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Ann Thorac Surg 2001;72:1797
© 2001 The Society of Thoracic Surgeons
a The Cardiothoracic Centre, Thomas Dr, Liverpool L14 3PE, United Kingdom
e-mail: javed{at}jhayat.freeserve.co.uk
To the Editor
We read with great interest yet another important article from the Northern New England Cardiovascular Disease Study Group [1]. We congratulate the authors for highlighting the importance of preoperative aspirin therapy in reducing mortality. Discontinuing aspirin a week before coronary artery bypass graft operation is common practice among cardiovascular surgeons. It is because of the belief that this will reduce postoperative blood loss and the need for hematologic support and reexploration. It has been shown that aspirin usage reduces early graft failure and thus justifies routine early usage after coronary artery bypass graft operation [2, 3]. A placebo-controlled, randomized trial, in which aspirin was administered an hour after the operation, showed improved graft patency, with no significant increase in postoperative blood loss and the incidence of perioperative myocardial infarction [3]. The Northern New England Study Group demonstrated reduced trends in rates of reexploration [4]. Risks of reexploration in this study were associated with patient age, level of sickness, and duration and complexity of the procedure. Tuman and colleagues [5] showed no significant difference in blood loss, usage of blood and clotting factors, and rates of reexploration when aspirin was used perioperatively in patients undergoing redo coronary artery bypass grafting.
We believe that the continuation of aspirin up to the time of coronary artery bypass graft operation reduces the perioperative incidence of myocardial events. We follow a strict protocol of continuing the preoperative dosage of aspirin (range, 75 to 325 mg daily) up to the day of operation and administering aspirin early postoperatively (between 2 and 6 hours postoperatively if there is no excessive blood loss). In our series of 306 patients who followed the above protocol, the incidence of perioperative myocardial infarction was 2%. The postoperative creatine kinase-MB levels were less then 50 U/L in 85% of the patients, and the usage of intraaortic balloon pump was 1%. As for the blood loss, the average was 873 mL. The reexploration rate for excessive bleeding was 3.4%.
Although usage of aspirin in the early postoperative period is now established as a major factor in preventing early graft failure, preoperative usage up to the time of operation is still uncommon. The use of aspirin in severe coronary artery disease with critical stenotic lesions is known to decrease the incidence of myocardial events. A concern is stopping aspirin in patients with unstable critical lesions, which may contribute to instability in the perioperative period. It is not common that patients are unstable before operation, but we have had the experience in which stable patients admitted for operation had a myocardial event before operation. Although the results from coronary artery bypass graft operation are improving, minor modifications in perioperative management may further improve these results. We believe there is a need for a larger prospective randomized trial to alleviate this fear. More aggressive usage of aspirin can be important in this era of multiple arterial grafting and off-pump coronary artery bypass grafting.
References
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