doi:10.1510/icvts.2011.271296

Interactive CardioVascular and Thoracic Surgery 13 (2011) 153-157

www.icvts.org

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Idiopathic thrombocytopenic purpura and coronary artery disease: comparison between coronary artery bypass grafting and percutaneous coronary intervention Antonio Russo*, Marina Cannizzo, Gabriele Ghetti, Elena Barbaresi, Elisa Filippini, Salvatore Specchia, Angelo Branzi Institute of Cardiology, Policlinico S. Orsola, Bologna, Italy Received 13 March 2011; received in revised form 20 April 2011; accepted 21 April 2011

Summary Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by a low platelet count and an increased risk of bleeding. At the same time, ITP patients present an increased risk of thrombosis and atherosclerosis related to the high presence of haemostatic factors and chronic steroid therapy. Although relatively rare, the association of ITP and coronary artery disease represents a complex therapeutic challenge. In particular, no recommendations exist regarding the best management approach. We reviewed the literature making a comparison between coronary artery bypass grafting and percutaneous coronary intervention.  2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Idiopathic thrombocytopenic purpura; Coagulation disorder; Coronary artery disease; Percutaneous coronary intervention; Coronary artery bypass grafting; Cardiopulmonary bypass

2. Materials and methods

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune syndrome involving antibody- and cell-mediated destruction of platelets and suppression of platelet produc­ tion that may predispose to bleeding [1]. Patients with ITP present an increased risk for thrombosis and coronary artery disease (CAD) related to more adhesive platelets, direct endothelial damage due to antigenic mimicry [2], and the negative effect of steroid therapy [3]. The relatively low number of patients with ITP and CAD has limited the conduct of clinical trials to evaluate, between percutaneous coronary intervention (PCI) and cor­ onary artery bypass grafting (CABG), the best revasculari­ zation strategy. Surgical interventions are associated with increased risk for bleeding in ITP patients compared to the general population. This is especially true for cardiac operations with cardiopulmonary bypass (CPB) because of the full heparinization and the destructive effects of CPB on all blood components, and particularly on platelets [4]. In addition, percutaneous procedures pose an obvious concern because stent implanting requires intensive antipla­ telet therapy. There are no previous studies comparing PCI and CABG in patients with ITP and CAD. Therefore, we reviewed all the cases in the literature involving surgery and percutaneous revascularization in these patients.

The review considered studies that focus on ITP patients undergoing myocardial revascularization performed by PCI or CABG. Candidate studies were identified by searching Google Scholar and PubMed. All searches covered the period November 1989 through July 2010. Key words used included ‘ITP’, ‘coagulation disorder’, ‘CAD’, ‘PCI’, ‘CABG’, and ‘CPB’. We also perused the bibliographies of retrieved articles and relevant reviews to identify further relevant studies. From each study, we extracted patient characteristics including platelet counts, perioperative treatments, type of myocardial revascularization, and outcomes. We reviewed 35 reports of cardiac revascularization in ITP patients.

*Corresponding author. Via Massarenti 9, 40100 Bologna, Italy. Tel.:   +  39051-6363112; fax:   +  39-051-6363112. E-mail address: [email protected] (A. Russo).  2011 Published by European Association for Cardio-Thoracic Surgery

3. Results 3.1. CABG in patients with ITP To the best of our knowledge, 20 reports involving 32 patients affected by ITP who underwent CABG have been published (Table 1) [5–24]. The mean age of the patients was 63 ± 10 years, and most were male. Five patients were affected by stable angina, three patients by unstable angi­ na, and four patients by acute myocardial infarction; data about CAD presentation were unreported. On admission, the range of platelet values was wide, from 8000/μl [6] to  > 80,000/μl [17, 18]. Most of patients had multivessel CAD, and two or more grafts were completed in 23 patients. A single graft was

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1. Introduction

A. Russo et al. / Interactive CardioVascular and Thoracic Surgery 13 (2011) 153-157

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Table 1.  Cases including patients affected by idiopathic thrombocytopenic purpura who were undergoing coronary artery bypass grafting Study

Thompson et al. (1989) [5] Koike et al. (1989) [6] Bowman (1990) [7] Terada et al. (1990) [8] Jubelier (1992) [9] Sato et al. (1994) [10] Briffa et al. (1994) [11] Hofmeister (1995) [12] Hayashi et al. (1996) [13] Mathew et al. (1997) [14]

Onoe et al. (1999) [15] Gaudino et al. (1999) [16] Christiansen et al. (2000) [17]

Koner et al. (2001) [18] Ohno et al. (2002) [19] Gotoh et al. (2002) [20] Inoue et al. (2004) [21] Tani et al. (2007) [22] Fatimi et al. (2010) [23] Rossi et al. (2010) [24]

Patients Age (years)

Sex

Platelet count on admission (/μl)

61 37 53 n.a. n.a. n.a. 60 69 64 76 72 72 69 57 72 Group 1 (5 patients) 65a Group 2 (5 patients) 53a 59 76 77 60 n.a. 54 47

M M F n.a. n.a. n.a. M M M F M F M M M M/F

68,000 8000 65,000 58,000 n.a. n.a. 14,000 63,000 18,000 53,000 40,000 49,000 65,000 26,000 19,300 54,000a

M

 > 80,000a

M F M F n.a. F M

88,000 57,000 50,000 42,000 n.a. n.a. 55,000

Treatment STER

Preoperative platelet count (/μl)

Procedure

Grafts number

Bleedings

On-pump On-pump On-pump On-pump On-pump On-pump On-pump On-pump On-pump On-pump On-pump On-pump On-pump On-pump On-pump On-pump

3 3 2 n.a. n.a. n.a. n.a. 1 3 3 3 3 3 n.a. 3 3.6a (2–5)

Major No No No Major

• • • •

68,000 n.a. 65,000 128,000 n.a. n.a. 87,000 64,000 110,000 199,000 57,000 168,000 87,000 26,000 46,000 112,000a

•

 > 80,000a

On-pump

2.8a (2–4)

• •

• •

• •

•

138,000 110,000 50,000 187,000 n.a. 135,000 55,000

On-pump On-pump MIDCAB Off-pump Off-pump On-pump On-pump

4 1 1 3 n.a. 3 3

Major 1 patient No No Minor No No No No

IVIG

PC

•

• • • • • • •

• • •

• •

•

•

• •

• • • • • • • • • •

SPLE

•

•

• • •

•

No No No Minor No No No No Major No

F, Female; IVIG, intravenous immunoglobulin; M, male; MIDCAB, minimally invasive direct coronary artery bypass; n.a., not available; PC, platelet concentrate; SPLE, splenectomy; STER, steroids. aData are shown as the mean.

made in three cases: in one patient with early re-stenosis after PCI, in one patient during reoperative CABG, and in one patient in whom multivessel grafting was infeasible because of hypoplasia and a diffuse lesion of the circumflex and right coronary arteries. Except for two patients, per­ ioperative support treatment was always administered. Nine patients were treated with steroids (STER) and 19 with intravenous immunoglobulins (IVIGs). Platelet trans­ fusion was completed in nearly every case. Prophylactic or combined splenectomy (SPLE) was performed in three patients [6, 10, 12]. At the time of operation, 20 patients had a platelet count  > 80,000/μl, and eight had a count of