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J Thorac Cardiovasc Surg 1999;118:980-981
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Abciximab (ReoPro) removal with a hemoconcentrator during cardiopulmonarybypass

John H. Lemmer, Jr, MD

Legacy Good Samaritan Hospital
NW Surgical Associates
2222 NWLovejoy, No. 315
Portland, OR 97210

To the Editor:

The problem of performing emergency cardiac surgery on patients whohave been recently treated with abciximab (ReoPro, Eli Lilly and Company,Indianapolis, Ind) as addressed by Poullis and associatesGo 1 is indeed of considerable interest to surgeons. Thein vitro experiment they described, however, may have limited applicabilityto the clinical situation of operating on a patient who has been recentlytreated with abciximab. In their method, abciximab was added to a solutionof saline and then subjected to hemoconcentration during circulation in anin vitro cardiopulmonary bypass circuit. However, platelets were not includedin the test solution. This protocol is quite different from the situationof a patient who has been recently treated with abciximab and who does haveplatelets.

Poullis and associates state that the purpose of hemofiltration is toremove free abciximab so that subsequently administered donor platelets willhave the role of providing hemostasis rather than "primarily absorbingfree antibody." This hypothesis, however, is not consistent with thepharmacodynamic profile of abciximab.

When abciximab is administered, the drug rapidly binds to the plateletglycoprotein IIb/IIIa receptors and results in severe inhibition of plateletaggregation and prolongation of the bleeding time.Go Go 2,3 The bindingof abciximab to the platelets is noncompetitive and the dissociation ratefrom platelets is slow. Excess non-bound abciximab is rapidly cleared, andwithin 30 minutes of abciximab administration less than 4% of the administereddose is present within the serum as free antibody.Go 4 Thus essentially no abciximab is available for removalby hemofiltration. Likewise, when donor platelets are transfused, no freeabciximab is present to be "absorbed." When platelets are transfusedthere is, however, redistribution of abciximab from native (bound) plateletreceptors to transfused (unbound) platelet receptors, resulting in an overallreduction in the percentage of bound receptors. When this overall percentageof blocked receptors falls below approximately 80%, the bleeding time andhemostasis return toward normal. This is the rationale for transfusing plateletsto reverse the effect of abciximab.Go Go 3,4

Potential methods to reduce the bleeding diathesis in patients requiringsurgery while under the effect of abciximab are welcome to surgeons who haveto deal with this problem. At present, however, platelet administration todilute the abciximab blockade of the platelet glycoprotein IIb/IIIa receptorswould appear to be the antidote of choice. My colleagues and IGo 5 recently reported experience with 12 patients whorequired emergency coronary artery bypass grafting shortly after abciximabtreatment. The routine transfusion of 1 apheresis platelet unit (volume equalto 6 random donor platelets but acquired from a single donor) after reversalof heparin effect by protamine, with additional blood product transfusionsgiven as required, was clinically successful.

12/8/101562

References

  1. Poullis M, Manning R, Haskard D, TaylorK. ReoPro removal during cardiopulmonary bypass using a hemoconcentrator.J Thorac Cardiovasc Surg 1999;117:1032-4.[Free Full Text]
  2. Tcheng JE, Ellis SG, George BS, et al.Pharmacodynamics of chimeric glycoprotein IIb/IIIa integrin antiplatelet antibodyFab 7E3 in high-risk coronary angioplasty. Circulation 1994;90:1757-64.[Abstract/Free Full Text]
  3. Mascelli MA, Lance ET, Damaraju L, WagnerCL, Weisman HF, Jordan RE. Pharmacodynamic profile of short-term abciximabtreatment demonstrates prolonged platelet inhibition with gradual recoveryfrom GP IIb/IIIa receptor blockade. Circulation 1998;97:1680-8.[Abstract/Free Full Text]
  4. Coller BS. GP IIb/IIIa antagonists: pathophysiologicand therapeutic insights from studies of c7E3 Fab. Thromb Haemost 1997;78:730-5.[Medline]
  5. Lemmer JH Jr, Metzdorff MT, Krause AH,Martin MA, Okies JE, Hill JG. Emergency coronary artery surgery in abciximab-treatedpatients. Ann Thorac Surg. In press.




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