A novel strategy for reducing time between antiplatelet drug cessation and urgent CABG surgery following acute coronary syndromes

Background Patients with acute coronary syndromes (ACS) who have received dual antiplatelet therapy with aspirin and ticagrelor prior to coronary angiography and subsequently require urgent coronary artery bypass graft (CABG) surgery may face delays to surgery and potential risk associated with cessation of ticagrelor for 3 days or more. Haemoadsorption with the CytoSorb device during cardiopulmonary bypass (CPB) is a potential means of removing ticagrelor and might reduce time delays and associated risk. Purpose To assess whether a novel strategy incorporating the CytoSorb device allows a shorter window between antiplatelet drug cessation and CABG surgery. Methods ACS patients treated with aspirin and ticagrelor who were referred for urgent CABG surgery were randomized to 2 groups: (A) cessation of aspirin and ticagrelor 2 days prior to surgery and use of the CytoSorb device during CPB; (B) local standard of care with continuation of aspirin and cessation of ticagrelor at least 5 days prior to surgery. Platelet function and skin bleeding time were assessed immediately prior to surgery and after completion of CPB. Chest tube drainage (CTD) and bleeding events according to Universal Definition of Perioperative Bleeding (UDPB) criteria were recorded. The primary outcome was platelet aggregation induced by collagen 4 ug/mL, assessed by light transmittance aggregometry (LTA) post-CPB; the difference between the means was assessed with a one-tailed unpaired t test with a non-inferiority margin of -21.5% for the lower 95% confidence limit. Results 30 patients were randomized and completed surgery (n=15 each group). There were no significant differences in participant characteristics and EuroScore II between the two groups. Maximum mean (± SD) LTA response to collagen following CPB was 48% (±22%) in group A and 51% (±24%) in group B (P=0.38), which met the non-inferiority criterion for the experimental approach (Figure 1). Platelet P2Y12 inhibition and serum thromboxane B2 levels post-CPB were both significantly higher in group A compared to group B; bleeding time and 24-hour CTD were not significantly different between the groups (Figure 2). 7 patients in each group had UDPB class 2 or 3 bleeding and none had UDPB class 4 bleeding. Conclusions Stopping ticagrelor and aspirin 2 days before urgent CABG surgery and using the CytoSorb device during CPB was non-inferior in its effect on collagen-induced platelet aggregation after CPB and was associated with similar haemostasis compared with cessation of ticagrelor 5 days before surgery and continuation of aspirin.