The impact of clopidogrel therapy on postoperative bleeding after robotic-assisted coronary artery bypass surgery.
OBJECTIVE
The purpose of this study was to determine whether patients undergoing robotic-assisted coronary artery bypass graft surgery (CABG) on clopidogrel had an increased risk of bleeding complications compared with those not on clopidogrel.


METHODS
From 2008 to 2011, 322 patients underwent robotic-assisted CABG either as an isolated procedure or as part of a hybrid coronary revascularization procedure (HCR). Patients were classified according to whether they received clopidogrel within 5 days of surgery or intraoperatively (n = 64) compared with those who never received or who had discontinued clopidogrel therapy >5 days before surgery (n = 258). A propensity analysis using 31 preoperative variables was used to control for confounding variables. In a subgroup analysis, patients undergoing one-stage HCR (clopidogrel load 600 mg in odds ratio (OR) prior to stenting) were compared with patients in the clopidogrel group who underwent two-stage HCR.


RESULTS
In the Clopidogrel group, the mean interval between surgery and last dose of clopidogrel was 2.1 ± 1.5 days. Compared with the No Clopidogrel group, the Clopidogrel group had greater 24-h chest tube drainage (1003 ± 572 vs 782 ± 530 ml, P = 0.004) and more blood transfusions (35.9%, 23 of 64 patients vs 20.9%, 54 of 258 patients, P = 0.01). On logistic regression analysis, there was greater 24-h chest tube drainage in the Clopidogrel group (+198 ml, P = 0.02) and a significantly higher incidence of blood transfusion (OR = 2.30, P = 0.01). In the subgroup analysis, patients undergoing one-stage HCR (n = 17) had greater 24-h chest tube drainage compared with patients undergoing two-stage HCR (1262 vs 909 ml, P = 0.03).


CONCLUSIONS
Patients undergoing robotic-assisted CABG on clopidogrel had more postoperative bleeding and a higher incidence of blood transfusion. Therefore, despite a less invasive approach, surgery should be delayed in these patients when possible.
Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA.
William T
WT
Daniel
Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
Henry A
HA
Liberman
Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA.
Patrick
P
Kilgo
Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA.
John D
JD
Puskas
Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA.
Thomas A
TA
Vassiliades
Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
Chandan
C
Devireddy
Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
Wissam
W
Jaber
Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA.
Robert A
RA
Guyton
Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA mhalkos@emory.edu.
Michael E
ME
Halkos
D001803:Blood Transfusion / Q000706:statistics & numerical data; D015505:Chest Tubes / Q000706:statistics & numerical data; D000077144:Clopidogrel; D001026:Coronary Artery Bypass; D004322:Drainage / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects*; D019106:Postoperative Hemorrhage / Q000453:epidemiology* / Q000628:therapy; D057216:Propensity Score; D065287:Robotic Surgical Procedures; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*
D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine
CABG; Minimally invasive surgery; Platelets; Postoperative bleeding