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Ann Thorac Surg 2004;78:1879
© 2004 The Society of Thoracic Surgeons

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Correspondence

Reply

Clinic for Cardiovascular Surgery, University Hospital Berne, Freiburgstrasse, CH-3010 Berne, Switzerland

friedrich.eckstein{at}insel.ch

To the Editor:

Implantation of mechanical connectors for proximal anastomoses in coronary artery bypass grafting procedues raises the question of antithrombotic treatment postoperatively, especially when first occlusions or stenoses are reported. To date, the only commercially available connector is the Symmetry device from St. Jude Medical. In the "instructions for use" of this product, no recommendation is made for any antithrombotic treatment or anticoagulation after implantation. This leads to the assumption that patient management after implantation of the Symmetry device should not differ from treatment after conventionally sutured anastomoses.

The literature is silent about how surgeons using this device manage anticoagulation. If we hypothesize that stenosis at the connector site has a similar pathogenesis as that seen in stenting, aggressive antiplatelet agents may dramatically reduce the incidence of this complication. However, there is no consensus regarding management when connectors are used. Some centers prescribe clopidogrel bisulfate, 75 mg daily, routinely for the first 3 months; others maintain a more classic approach with aspirin, 300 mg [1]. Mack and colleagues [2] routinely give antiplatelet therapy with aspirin and clopidogrel. Their patients are treated with aspirin, 325 mg/d, and clopidogrel, 300 mg immediately after operation and 75 mg/d for 30 days. In our institution we use low-molecular-weight heparin sodium during the hospital stay and oral aspirin, 100 mg/d, and clopidogrel, 75 mg/d, for the first 6 months. This is followed by aspirin, 100 mg/d, indefinitely. As concerns exist regarding the long-term and stenosis-free patency rates of these mechanically connected bypass grafts, additional studies are mandatory to elucidate the best anticoagulation management. Until these results are available, aggressive antiplatelet therapy similar to that used with stenting should be considered. To our knowledge, there is no evidence that oral anticoagulation prevents acute thrombosis better than antithrombotic treatment in patients after coronary intervention, coronary artery bypass grafting, or both.

References

1. Carrel TP, Eckstein FS, Englberger L, Windecker S, Meier B. Pitfalls and key lessons with the Symmetry proximal anastomotic device in coronary artery bypass surgery. Ann Thorac Surg. 2003;75:1434–1436[Abstract/Free Full Text]
2. Mack MJ, Emery RW, Ley LR, et al. Initial experience with proximal anastomoses performed with a mechanical connector. Ann Thorac Surg. 2003;75:1866–1871[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Friedrich S. Eckstein Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Eckstein, F. S. Search for Related Content PubMed Articles by Eckstein, F. S.