Post-operative bleeding in myocardial revascularization under cardiopulmonary bypass for patients treated with aspirin or dual antiplatelet therapy using reduced goal-directed anticoagulation

Antiplatelet therapy increases the risk of bleeding and transfusion in patients undergoing extracorporeal circulation. Reduced goal-directed anticoagulation (RGDA) is a personalized approach to reduce the anticoagulation based on a lower targeted activated clotting time (ACT). We assessed whether RGDA using optimized extracorporeal circulation (OpECC) alleviates the risk of severe bleeding in patients treated by dual antiplatelet therapy (DAPT) compared to aspirin alone during coronary artery bypass grafting (CABG). 2275 patients undergoing CABG from 2002 to 2022 were selected after propensity matching from a retrospective cohort of 3018 patients. Patients treated with a combination of aspirin and prasugrel or ticagrelor or clopidogrel were included in the DAPT group (n = 1111). Patients treated with aspirin alone (ASA) constituted the control group (n = 1164). OpECC was conducted under reduced systemic anticoagulation with a target ACT 250 s. Severe bleeding was assessed using 3 validated scores of bleeding: UDPB, E-CABG and BARC-4. While all scores showed low ranges of severe bleeding (less than 6%), they were significantly higher after DAPT compared to ASA (p values for UDPB, E-CABG and BARC-4 at 0.016, 0.006 and 0.063 respectively). Higher maximal ACT was associated with higher rate of transfusion (p