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Antithrombotic therapy in cardiac surgery

[Traitement antithrombotique en chirurgie cardiaque]

André Vincentelli, MD^*, Brigitte Jude, MD and Sylvain Bélisle, MD

^* From the Centre Hospitalier Régional Universitaire de Lille, Clinique de Chirurgie Cardiovasculaire; the
Institut d’Hématologie-Transfusion; Université de Lille, Lille, France; and the
Institut de Cardiologie de Montréal et Centre Hospitalier de l’Université de Montréal (CHUM), Département d’Anesthésiologie de l’Université de Montréal, Montréal, Québec, Canada.

Address correspondence to: Dr. Brigitte Jude, Laboratoire d’Hématologie, Hôpital Cardiologique, 59037, Lille cedex, France. E-mail: b-jude{at}chru-lille.fr

Purpose: To review the perioperative management of antithrombotic therapy in cardiac surgery, including the management of cardiopulmonary bypass (CPB) and off-pump surgery.

Methods: A review of the relevant English literature over the period 1975–2005 was undertaken, in addition to a review of international practices in antithrombotic therapy in cardiac surgery.

Principal findings: Cardiopulmonary bypass is required in most procedures and makes anticoagulation mandatory. Anticoagulation is, usually, achieved with unfractionnated heparin (UFH). Unfractionated heparin is monitored by point-of-care (POC) testing, such as the activated clotting time or the determination of heparin concentration. The target values of both tests remain empirical, with no clearly validated thresholds. The target value needs to be adjusted according to the POC test, given significant variations between devices and activators. After CABG, the need for antiplatelet therapy is well demonstrated, in order to limit the risk of postoperative death or ischemic events, and improve venous graft patency. Immediately after valvular surgery, antithrombotic therapy should take into account the specific risk carried by each patient and by each prosthetic device. The risk of venous thromboembolism, though poorly defined, is also present in the postoperative period and may require additional attention. Given the frequent exposure to UFH, occurrence of heparin-induced thrombocytopenia is not infrequent in these patients and requires careful individual management.

Conclusions: Antithrombotic therapy is an essential component of cardiac surgery. Yet, with the exception of antiplatelet agents in CABG patients, antithrombotic therapy is often based on the clinical experience of medical teams more than on an evidence-based assessment of the literature.

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