Impact of Preoperative Use of Low-molecular-weight Heparin on Early Outcomes of Off-pump Coronary ArteryBypass Grafting_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIU Bo , GU Tianxiang , ZHANG Yuhai , FANG Qin , YU Peng , LIU Lu.

Department of Cardiac Surgery，the First Affiliated Hospital of China Medical University，Shenyang 110001，P. R. China;

Corresponding?author：

Keywords：

Low-molecular-weight heparin; Coronary artery bypass grafting; Blood transfusion

DOI：

10.7507/1007-4848.20130168

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Objective To investigate the impact of preoperative use of low-molecular-weight heparin （LMWH） on early outcomes of off-pump coronary artery bypass grafting （OPCAB） . Methods Clinical data of 809 patients undergoingisolated OPCAB from April 1st，2011 to September 30th，2012 in the First Affiliated Hospital of China Medical University were retrospectively analyzed. All the patients were divided into LMWH group and control group according to preoperative use of LMWH or not. In LMWH group，there were 386 patients including 290 male and 96 female patients with their age of 49-81 years，who routinely received anticoagulation therapy with LMWH （LMWH sodium or LMWH calcium，4 000 U twice a day，subcutaneous injection） after discontinuation of anti-platelet therapy until the day before surgery. In the control group，there were 423 patients including 321 male and 102 female patients with their age of 46-78 years，who didn’t receive LMWH or any other anticoagulant after discontinuation of anti-platelet therapy. Postoperative mortality，incidence of perioperative myocardial infarction （MI），operation time，amount of blood loss and transfusion，and incidence of postoperative acute renal injury were compared between the 2 groups. Results Intraoperative blood loss （296±94 ml vs. 249±81 ml，P=0.03），postoperative thoracic drainage （526±159 ml vs. 410±125 ml，P=0.02），blood transfusion （2.6±1.1 U vs. 1.4±0.9 U，P=0.04） and operation time （172±34 min vs. 154±41 min，P=0.04） of LMWH group were significantly larger or longer than those of the control group. There was no statistical difference in postoperative mortality（1.0% vs. 1.2%，P=1.00）or incidence of perioperative MI（4.4% vs. 3.8%，P=0.55）between the 2 groups. Conclusion For OPCAB patientswith stable ischemic heart disease，preoperative management without use of LMWH can decrease operation time and amountof blood loss and transfusion without increasing postoperative mortality or incidence of perioperative MI.

Citation： LIU Bo,GU Tianxiang,ZHANG Yuhai,FANG Qin,YU Peng,LIU Lu.. Impact of Preoperative Use of Low-molecular-weight Heparin on Early Outcomes of Off-pump Coronary ArteryBypass Grafting. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2013, 20(5): 533-537. doi: 10.7507/1007-4848.20130168 Copy

