BACKGROUND AND AIM The P2Y12 platelet receptor inhibitor ticagrelor is widely used in patients following acute coronary syndromes or in those who have received coronary stents. Bentracimab is a monoclonal antibody-based reversal agent that is being formally evaluated in a Phase 3 clinical trial. Here, we probe the knowledge, attitudes, and practice patterns of cardiac surgeons regarding their perioperative management of ticagrelor and potential application of a ticagrelor reversal agent. METHODS A questionnaire was developed by a working group of cardiac surgeons to inquire into participants' practices and beliefs regarding ticagrelor and disseminated to practicing, Canadian-trained cardiac surgeons. RESULTS A total of 70 Canadian-trained cardiac surgeons participated. Bleeding risk was identified as the most significant consideration when surgically revascularizing ticagrelor-treated patients (90%). There is variability in the duration of withholding ticagrelor before coronary artery bypass graft procedure in a stable patient; 44.3% wait 3 days and 32.9% wait 4 days or longer. Currently, 15.7% of cardiac surgeons prophylactically give platelet transfusions and fresh frozen plasma intraoperatively following protamine infusion in patients who have recently received ticagrelor. Interestingly, 47.1% of surveyed surgeons were aware of a reversal agent for ticagrelor, 91.4% of cardiac surgeons would consider utilizing a ticagrelor reversal agent if available, and 51.4% acknowledged that the introduction of such an agent would be a major advance in clinical practice. CONCLUSIONS The present survey identified ticagrelor-related bleeding as a major concern for cardiac surgeons. Surgeons recognized the significant unmet need that a ticagrelor reversal agent would address.

Ticagrelor use and practice patterns among Canadian cardiac surgeons.

\n \n \n Ticagrelor, in addition to aspirin, has been demonstrated to reduce morbidity and mortality in patients with acute coronary syndrome compared to clopidogrel with aspirin. The treatment effect appeared to be maintained in the subgroup of patients who underwent urgent surgical revascularization. However, the risk of postoperative bleeding in these patients has not been well described.\n \n \n \n We aimed to establish the effect of ticagrelor exposure within 7 days before surgery on blood loss as measured by postoperative chest tube output and blood product use.\n \n \n \n In a nested cohort study of patients enrolled in the Transfusion Requirements in Cardiac Surgery III (TRICS III) trial, we compared chest tube output and blood product use in patients based on their preoperative exposure to ticagrelor ≤3 days versus >3 days before surgery.\n \n \n \n Of the 5243 patients in TRICS III, 87 patients were exposed to ticagrelor within 7 days with a mean age of 78 years (SD 6) and 74% were male. Patients exposed to ticagrelor 3 days or less before surgery bled a median of 730 ml (IQR 295, 2195) postoperatively in the first 24 hours postoperatively, compared to 518 ml (IQR 350, 1000) for those for whom ticagrelor was held for more than 3 days. We log-transformed the data and found that recent ticagrelor exposure (≤3 days) was associated with significantly more blood loss compared to no exposure for more than 3 days (P-value: 0.01).\n 69.6% of patients in the recent exposure group received at least one red blood cell transfusion versus 54.7% in patients exposed to ticagrelor more than 3 days pre-operatively (p-value: 0.214). Platelet and fresh frozen plasma transfusion were 52.2% vs 15.6% (p-value 0.001), and 39.1% vs 9.4% (p-value 0.003), respectively, for ticagrelor exposure ≤3 days compared to >3 days.\n Cryoprecipitate use was 17.4% in the ≤3 days group and 3.1% in the >3 days group (p-value 0.04). Only 1 patient in each group received prothrombin complex concentrate (PCC) transfusion. And 1 patient with exposure ≤3 days received Factor VII.\n \n \n \n Exposure to ticagrelor within 3 days of surgery is associated with an increased risk of postoperative bleeding as assessed by greater chest tube output at 24 hours and more patients requiring blood product transfusion. A ticagrelor-reversing agent may improve the outcomes of patients who have been recently exposed to ticagrelor and require urgent cardiac surgery.\n \n \n \n \n Type of funding source: None\n

Transfusion requirements in cardiac Surgery III (TRICS III), Ticagrelor Substudy

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Transfusion requirements in cardiac Surgery III (TRICS III), Ticagrelor Substudy