• Manne Holm, Fausto Biancari, Sorosh Khodabandeh, Riccardo Gherli, Juhani Airaksinen, Giovanni Mariscalco, Giuseppe Gatti, Daniel Reichart, Francesco Onorati, Marisa De Feo, Giuseppe Santarpino, Antonino S Rubino, Daniele Maselli, Francesco Santini, Francesco Nicolini, Marco Zanobini, Eeva-Maija Kinnunen, Vito G Ruggieri, Andrea Perrotti, Stefano Rosato, and Magnus Dalén.
• Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
• Ann. Thorac. Surg. 2019 Jun 1; 107 (6): 1690-1698.

BackgroundWe evaluated perioperative bleeding after coronary artery bypass grafting (CABG) in patients preoperatively treated with ticagrelor or clopidogrel, stratified by discontinuation of these P2Y12 inhibitors.MethodsAll patients from the prospective, European Multicenter Registry on Coronary Artery Bypass Grafting (E-CABG) treated with ticagrelor or clopidogrel undergoing isolated primary CABG were eligible. The primary outcome measure was severe or massive bleeding defined according to the Universal Definition of Perioperative Bleeding, stratified by P2Y12 inhibitor discontinuation. Secondary outcome measures included four additional definitions of major bleeding. Propensity score matching was performed to adjust for differences in preoperative and perioperative covariates.ResultsOf 2,311 patients who were included, 1,293 (55.9%) received clopidogrel and 1,018 (44.1%) ticagrelor preoperatively. Mean time between discontinuation and the operation was 4.5 ± 3.2 days for clopidogrel and 4.9 ± 3.0 days for ticagrelor. In the propensity score-matched cohort, ticagrelor-treated patients had a higher incidence of major bleeding according to Universal Definition of Perioperative Bleeding when ticagrelor was discontinued 0 to 2 days compared with 3 days before the operation (16.0% vs 2.7%, p = 0.003). Clopidogrel-treated patients had a higher incidence of major bleeding according to the Universal Definition of Perioperative Bleeding when clopidogrel was discontinued 0 to 3 days compared with 4 to 5 days before the operation (15.6% vs 8.3%, p = 0.031).ConclusionsIn patients receiving ticagrelor 2 days before CABG and in those receiving clopidogrel 3 days before CABG, there was an increased rate of severe bleeding. Postponing nonemergent CABG for at least 3 days after discontinuation of ticagrelor and 4 days after clopidogrel should be considered.Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

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