Current status of cardiac surgery in the abciximab-treated patient

Background. Early surgical experience with abciximab and other glycoprotein (CP) IIb/IIIa receptor antagonists suggested a tendency toward excessive b leeding in patients treated with these agents. With increased use of GP IIb /IIIa inhibitors, cardiac surgeons have become aware of their hazards, as w ell as potential benefits, during and after cardiac surgery. Although publi shed experience with the GP IIb/IIIa inhibitor abciximab is limited in scop e, it suggests management guidelines for urgent coronary artery bypass graf ting in abciximab-treated patients. As more urgent and elective surgical da ta are presented, a clearer picture of true bleeding risk will evolve. Methods. Two large retrospective studies examining reexploration for postop erative bleeding have identified risk factors, including advanced age, preo perative renal dysfunction, and operation/reoperation other than coronary a rtery bypass grafting. Other risk factors for transfusion requirement and i ncreased morbidity and mortality are emergent operation, postoperative coag ulopathy, and prolonged bypass time. Results. To minimize real and perceived bleeding effects, some authors have suggested delaying operation until platelet function has normalized, emplo ying platelet transfusion in patients in whom delay is not possible, and ex acting heparin management during cardiopulmonary bypass. Later reports have not noted increased bleeding when incorporating these modifications plus e arly platelet transfusion, if required. Further experience with abciximab r emoval and reversal may also ultimately reduce or eliminate excess transfus ion requirements. Conclusions. Surgeons should work closely with perfusionists and anesthesio logists on issues of heparinization in the abciximab-treated patient. The a pparent paradox of preserved platelet numbers and depressed platelet functi on with abciximab use has led to speculation about a role for this agent an d other shorter-acting GP IIb/IIIa inhibitors for "platelet anesthesia" dur ing cardiopulmonary bypass. With careful surgical care, GP IIb/IIIa recepto r antagonists can maintain and improve beneficial outcomes. (Ann Thorac Sur g 2000;70:S12-9) (C) 2000 by The Society of Thoracic Surgeons.