Use of Cangrelor as a Bridge to Left Ventricular Assist Device Implantation in a Patient with a Recent Drug‐Eluting Stent Who Developed Acute Tirofiban‐Related Thrombocytopenia

Abstract

Current guidelines emphasize the need for at least 6-12 months of oral dual antiplatelet therapy consisting of aspirin and a P2Y12 inhibitor following drug-eluting coronary artery stent implantation. In patients with recently implanted coronary artery stents who require urgent cardiac or noncardiac surgery, the benefits of maintaining oral dual antiplatelet therapy must be carefully weighed against the risks of excessive bleeding, and current practice is largely guided by individual surgeon preferences. When the effects of a second oral antiplatelet agent are undesirable during the perioperative period, the use of a short-acting intravenous antiplatelet agent as "bridge" therapy that can be discontinued shortly before surgery is associated with a reduced occurrence of adverse clinical events in patients with recently implanted coronary stents requiring urgent coronary artery bypass graft surgery. Cangrelor is an intravenous adenosine triphosphate analog P2Y12 receptor antagonist with a short plasma half-life that has been used off label in patients with recent coronary stents as a bridge to invasive procedures with excessive bleeding risk. To our knowledge, this is the first case report to demonstrate the safe and effective use of cangrelor as a bridge to left ventricular assist device implantation in a patient with a recently implanted drug-eluting coronary artery stent who developed acute thrombocytopenia following reexposure to tirofiban, a glycoprotein IIb/IIIa inhibitor. KEY WORDS cangrelor, glycoprotein IIb/IIIa inhibitor, thrombocytopenia, dual antiplatelet therapy, left ventricular assist device, bridge therapy. Current guidelines emphasize the need for at least 6-12 months of oral dual antiplatelet therapy (DAPT) consisting of aspirin and a P2Y12 inhibitor following coronary artery drug-eluting stent (DES) implantation. 1 This recommendation is based on prospective evidence that interruptions in DAPT may lead to increased rates of stent thromboses and adverse outcomes

Perioperative Antiplatelet Bridging With Cangrelor: A Cohort Study and Narrative Review

“…8 Retrospective studies of cangrelor bridging for NCS report either no bleeding or minor procedural bleeding (Table 4), suggesting that this is a safe approach to perioperative platelet inhibition. [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]…”

“…Similarly, the BRIDGE trial reported a low incidence of preoperative ischemic events, and retrospective studies of cangrelor bridging for NCS report a low incidence of perioperative MACE (Table 4). 8,[13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] Thus, cangrelor bridging appears to be an effective approach for mitigating the risk of perioperative MACE.…”

“…Patient selection and bridging practices vary somewhat across studies, though the literature consistently reports a low incidence of perioperative bleeding and ischemic events. [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] Although an international consensus statement provides guidance on using cangrelor for off-label perioperative bridging, there remain areas of uncertainty. 10 It is not fully known whether the VerifyNow PRUTest of platelet reactivity can be used to guide timing of cangrelor after oral washout.…”

Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience

“…22 To date, there is no randomized trial of bridging with cangrelor in NCS, and limited observational experience are available with heterogenous prescribing and monitoring practices, which may contribute to suboptimal outcomes. [10][11][12][13][14][15][16] Likewise, data on bridging use of short-acting GPIs are heterogeneous as well with regard to type of surgery, inclusion criteria, time windows between stent implantation or ACS and surgery, and antiplatelet strategies during the perioperative period which may partly explain the reported variability in success rates. 37 Despite the inclusion of a similar miscellaneous of surgical procedures, we believed that the strength of our study is a standardize case by case approach evaluation to weight the ischemic and bleeding risk and the use of a bridging protocol with a close postoperative monitoring which could have had a positive impact on our study findings.…”

“…9 However, there is limited reported data on the use of cangrelor among patients undergoing noncardiac surgery (NCS). [10][11][12][13][14][15][16] On this background, we report the results of a prospective, multicenter registry describing realworld experience of a prespecified bridging protocol using cangrelor conducted in patients referred to nondeferrable intermediate to high bleeding risk surgery requiring withdrawal of DAPT.…”