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Letter to the Editor
Coronary Artery Bypass Surgery, Angioplasty and Long Term Anti-Platelet Treatment in a Type B Hemophilia Patient
Antonio Eduardo PesaroI, Marcus Vinicius GazI, Ralf KarbsteinI, Marco PerinI, Carlos Vicente Serrano Jr.II, Élbio DamicoI,III
I CTI, Hospital Albert Einstein - São Paulo/SP, Brazil
II Cardiology, Instituto do Coração do Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
III Hematology, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - São Paulo/SP, Brazil
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">A&#46; Circumflex coronary artery with 95&#37; obstruction&#46; B&#46; Anterior descending coronary artery with 70&#37; obstruction&#46; C&#46; Right coronary artery with a 100&#37; distal occlusion</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Hemophilia patients usually have a lower incidence of coronary artery disease &#40;CAD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> However&#44; as their life expectancy increases so does the incidence of CAD&#46; Anti-platelet drugs&#44; diagnostic coronary catheterization&#44; angioplasty and coronary artery bypass surgery &#40;CABG&#41; have rarely been used in this population&#46;<a class="elsevierStyleCrossRef" href="#bib2">2</a></p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">CASE DESCRIPTION</span><p id="para20" class="elsevierStylePara elsevierViewall">In this case-report&#44; we describe the case of a 37-year-old man with severe type B hemophilia&#44; HIV &#40;on antiretroviral treatment&#41; and activity-limiting angina unresponsive to clinical treatment&#46; Myocardial cintilography detected ventricular dysfunction with lateral and inferior ischemia&#46; Coronarography was performed with specific hematological support&#46; The patient received enough factor IX to reach 100&#37; plasma concentration &#40;6&#44;500 IU&#41;&#44; followed by 3&#44;500 IU the next day&#46; Severe coronary obstructions were observed during coronarography &#40;<a class="elsevierStyleCrossRef" href="#f1-cln64_8p822">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="f1-cln64_8p822"></elsevierMultimedia><p id="para30" class="elsevierStylePara elsevierViewall">The patient then underwent an off-pump CABG with an appropriate factor IX infusion &#40;6&#44;500 IU pre-surgery&#44; 2&#44;000 IU post-surgery with continuous infusion in order to keep the plasma concentration at 40&#37; for the first 2 days&#44; 30&#37; for the third through sixth days&#44; and 20&#37; for the seventh through twelfth days&#41;&#46; Two grafts were performed &#40;left internal thoracic artery to anterior descending artery and saphenous graft to circumflex artery&#41;&#44; and no adverse cardiac or hematological events occurred&#46; After surgery&#44; the patient was not treated with anti-platelet drugs&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">Six months after CABG&#44; activity-limiting angina&#44; ischemia and ventricular dysfunction persisted&#46; An angiotomography showed obstruction of the saphenous vein graft&#46; We performed an angioplasty of the circumflex coronary artery with a bare metal stent and used factor IX during the procedure&#44; as described for the previous coronarography&#46; The patient was treated with heparin&#44; clopidogrel and acetyl salicylic acid &#40;ASA&#41;&#46; Clopidogrel was administered for 30 days&#44; and ASA was prescribed permanently&#46; During the first month following stent placement&#44; daily factor IX boluses were given in order to keep the factor IX plasma level at 30&#37;&#46; Six months following angioplasty&#44; the patient remained asymptomatic&#44; and his lateral ischemia had resolved&#46; No hemorrhagic event was detected&#46;</p></span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">DISCUSSION</span><p id="para50" class="elsevierStylePara elsevierViewall">In this case&#44; the initial intervention indicated was a CABG based on the following&#58; &#40;1&#41; Cardiac surgery is a relatively safe procedure for hemophilia patients&#59; &#40;2&#41; The risks of using anti-platelet drugs are unknown in hemophiliacs&#59; and &#40;3&#41; Multi-vessel angioplasty without anti-platelet treatment should be avoided&#46; After the CABG&#44; the patient continued to have angina due to obstruction of the saphenous graft&#46; We opted for a single angioplasty based on the fact that a second CABG was not indicated for treating the remaining single vessel disease&#46; After that&#44; we introduced ASA because reports of hemorrhagic complications while on ASA are based on a few anecdotal reports&#44;<a class="elsevierStyleCrossRef" href="#bib3">3</a> and stent thrombosis is still a major threat&#44; even in hemophiliacs&#46;<a class="elsevierStyleCrossRef" href="#bib4">4</a></p><p id="para60" class="elsevierStylePara elsevierViewall">This report highlights important issues surrounding the treatment of CAD in hemophilia patients&#58; when indicated&#44; angiography is a safe procedure and should not be delayed&#59; CABG is a feasible option for patients who have multiple coronary obstructions&#44; as long as factor IX is properly replaced&#46;<a class="elsevierStyleCrossRef" href="#bib5">5</a> Angioplasty may also be an option for treating this hemophilic population&#44; but conclusive evidence is lacking&#46;<a class="elsevierStyleCrossRef" href="#bib6">6</a> More importantly&#44; anti-platelet treatment should always be considered&#46;</p></span></span>"
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