinine level on mortality following cardiac surgery. Crit Care Med. In press. PMID 24810529 4. Leslie K, Myles PS, Forbes A, Chan MT. The effect of bispectral index monitoring on long-term survival in the B-aware trial. Anesth Analg 2010;110:816–22. 5. Engoren M, Schwann TA, Habib RH, Neill SN, Vance JL, Likosky DS. The independent effects of anemia and transfusion on mortality after coronary artery bypass. Ann Thorac Surg 2014;97:514–20. 6. Harlaar JJ, Gosselink MP, Hop WC, Lange JF, Busch OR, Jeekel H. Blood transfusions and prognosis in colorectal cancer: long-term results of a randomized controlled trial. Ann Surg 2012;256:681–6.
Clopidogrel After Surgical Coronary Revascularization Increases Venous Graft Patency To the Editor: I read with great interest the article by Ebrahimi and colleagues [1] regarding the effect of the combination of aspirin and clopidogrel on vein graft patency after coronary artery bypass grafting (CABG) surgery. In this observational analysis of data from the Randomized On and Off-Pump Bypass trial, the authors concluded that clopidogrel use after CABG did not significantly reduce the incidence of 1-year venous graft failure. A recent meta-analysis [2] of five randomized controlled studies investigating the effect of single versus dual antiplatelet therapy on early patency of graft conduits after CABG concluded that dual antiplatelet therapy significantly reduced the risk of venous graft occlusion. It is important to note that for vein grafts, single antiplatelet therapy was associated with a significantly increased graft failure rate (91 of 846; 10.8%) versus dual antiplatelet therapy (57 of 860; 6.6%; p ¼ 0.003). Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
783
In the latest guidelines on myocardial revascularization from the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery [3], the task force authors recommend the use of clopidogrel after CABG only in cases of aspirin intolerance because there are no randomized controlled trial comparing the efficacy of clopidogrel plus aspirin versus aspirin alone on graft patency. With the present strong and persuasive scientific evidence, this statement is now outdated. Grafts are especially vulnerable in the early postoperative period, and effective prompt postoperative antiplatelet therapy is paramount to preserve the revascularization benefit [4]. This underscores the importance of rapid identification of patients with aspirin resistance, thus allowing a timely intervention. The beneficial effect of clopidogrel is attributable to the fact that dual antiplatelet therapy overcomes single drug resistances as shown in the CRYSSA (prevention of coronary artery bypass occlusion after off-pump procedures) trial [5]. Jamil Hajj-Chahine, MD Department of Cardio-thoracic Surgery University Hospital of Poitiers 2 Rue de la Miletrie 86021 Poitiers, France e-mail: [email protected]
References 1. Ebrahimi R, Bakaeen FG, Uberoi A, et al. Effect of clopidogrel use post coronary artery bypass surgery on graft patency. Ann Thorac Surg 2014;97:15–21. 2. Nocerino AG, Achenbach S, Taylor AJ. Meta-analysis of effect of single versus dual antiplatelet therapy on early patency of bypass conduits after coronary artery bypass grafting. Am J Cardiol 2013;112:1576–9. 3. Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI), Kolh P, Wijns W, Danchin N, et al. Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2010;38(Suppl):S1–52. 4. Gluckman TJ, McLean RC, Schulman SP, et al. Effects of aspirin responsiveness and platelet reactivity on early vein graft thrombosis after coronary artery bypass graft surgery. J Am Coll Cardiol 2011;57:1069–77. 5. Mannacio VA, Di Tommaso L, Antignan A, De Amicis V, Vosa C. Aspirin plus clopidogrel for optimal platelet inhibition following off-pump coronary artery bypass surgery: results from the CRYSSA (prevention of Coronary arteRY bypass occlusion After off-pump procedures) randomised study. Heart 2012;98:1710–5.
Acute Kidney Injury and Cardiopulmonary Bypass Surgery To the Editor: In a recent issue of The Annals of Thoracic Surgery, Sickeler and colleagues [1] did not confirm any association of cardiac surgery–related acute kidney injury (AKI) risk with the cooccurrence of hypotension and anemia during cardiopulmonary bypass (CPB) relative to anemia alone. Also, they found no association between CPB hypotension (alone) and postoperative AKI. These findings are surprising. However, an important point that should be kept in mind when drawing conclusions from this study is that cerebral 0003-4975/$36.00
MISCELLANEOUS
Robert H. Habib, PhD
CORRESPONDENCE
