Abciximab and Excessive Bleeding in Patients Undergoing Emergency Cardiac Operations

doi:10.1016/S0003-4975(97)01299-X

The Annals of Thoracic Surgery

Volume 65, Issue 2, February 1998, Pages 465-469

https://doi.org/10.1016/S0003-4975(97)01299-X Get rights and content

Abstract

Background. Abciximab (ReoPro; Eli Lilly and Co, Indianapolis, IN) is a monoclonal antibody that binds to the platelet glycoprotein IIb/IIIa receptor and produces powerful inhibition of platelet function. Clinical trials of abciximab in patients undergoing coronary angioplasty have demonstrated a reduction in thrombotic complications and have encouraged the widespread use of this agent. We have observed a substantial incidence of excessive bleeding among patients who receive abciximab and subsequently require emergency cardiac operations.

Methods. The records of 11 consecutive patients who required emergency cardiac operations after administration of abciximab and failed angioplasty or stent placement were reviewed.

Results. The interval from the cessation of abciximab administration to operation was critical in determining the degree of coagulopathy after cardiopulmonary bypass. The median values for postoperative chest drainage (1,300 versus 400 mL; p < 0.01), packed red blood cells transfused (6 versus 0 U; p = 0.02), platelets transfused (20 versus 0 packs; p = 0.02), and maximum activated clotting time (800 versus 528 seconds; p = 0.01) all were significantly greater in the early group (cardiac operation <12 hours after abciximab administration; n = 6) compared with the late (cardiac operation >12 hours after abciximab administration; n = 5) group.

Conclusions. This report suggests that the antiplatelet agent abciximab is associated with substantial bleeding when it is administered within 12 hours of operation.

Section snippets

Material and Methods

We reviewed the records of all patients at the University of Pittsburgh Medical Center and the Mercy Heart Institute who were administered abciximab during PTCA and subsequently required urgent cardiac operation. All patients received aspirin and heparin before PTCA. Heparin was given intravenously at an initial dose of 5,000 to 10,000 U (70 U/kg), followed by intermittent boluses to maintain an activated clotting time (ACT) between 200 and 300 seconds. Abciximab was administered as a bolus of

Precatheterization Characteristics

Between November 1995 and December 1996, 175 patients received abciximab before undergoing high-risk PTCA. Of these, 11 (6.3%, 9 men and 2 women) required urgent cardiac operations because of failed PTCA or intracoronary stent placement. The patients ranged in age from 43 to 80 years. Coronary artery bypass grafting (CABG) was required in 7 patients for failed stent placement and in 3 patients for unsuccessful PTCA. One patient underwent the placement of a left ventricular assist device for

Comment

This study documents an early experience with cardiac operations in patients treated with the antiplatelet agent abciximab during percutaneous revascularization. The interval between abciximab administration and operation was critical in determining the extent of perioperative mediastinal bleeding and the necessity for blood product support. Our initial experience suggests that abciximab, when given within 12 hours of cardiac operation, is associated with significantly increased blood loss and

Acknowledgements

We thank Albert G. Marrangoni, MD, for his generous assistance with data collection.

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Citation Excerpt :
Aspirin had been administered to 93% and ticlopidine to 23% of patients before surgery. On the other hand, previous very small, non-randomized, single-institution reports described the need for large amounts of blood products in a total of 13 abciximab-treated patients undergoing CABG [28–30], with a possible increase in morbidity and costs. Based on these episodic experiences, delaying emergency or urgent CABG for 12 h has de facto been recommended in patients treated with abciximab [11,31], despite that a careful analysis of the literature does not support this concept.
Glycoprotein (GP) IIb/IIIa receptor inhibitors before primary angioplasty in patients with ST-elevation acute myocardial infarction (STEMI) are recommended by current guidelines. Thus, an increasing number of patients receive these drugs before coronary angiography, particularly if a between-hospital transfer is needed. However, when coronary anatomy is unsuitable for angioplasty, emergency coronary artery bypass grafting (CABG) under GP IIb/IIIa inhibitor treatment may be needed, with a potential increase in bleeding risk.
Abciximab has a long duration of action, because of its high-affinity binding to GP IIb/IIIa receptors. Initial retrospective studies reported a higher incidence of major bleeding during emergency CABG after abciximab administration, leading to the recommendation of delaying surgery > 12 h. However, data from the prospective trials on abciximab do not confirm the increase in bleeding risk, and current evidence shows that emergency surgery can be performed safely soon after abciximab cessation. Monitoring of activated clotting time during surgery and platelet transfusion in case of postoperative relevant bleeding are the only measures needed.
No data are available on emergency surgery in patients with STEMI treated with eptifibatide or tirofiban. However, their short-lasting effects and the results of trials on non-ST-elevation acute coronary syndromes suggest that they could even reduce postoperative bleeding by preventing platelet consumption during cardiopulmonary bypass.
In conclusion, the early administration of GP IIb/IIIa inhibitors, in particular of abciximab, in patients with STEMI in whom primary angioplasty is planned should not be discouraged because of the potential bleeding risk in case of emergency CABG.

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Original ArticlesAbciximab and Excessive Bleeding in Patients Undergoing Emergency Cardiac Operations

Abstract

Section snippets

Material and Methods

Precatheterization Characteristics

Comment

Acknowledgements

Ann Thorac Surg

Am J Cardiol

Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty

N Engl J Med

Role of platelets in restenosis after percutaneous coronary revascularization

J Am Coll Cardiol

A new murine monoclonal antibody reports an activation-dependent change in the conformation and/or microenvironment of the platelet glycoprotein IIb/IIIa complex

J Clin Invest

Monoclonal antibodies to platelet GPIIb/IIIa as antithrombotic agents

Ann NY Acad Sci

Inhibitors of the platelet glycoprotein IIb/IIIa receptor as conjunctive therapy for coronary artery thrombolysis

Coron Artery Dis

Original Articles
Abciximab and Excessive Bleeding in Patients Undergoing Emergency Cardiac Operations