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J Thorac Cardiovasc Surg 1998;115:472-473
© 1998 Mosby, Inc.

BRIEF COMMUNICATIONS

Emergency coronary bypass grafting for failed percutaneous coronaryartery stenting: increased costs and platelet transfusion requirements after theuse of abciximab

Melbourne, Australia

From the Department of Cardiothoracic Surgery, Monash MedicalCentre, Clayton 3168, Melbourne, Australia.

Received for publication Sept. 7, 1997 Accepted for publication Oct. 9, 1997. The adjunctive use of abciximab (ReoPro), a platelet glycoproteinIIb/IIIa receptor antagonist, with aspirin as pretreatment for percutaneouscoronary artery stenting (PTCS) has risen dramatically. ^1,2Reports on the outcomes of patients who require emergency coronary bypassgrafting (CABG) for unsuccessful PTCS are scarce. ³ This report documents three cases.Table I outlines cardiopulmonary bypass (CPB), hematologic, and coagulationassays. All patientshad received aspirin (300 mg) and abciximab (0.25 mg/kg/5 min bolus and 9 mg/500ml normal saline solution at 10 µg/min intravenous infusion) before theoperation. All had a profound bleeding diathesis evident from skin incision andpersisting for 4 to 5 hours after the operation.

PATIENT 1. A 38-year-old man had acute stent thrombosis 14 days afterPTCS to the left anterior descending coronary artery. Cardiogenic shock ensued,necessitating emergency CABG. Ticlopidine (Ticlid) at 250 mg twice a day hadbeen continued since the original PTCS.

CABG with a left internal thoracic artery graft to the left anteriordescending coronary artery and a saphenous vein graft to a first diagonal wasperformed. After reversal of heparinization, 5 units of platelets were given andthe chest was closed. By 60 minutes, the mediastinal blood loss was 1500 ml. Atresternotomy, no specific surgical source was evident. A 1.5 mg dose of1-deamino-8-D-arginine vasopressin (Minirim)and a 4  x 10⁶ kallikrein activation unit (KIU) dose ofaprotinin (Trasylol) were given intravenously. An additional 1900 ml blood lossoccurred during the next 24 hours. The patient was discharged on postoperativeday 10.

PATIENT 2. A 73-year-old man in cardiogenic shock with intraaorticballoon pump support was referred for operation with a postinfarct inferiorventricular septal rupture; PTCS to the proximal right coronary artery had beenperformed. The operation entailed polyethylene terephthalate (Dacron) patchclosure of the ventricular septal defect and placement of four venous coronarybypass grafts. Because of the previous experience, intravenous aprotinin ("high"Hammersmith dose [7 x 10⁶ KIU]) was given at induction,and after CPB 10 units of platelets were given. This patient died of low cardiacoutput syndrome 96 hours after the operation.

PATIENT 3. A 39-year-old woman, in cardiogenic shock from an evolvinganterolateral acute myocardial infarction after PTCS to the circumflex coronaryartery required emergency CABG. A left internal thoracic artery graft to theleft anterior descending coronary artery and two additional venous bypass graftswere performed. "High" Hammersmith dose aprotinin was used (total 5 x10⁶ KIU); after CPB, 10 units of platelets were also given. Thepatient was discharged home 6 days after the operation.

Discussion. This limited experiencefocuses attention on the potential impact of abciximab on patients undergoingemergency CABG; the message is sharp. In all three cases, results of history,physical examination, and hematologic and coagulation assays were normal beforethe operation, yet perioperative blood loss was in excess of what was expected.Aprotinin in the "high" Hammersmith dose and immediate, repeatedplatelet transfusions after CPB appear necessary and effective in reducingmediastinal blood loss.

Abciximab use is based on the reduction in the 30-day primary end point(death, acute myocardial infarction, revascularization) reported by the EPIC ¹ (placebo 12.8% vs treated 8.5%),EPILOG ² (placebo 11.7%vs treated 5.2%), and CAPTURE (placebo 15.9% vs treated 11.3%)trials. ^1,2 Only the EPIC trial reported onpatients requiring urgent CABG for failed PTCS. ³ Their operative mortality rate oftreated versus placebo groups is disturbing (placebo 8% versus treated29.4% for bolus plus infusion). Claims by the EPIC investigators thatthese results are acceptable are contradicted by their quoted references. Eightreferences had operative mortality rates ranging from 0% to 6.3%.In the remaining two, the Mid America Heart group had a total series operativemortality rate of 6.3% (18/286). ⁴Of the 113 emergency CABGs, 45% were performed on patients in cardiogenicshock (mortality rate 15%) or receiving cardiopulmonary resuscitation(mortality rate 62%). The remainder of patients undergoing emergency CABGhad a mortality rate of 3% to 4%. The Mid America Heart groupquote the mortality rate for the 1983 National Heart and Lung Institutepercutaneous transluminal coronary angioplasty surgical registry as 6.9%.In the series of Buffet and coworkers, ⁵all were emergency cases; 23% of patients were in cardiogenic shock orrequiring cardiopulmonary resuscitation. Excluding these cases in extremis,accounting for 14 of 19 deaths, the operative mortality rate for the remainderof emergency cases was 6.5%.

Thus, the 29.4% operative mortality rate of the EPIC trial is notreflective of the published mortality rates of 3% to 6% for thesame group of patients undergoing CABG, particularly because the EPIC patientsare not comparable with the in extremis cases reported on by Buffet andcoworkers ⁵ and the Mid AmericaHeart Institute. ⁴ This 30-day,nominal 4% to 6% benefit attributed to abciximab for PTCS must bequestioned if surgical mortality rate is increased among those needing CABG forfailed PTCS.

In addition, blood transfusion costs were $23,500 Australian, the cost ofabciximab was $1500 Australian/case, and three patients were exposed to 131donors. In Australian public hospitals, $28,000 Australian would cover 70%of the cost of all three CABGs. Trials analyzing the effects of this drug mustinclude data on patients who required urgent CABG if sensible conclusions are tobe reached. Before giving abciximab, the cardiologist must therefore criticallyassess the risk of PTCS failure, because the impact of abciximab on CABG is notbenign.

References

1. The EPIC Investigators. Use of a monoclonalantibody directed against the platelet glycoprotein IIb/IIIa receptor in highrisk coronary angioplasty. N Engl J Med 1994;330:956-61.[Abstract/Free Full Text]
   
2. Holmes DR Jr. Preventing coronary restenosisand complications. N Engl J Med 1997;336:1748-9.
   
3. Boehrer JD, Kereiakes DJ, Navetta FI, CaliffRM, Topol EJ. Effects of profound platelet inhibition with c7E3 before coronaryangioplasty on complications of coronary bypass surgery. Am J Cardiol 1994;74:1166-70.[Medline]
   
4. Killen DA, Hamaker WR, Reed WA. Coronaryartery bypass following percutaneous transluminal coronary angioplasty. AnnThorac Surg 1985;40:133-8.[Abstract]
   
5. Buffet P, Danchin N, Villemon JP, Amrein D,et al. Early and long term outcome after emergency coronary artery bypasssurgery after failed coronary angioplasty. Circulation 1991;84(suppl)III254-9.
   

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