1.	Holinski S， Claus B， Barajas T， et al. Cerebroprotective effect of preoperative dual antiplatelet therapy in patients undergoing coronarybypass surgery. Ann Thorac Cardiovasc Surg， 2013， 31. [Epub aheadof print].
2.	Mangano DT， Multicenter Study of Perioperative Ischemia Research Group. Aspirin and mortality from coronary bypass surgery. N Engl J Med， 2002， 347 （17）：1309-1317.
3.	Al-Lawati AA， Muthuswamy V. Continuing aspirin causes higherdrainage even under full protection with antifibrinolytics. Thorac Cardiovasc Surg， 2013， 23. [Epub ahead of print].
4.	Deja MA， Kargul T， Domaradzki W， et al. Effects of preoperative aspirin in coronary artery bypass grafting：a double-blind， placebo-controlled，randomized trial. J Thorac Cardiovasc Surg， 2012， 144 （1）：204-209.
5.	Ferraris VA， Ferraris SP， Moliterno DJ， et al. The society of thoracicsurgeons practice guideline series：aspirin and other antiplatelet agentsduring operative coronary revascularization （executive summary）. Ann Thorac Surg， 2005， 79 （4）：1454-1461.
6.	Eagle KA， Guyton RA， Davidoff R， et al. ACC/AHA 2004 guidelineupdate for coronary artery bypass graft surgery：summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines （Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery）. J Am Coll Cardiol， 2004， 44 （5）：e213-310.
7.	Handeland GF， Abildgaard U， Holm HA， et al. Dose adjusted heparintreatment of deep venous thrombosis：a comparison of unfractionated and low molecular weight heparin. Eur J Clin Pharmacol， 1990， 39 （2）：107-112.
8.	Farge D， Debourdeau P， Beckers M， et al. International clinicalpractice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J Thromb Haemost， 2013，11 （1）：56-70.
9.	Costantino G， Ceriani E， Rusconi AM， et al. Bleeding risk during treatment of acute thrombotic events with subcutaneous LMWH compared to intravenous unfractionated heparin；a systematic review. PLoS One， 2012， 7 （9）：e44553.
10.	Rothberg MB， Pekow PS， Lahti M， et al. Comparative effectiveness of low-molecular-weight heparin versus unfractionated heparin for thromboembolism prophylaxis for medical patients. J Hosp Med，2012， 7 （6）：457-463.
11.	Puymirat E， Aïssaoui N， Collet JP，et al. Comparison of bleedingcomplications and one-year survival of low molecular weight heparinversusunfractioned heparin for acute myocardial infarction in elderlypatients. The FAST-MI registry. Int J Cardiol， 2013， 166 （1）：106-110.
12.	Jones HU， Muhlestein JB， Jones KW， et al. Preoperative use of enoxaparin compared with unfractionated heparin increases the incid-ence of re-exploration for postoperative bleeding after open-heart surgery in patients who present with an acute coronary syndrome：clinical investigation and reports. Circulation， 2002， 106 （12 Suppl 1）：I19-I22.
13.	Kincaid EH， Monroe ML， Saliba DL， et al. Effects of preoperativeenoxaparin versus unfractionated heparin on bleeding indices inpatients undergoing coronary artery bypass grafting. Ann Thorac Surg，2003， 76 （1）：124-128.
14.	Medalion B， Frenkel G， Patachenko P， et al. Preoperative use of enoxaparin is not a risk factor for postoperative bleeding after coronaryartery bypass surgery. J Thorac Cardiovasc Surg， 2003， 126 （6）：1875-1879.
15.	Loop FD， Lytle BW， Cosgrove DM， et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med， 1986， 314 （1）：1-6.
16.	Puskas JD， Sadiq A， Vassiliades TA， et al. Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival，even among diabetic patients. Ann Thorac Surg， 2012， 94 （3）：710-716.
17.	Vincent JL， Baron JF， Reinhart K， et al. Anemia and blood transfusion in critically ill patients. JAMA， 2002， 288 （12）：1499-1507.
18.	Engoren MC， Habib RH， Zacharias A， et al. Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg， 2002， 74 （4）：1180-1186.
19.	Surgenor SD， Kramer RS， Olmstead EM， et al. The association of perioperative red blood cell transfusions and decreased long-term survival after cardiac surgery. Anesth Analg， 2009， 108 （6）：1741-1746.
20.	Leal-Noval SR， Rincón-Ferrari MD， García-Curiel A， et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery. Chest， 2001， 119 （5）：1461-1468.
21.	Nuttall GA， Erchul DT， Haight TJ， et al. A comparison of bleedingand transfusion in patients who undergo coronary artery bypass graftingvia sternotomy with and without cardiopulmonary bypass. JCardiothorac Vasc Anesth， 2003， 17 （4）：447-451.
22.	Sohrabi F， Mispireta LA， Fiocco M， et al. Effects of off-pump coronary artery bypass grafting on patient outcome. J Investig Med，2003， 51 （1）：27-31.
23.	Wijeysundera DN， Beattie WS， Djaiani G， et al. Off-pump coronaryartery surgery for reducing mortality and morbidity：meta-analysis of randomized and observational studies. J Am Coll Cardiol， 2005， 46 （5）：872-882.
24.	喻磊，谷天祥，師恩祎，等. 70歲以下多支冠狀動脈病變患者體外與非體外循環冠狀動脈旁路移植術的比較. 中國胸心血管外科臨床雜志， 2010， 17 （4）：292-296．.
25.	柏本健，魏維強，解洪濤，等. 體外循環和非體外循環冠狀動脈旁路移植術的早期療效比較. 中國胸心血管外科臨床雜志， 2010， 17 （3）：244-246.
26.	Gansera B， Schmidtler F， Gillrath G， et al. Does bilateral ITA graftingincrease perioperative complications ? Outcome of 4462 patients with bilateral versus 4204 patients with single ITA bypass. Eur JCardiothorac Surg， 2006， 30 （2）：318-323.
27.	Matsuzaki K， Matsui K， Haraguchi N， et al. Ischemic heart attacks following cessation of aspirin before coronary artery bypass surgery：A report of two cases. Ann Thorac Cardiovasc Surg， 1999， 5 （2）：121-122.
28.	Biondi-Zoccai GG， Lotrionte M， Agostoni P， et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhe-ring to aspirin among 50， 279 patients at risk for coronary artery disease.Eur Heart J， 2006， 27 （22）：2667-2674.
29.	García Rodríguez LA， Cea Soriano L， Hill C， et al. Increased risk of stroke after discontinuation of acetylsalicylic acid：a UK primary care study. Neurology， 2011， 76 （8）：740-746.
30.	Jacob M， Smedira N， Blackstone E， et al. Effect of timing of chronic preoperative aspirin discontinuation on morbidity and mortality in coronary artery bypass surgery. Circulation， 2011， 123 （6）：577-583.

