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Antithrombotic therapy management of adult and pediatric cardiac surgery patients. J Thromb Haemost 2018 Nov;16(11):2133-2146

Date

08/29/2018

Pubmed ID

30153372

DOI

10.1111/jth.14276

Scopus ID

2-s2.0-85054166553   11 Citations

Abstract

Despite the development of catheter-based interventions for ischemic and valvular heart disease, hundreds of thousands of people undergo open heart surgery annually for coronary artery bypass graft (CABG), valve replacement or cardiac assist device implantation. Cardiac surgery patients are unique because therapeutic anticoagulation is required during cardiopulmonary bypass. Developmental hemostasis and altered drug metabolism affect management in children. This narrative review summarizes the current evidence-based and consensus guidelines regarding perioperative, intraoperative and postoperative antithrombotic therapy in patients undergoing cardiac surgery. Anticoagulation preoperatively is required in the setting of cardiac arrhythmias, prior valve replacement or history of venous thromboembolism. In patients with ischemic heart disease, aspirin is continued in the perioperative period, whereas oral P2Y12 antagonists are withheld for 5-7 days to reduce the risk of perioperative bleeding. Intraoperative management of cardiopulmonary bypass in adults and children includes anticoagulation with unfractionated heparin. Variability in dose-response to heparin and influence of other medical conditions on dosing and reversal of heparin make intraoperative anticoagulation challenging. Vitamin K antagonist therapy is the standard anticoagulant after mechanical heart valve or left ventricular assist device (LVAD) implantation. Longer duration of dual antiplatelet therapy is recommended after CABG if patients undergo surgery because of acute coronary syndrome. Antiplatelet therapy after LVAD implantation includes aspirin, dipyridamole and/or clopidogrel in children and aspirin in adults. A coordinated approach between hematology, cardiology, anesthesiology, critical care and cardiothoracic surgery can assist to balance the risk of thrombosis and bleeding in patients undergoing cardiac surgery.

Author List

Baumann Kreuziger L, Karkouti K, Tweddell J, Massicotte MP

Author

Lisa M. Baumann Kreuziger MD Associate Professor in the Medicine department at Medical College of Wisconsin




MESH terms used to index this publication - Major topics in bold

Adolescent
Adult
Anticoagulants
Aspirin
Blood Coagulation
Cardiac Surgical Procedures
Cardiology
Child
Coronary Artery Bypass
Drug Administration Schedule
Evidence-Based Medicine
Fibrinolytic Agents
Heart Valve Diseases
Heart-Assist Devices
Hemorrhage
Hemostasis
Heparin
Humans
Inflammation
Intraoperative Period
Perioperative Period
Platelet Aggregation Inhibitors
Practice Guidelines as Topic
Protamines
Risk
Thrombolytic Therapy
Thrombosis
Vitamin K