The purpose of this study is to find out whether it is safe and practical to perform MIDCAB surgery (a minimally invasive heart bypass procedure) while patients receive a continuous cangrelor infusion during the operation. Cangrelor is a medicine that helps prevent blood clots and works quickly through a vein drip.
The study compares patients receiving cangrelor during surgery to patients who had the same surgery in the past while on aspirin, with or without cangrelor given beforehand.
Study Question: Can MIDCAB surgery be safely performed under cangrelor infusion, without increasing the risk of bleeding or other complications?
Hypothesis: Using cangrelor during MIDCAB surgery is safe and feasible, and it provides effective protection against blood clots during the procedure.
This study will help doctors understand whether intraoperative cangrelor can improve patient safety and outcomes in minimally invasive heart surgery.
Age ≥18 years old
CABG with IMA-LAD graft in MIDCAB technique
Age ≥18 years old
CABG with IMA-LAD graft in MIDCAB technique
Administration of fibrinolytics or GP IIb/IIIa inhibitors
Previous intracranial hemorrhage
Known bleeding diathesis
Patients undergoing concomitant PCI and MIDCAB
The study population includes adult patients scheduled for minimally invasive direct coronary artery bypass (MIDCAB) surgery at Cardiocentro Ticino Institute, Lugano, Switzerland. Patients will be selected for either prospective cangrelor-guided MIDCAB or retrospective historical control MIDCAB under aspirin therapy. The population includes individuals with multivessel coronary artery disease requiring LIMA-LAD bypass, regardless of sex or comorbidities, who meet all inclusion and no exclusion criteria. Patients with planned concomitant PCI are excluded. This population represents real-world candidates for MIDCAB surgery under antiplatelet management protocols.
Case-control
Other
Cangrelor-guided MIDCAB surgery (for the prospective cases)
Procedure/SurgeryCangrelor-guided MIDCAB surgery: Patients undergo minimally invasive direct coronary artery bypass (MIDCAB) with continuous intravenous cangrelor infusion at 0.75 μg/kg per minute. Prior oral antiplatelet therapy is discontinued, and platelet function is monitored daily using Multiplate® testing. Cangrelor infusion is started when platelet aggregation reaches predefined thresholds and continued throughout surgery until it is safe to restart oral antiplatelet therapy.
Aspirin MIDCAB surgery (for the historical controls)
Procedure/SurgeryAspirin MIDCAB surgery: Historical control patients underwent MIDCAB under aspirin therapy, with or without prior bridging with cangrelor. Perioperative management follows standard care, including anticoagulation with unfractionated heparin during surgery and routine monitoring of laboratory and clinical outcomes.
Excessive CABG-related bleeding during and after MIDCAB surgery
Excessive bleeding is defined as the occurrence of at least one of the following: (1) bleeding requiring surgical re-exploration, (2) 24-hour chest tube output greater than 1 liter, or (3) transfusion of more than 4 units of packed red blood cells. This measure assesses the safety of cangrelor-guided MIDCAB compared with historical aspirin-treated controls.
In-hospital MACCE
Occurrence of all-cause death, myocardial infarction, stroke, or urgent revascularization; each component assessed separately.
Probable or Defined Stent Thrombosis
Incidence of stent thrombosis confirmed by angiography or clinical criteria (probable or definite).
Cardiac Injury (High-Sensitivity Troponin)
Daily measurement of high-sensitivity troponin before and after MIDCAB to assess perioperative myocardial injury.
Chest Tube Output
Volume of postoperative chest drainage measured at 6, 12, 24, and 48 hours after surgery.
Serious Adverse Events and Adverse Drug Reactions
Any untoward medical occurrence during the study that meets criteria for a Serious Adverse Event (death, life-threatening event, hospitalization, permanent impairment, or medical/surgical intervention to prevent permanent damage) or an Adverse Drug Reaction related to cangrelor infusion. Expected ADRs include bleeding, cardiac tamponade, acute kidney injury, hypersensitivity, dyspnea, or fructose intolerance. Other adverse events are monitored and recorded per protocol.
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