Tricuspid regurgitation secondary to severe pulmonary regurgitation: when to operate on which valves? (letter)
- JP Bokma, MM Winter, BJM Mulder, BJ. Bouma
- Ann Thorac Surg 2015;100:2417–8
We read with great interest the Invited Commentary by Svensson and colleagues , which centered on the risk of bleeding after treatment of carotid artery stenosis by stenting (CAS) followed by coronary and noncoronary cardiac surgical intervention as proposed by our institution . In our protocol, aspirin was started at least 2 days before CAS, and clopidogrel was added just 6 hours after the surgical procedure  in order to reduce the risk of early formation of platelet aggregates immediately after CAS, without increasing the risk of bleeding during the cardiac operation. The incidence of stroke during weaning from general anesthesia was 0.75%: 0% in group 1 and 2.86% in group 2. In order to reduce the risk of bleeding, other authors have proposed starting antiplatelet therapy immediately after the operation or after the first postoperative day, without preoperative use of acetylsalicylic acid. Velissaris and colleagues , in 90 patients undergoing 1-stage CAS and cardiac operations, avoided preoperative use of antiaggregation therapy completely. Indeed, they did not report bleeding complications but reported a 2.2% incidence of stroke and ischemic transient attack after weaning from general anesthesia after cardiac operations. Barrera and colleagues , in a selected population of 15 patients undergoing synchronous CAS and isolated coronary artery bypass grafting (CABG), interrupted aspirin administration the day of the CAS and CABG procedure and restarted aspirin 2.2 days after CABG as well as clopidogrel after the second postoperative day. There was no episode of postoperative bleeding requiring reexploration, and the median number of red blood cell transfusions was 3. However, 1 patient (6.6%) experienced a transient ischemic episode 24 hours after CABG . In our experience, surgical reexploration for bleeding was needed in 8 patients (6%), and the mean number of blood units transfused per patient was 4.6 2.4. In detail, in group 1 (CAS, isolated CABG) the incidence of surgical reexploration for bleeding was 4.1% (4 of 97 cases), in group 2 (CAS, isolated noncoronary or complex surgical procedures—ie, aortic or mitral valve surgical procedures plus CABG or ascending aorta replacement), it was 11.4% (4 of 35 cases). Because approximately 25% of the surgical procedures were complex, the overall incidence of bleeding with our protocol seemed acceptable compared with The Society of Thoracic Surgeons data, which report in the period 2007 to 2009 an incidence of reexploration for bleeding or any reoperation of 2.5% in isolated CABG, 5.4% to 7.9% in combined aortic valve replacement or mitral valve operations plus CABG, 15.7% in double mitral and aortic valve replacement, and 14.7% in ascending aorta replacement. In conclusion, the risk of bleeding from single or double perioperative antiplatelet therapy is acceptable for straightforward procedures, but it certainly should be taken into consideration when complex and more extensive surgical procedures are required (eg, aortotomy, atriotomy, aneurysmal resection), but it seems that double antiplatelet therapy reduces the risk of embolic stroke related to carotid stenting during the hours after the implantation.