Cikirikcioglu, Mustafa

Kalangos, Afksendiyos

Myers, Patrick O.

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First do no harm: postoperative thromboprophylaxis followingopen heart surgeryMustafa Cikirikcioglu*, Patrick O. Myers and Afksendiyos KalangosDivision of Cardiovascular Surgery, Department of Surgery, University Hospital of Geneva, Geneva, Switzerland* Corresponding author. Division of Cardiovascular Surgery, Department of Surgery, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4,1211 Genève 14, Switzerland. Tel: +41-22-3727663; fax: +41-22-3727634; e-mail: mustafa.cikirikcioglu@hcuge.ch (M. Cikirikcioglu).Received 4 October 2012; accepted 26 November 2012Keywords: Open heart surgery • Thromboprophylaxis • Venous thromboembolism • Pulmonary embolismWe recently operated on a patient with an acute aortic dissec-tion Stanford Type A. The postoperative period was uneventful.Our intensive care unit team started anticoagulation for throm-boprophylaxis within the ﬁrst postoperative day, basing their de-cision on the European Association for Cardio-thoracic Surgery(EACTS) guidelines [1]. After reviewing these and other guidelinescarefully, we realize that the EACTS guidelines give a general rec-ommendation for all comers, advising that all patients whoundergo cardiac surgery receive prophylactic anticoagulationfrom the ﬁrst postoperative day [1]. We ﬁnd that this recommen-dation is too broad and merits discussion until updated guide-lines are available.There is a risk of deep vein thrombosis (DVT) and pulmonaryembolism (PE) following cardiac surgery. This complication is notrare, but it not as high as in other types of surgery, such asorthopedic surgery. The risk of DVT and/or PE after cardiacsurgery is deﬁned as moderate by the latest American College ofChest Physicians guidelines [2].The EACTS guidelines advise prophylactic anticoagulation forall patients who have undergone cardiac surgery, which is notcorrect, in our opinion. Every patient should be evaluated onhis/her own basis according to personal risk factors, operationtype, bleeding risk and platelet count, as mentioned in theNational Institute for Health and Clinical Excellence (NICE)recommendations [3].We commend Dunning et al. for producing the EACTSguidelines based on the available literature; however, thestudies they are based on are quite old. For example, the refer-ences of the NICE recommendations are from 1980 to 1996and include a limited number of patients; some of them do noteven include cardiac surgery patients. Among the ﬁve studiesused for the NICE recommendations on thromboprophylaxis fol-lowing cardiac surgery, two include only vascular surgerypatients, and the study populations are very small. Interestingly,one study shows eight times more bleeding with prophylacticanticoagulation, although this is not mentioned as the P-valuewas >0.05.Cardiac surgery patients are a different population fromgeneral or orthopedic surgery patients who represent the major-ity of patients included in the studies that were used as the basisof the EACTS guidelines. How many general surgery patientshave 2 h of foreign surface-blood contact, haemostatic hurricaneand low platelet count with poor function? Finally, among thestudies that included cardiac surgery patients, the entire spec-trum of cardiac surgery was not included. None of the studiesincluded enough aortic surgery patients, and most likely, noaortic dissection patients. These are the subset of patients athighest risk of bleeding and tamponade, yet should the recom-mendations for prophylactic anticoagulation apply to them?Clearly, there is a need to redraw the frame of thromboprophy-laxis following cardiac surgery, including the indications andtiming, by organizing more studies including all subsets of patients.Until these guidelines are prepared by our societies, all patientsshould be discussed personally by calculating their risks of DVT,bleeding, pericardial tamponade and beneﬁts of preventing PE.REFERENCES[1] Dunning J, Versteegh M, Fabbri A, Pavie A, Kolh P, Lockowandt U et al.Guideline on antiplatelet and anticoagulation management in cardiacsurgery. Eur J Cardiothorac Surg 2008;34:73–92.[2] Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA et al.Prevention of VTE in nonorthopedic surgical patients antithrombotictherapy and prevention of thrombosis, 9th ed: American college of chestphysicians evidence-based clinical practice guidelines. Chest 2012;141(Suppl):e227S–77S.[3] The National Collaborating Centre for Acute Care. Venous thrombo-embolism: reducing the risk of venous thromboembolism (deep veinthrombosis and pulmonary embolism) in inpatients undergoing surgery,NICE clinical guideline 46. London (UK): National Institute for Health andClinical Excellence, 2009, pp. 290–8.© The Author 2012, 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.European Journal of Cardio-Thoracic Surgery 44 (2013) 184 LETTER TO THE EDITORdoi:10.1093/ejcts/ezs669 Advance Access publication 7 January 2013

First do no harm: postoperative thromboprophylaxis following open heart surgery

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