1. 　Holinski S， Claus B， Barajas T， et al. Cerebroprotective effect of preoperative dual antiplatelet therapy in patients undergoing coronarybypass surgery. Ann Thorac Cardiovasc Surg， 2013， 31. [Epub aheadof print].
2. 　Mangano DT， Multicenter Study of Perioperative Ischemia Research Group. Aspirin and mortality from coronary bypass surgery. N Engl J Med， 2002， 347 （17）：1309-1317.
3. 　Al-Lawati AA， Muthuswamy V. Continuing aspirin causes higherdrainage even under full protection with antifibrinolytics. Thorac Cardiovasc Surg， 2013， 23. [Epub ahead of print].
4. 　Deja MA， Kargul T， Domaradzki W， et al. Effects of preoperative aspirin in coronary artery bypass grafting：a double-blind， placebo-controlled，randomized trial. J Thorac Cardiovasc Surg， 2012， 144 （1）：204-209.
5. 　Ferraris VA， Ferraris SP， Moliterno DJ， et al. The society of thoracicsurgeons practice guideline series：aspirin and other antiplatelet agentsduring operative coronary revascularization （executive summary）. Ann Thorac Surg， 2005， 79 （4）：1454-1461.
6. 　Eagle KA， Guyton RA， Davidoff R， et al. ACC/AHA 2004 guidelineupdate for coronary artery bypass graft surgery：summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines （Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery）. J Am Coll Cardiol， 2004， 44 （5）：e213-310.
7. 　Handeland GF， Abildgaard U， Holm HA， et al. Dose adjusted heparintreatment of deep venous thrombosis：a comparison of unfractionated and low molecular weight heparin. Eur J Clin Pharmacol， 1990， 39 （2）：107-112.
8. 　Farge D， Debourdeau P， Beckers M， et al. International clinicalpractice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J Thromb Haemost， 2013，11 （1）：56-70.
9. 　Costantino G， Ceriani E， Rusconi AM， et al. Bleeding risk during treatment of acute thrombotic events with subcutaneous LMWH compared to intravenous unfractionated heparin；a systematic review. PLoS One， 2012， 7 （9）：e44553.
10. 　Rothberg MB， Pekow PS， Lahti M， et al. Comparative effectiveness of low-molecular-weight heparin versus unfractionated heparin for thromboembolism prophylaxis for medical patients. J Hosp Med，2012， 7 （6）：457-463.
11. 　Puymirat E， Aïssaoui N， Collet JP，et al. Comparison of bleedingcomplications and one-year survival of low molecular weight heparinversusunfractioned heparin for acute myocardial infarction in elderlypatients. The FAST-MI registry. Int J Cardiol， 2013， 166 （1）：106-110.
12. 　Jones HU， Muhlestein JB， Jones KW， et al. Preoperative use of enoxaparin compared with unfractionated heparin increases the incid-ence of re-exploration for postoperative bleeding after open-heart surgery in patients who present with an acute coronary syndrome：clinical investigation and reports. Circulation， 2002， 106 （12 Suppl 1）：I19-I22.
13. 　Kincaid EH， Monroe ML， Saliba DL， et al. Effects of preoperativeenoxaparin versus unfractionated heparin on bleeding indices inpatients undergoing coronary artery bypass grafting. Ann Thorac Surg，2003， 76 （1）：124-128.
14. 　Medalion B， Frenkel G， Patachenko P， et al. Preoperative use of enoxaparin is not a risk factor for postoperative bleeding after coronaryartery bypass surgery. J Thorac Cardiovasc Surg， 2003， 126 （6）：1875-1879.
