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Ann Thorac Surg 2009;88:1048. doi:10.1016/j.athoracsur.2009.03.022
© 2009 The Society of Thoracic Surgeons
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Correspondence

Acute Profound Thrombocytopenia After Treatment With Tirofiban and Off-Pump Coronary Artery Bypass Grafting: Is There a Paradox?

Federico Bizzarri, MD, Giacomo Frati, MD

Cardiac Surgery Unit-Polo Pontino, Department of Heart and Great Vessels "Attilio Reale", University of Rome "Sapienza", Via F. Faggiana 34, Latina, 04100 Italy

(Email: federico.bizzarri{at}uniroma1.it).

To the Editor:

I read with interest the case report by Beiras-Fernandez and colleagues [1].

This case report reveals one more time how challenging it is to operate on patients with acute coronary syndrome and IIB–IIIa receptor antagonist infusion, such as tirofiban hydrochloride, because of the risk of profound bleeding complications and thrombocytopenia.

We studied the effects of this drug on patients undergoing coronary artery bypass grafting with extracorporeal circulation [2]. Paradoxically, in our study, the infusion of tirofiban hydrochloride immediately before surgery did not adversely affect clinical outcome and did not have any deleterious effect on postoperative bleeding, maintaining hemoglobin, and platelet counts at stable levels. The reason is not yet clear, but tirofiban probably provides a sort of "platelet anestesia" during cardiopulmonary bypass [3]; in fact, this short-acting drug can be safely metabolized during extracorporeal circulation, "protecting" platelets that can act "normally" at the end of the operation.

Tirofiban hydrochloride is per se' a powerful and strong bleeding and antiplatelet drug, and the risk related to these properties are high during an off-pump procedure, because this is really performed during the period of action of the drug (3 hours). Stopping the infusion of this molecule at the beginning of the operation exposes these patients to all these risks.

In conclusion, it seems, in my opinion, that Tirofiban hydrochloride has paradoxically "protective effects" during extracorporeal circulation, but during an off-pump coronary artery bypass grafting, the risks of bleeding must be heavily considered, and the infusion of the drug probably must be stopped earlier.


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  1. Beiras-Fernandez A, Kowert A, Jiru P, et al. Acute profound thrombocytopenia after treatment with tirofiban and off-pump coronary artery bypass grafting Ann Thorac Surg 2009;87:629-631.[Abstract/Free Full Text]
  2. Bizzarri F, Scolletta S, Tucci E, et al. Perioperative use of tirofiban hydrocloride (Aggrastat) does not increase surgical bleeding after emergency or urgent coronary artery bypass grafting J Thorac Cardiovasc Surg 2001;122:1181-1185.[Abstract/Free Full Text]
  3. Hiramatsu Y, Gikakis N, Anderson 3rd HL, et al. Tirofiban provides "platelets anestesia" during cardiopulmonary bypass in baboons J Thorac Cardiovasc Surg 1997;113:182-193.[Abstract/Free Full Text]

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Andres Beiras-Fernandez, Marion Weis, and Michael Schmoeckel
Ann. Thorac. Surg. 2009 88: 1048. [Extract] [Full Text] [PDF]



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Ann. Thorac. Surg., September 1, 2009; 88(3): 1048 - 1048.
[Full Text] [PDF]

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