15. 　Loop FD， Lytle BW， Cosgrove DM， et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med， 1986， 314 （1）：1-6.
16. 　Puskas JD， Sadiq A， Vassiliades TA， et al. Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival，even among diabetic patients. Ann Thorac Surg， 2012， 94 （3）：710-716.
17. 　Vincent JL， Baron JF， Reinhart K， et al. Anemia and blood transfusion in critically ill patients. JAMA， 2002， 288 （12）：1499-1507.
18. 　Engoren MC， Habib RH， Zacharias A， et al. Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg， 2002， 74 （4）：1180-1186.
19. 　Surgenor SD， Kramer RS， Olmstead EM， et al. The association of perioperative red blood cell transfusions and decreased long-term survival after cardiac surgery. Anesth Analg， 2009， 108 （6）：1741-1746.
20. 　Leal-Noval SR， Rincón-Ferrari MD， García-Curiel A， et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery. Chest， 2001， 119 （5）：1461-1468.
21. 　Nuttall GA， Erchul DT， Haight TJ， et al. A comparison of bleedingand transfusion in patients who undergo coronary artery bypass graftingvia sternotomy with and without cardiopulmonary bypass. JCardiothorac Vasc Anesth， 2003， 17 （4）：447-451.
22. 　Sohrabi F， Mispireta LA， Fiocco M， et al. Effects of off-pump coronary artery bypass grafting on patient outcome. J Investig Med，2003， 51 （1）：27-31.
23. 　Wijeysundera DN， Beattie WS， Djaiani G， et al. Off-pump coronaryartery surgery for reducing mortality and morbidity：meta-analysis of randomized and observational studies. J Am Coll Cardiol， 2005， 46 （5）：872-882.
24. 　喻磊，谷天祥，師恩祎，等. 70歲以下多支冠狀動脈病變患者體外與非體外循環冠狀動脈旁路移植術的比較. 中國胸心血管外科臨床雜志， 2010， 17 （4）：292-296．.
25. 　柏本健，魏維強，解洪濤，等. 體外循環和非體外循環冠狀動脈旁路移植術的早期療效比較. 中國胸心血管外科臨床雜志， 2010， 17 （3）：244-246.
26. 　Gansera B， Schmidtler F， Gillrath G， et al. Does bilateral ITA graftingincrease perioperative complications ? Outcome of 4462 patients with bilateral versus 4204 patients with single ITA bypass. Eur JCardiothorac Surg， 2006， 30 （2）：318-323.
27. 　Matsuzaki K， Matsui K， Haraguchi N， et al. Ischemic heart attacks following cessation of aspirin before coronary artery bypass surgery：A report of two cases. Ann Thorac Cardiovasc Surg， 1999， 5 （2）：121-122.
28. 　Biondi-Zoccai GG， Lotrionte M， Agostoni P， et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhe-ring to aspirin among 50， 279 patients at risk for coronary artery disease.Eur Heart J， 2006， 27 （22）：2667-2674.
29. 　García Rodríguez LA， Cea Soriano L， Hill C， et al. Increased risk of stroke after discontinuation of acetylsalicylic acid：a UK primary care study. Neurology， 2011， 76 （8）：740-746.
30. 　Jacob M， Smedira N， Blackstone E， et al. Effect of timing of chronic preoperative aspirin discontinuation on morbidity and mortality in coronary artery bypass surgery. Circulation， 2011， 123 （6）：577-583.

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Impact of Preoperative Use of Low-molecular-weight Heparin on Early Outcomes of Off-pump Coronary ArteryBypass Grafting

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