Cangrelor and Heparin for Pulmonary Thromboendarterectomy in Heparin-Induced Thrombocytopenia

Ta, Jackie; Mishra, Suraj; Vaidya, Anjali; Forfia, Paul R.; Toyoda, Yoshiya; Auger, William R.; Salamanca-Padilla, Y. Yuliana; Morewood, Gordon H.

doi:10.1016/j.athoracsur.2020.01.051

Cited by 5 publications

(5 citation statements)

References 6 publications

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“…As previously proposed [2,3], platelet function monitoring might help to adapt the dose of cangrelor. Gernhofer et al [2] monitored the antiplatelet effect of cangrelor with the VerifyNow-PRU assay and adjusted the infusion rate to maintain PRU below 180 [3]. However, this threshold is not validated and may be too high.…”

Section: Discussionmentioning

confidence: 92%

“…At the acute phase of HIT, characterized by intense platelet activation, Ta et al [3] reported ontreatment platelet reactivity more than 150 PRU during CPB, suggesting that the standard cangrelor dose is too low. As previously proposed [2,3], platelet function monitoring might help to adapt the dose of cangrelor. Gernhofer et al [2] monitored the antiplatelet effect of cangrelor with the VerifyNow-PRU assay and adjusted the infusion rate to maintain PRU below 180 [3].…”

Section: Discussionmentioning

confidence: 99%

“…However, for the same dose, the intensity of platelet inhibition may vary according to the situation and decrease, while the preexisting level of platelet activation increases: in patients with stable coronary artery disease (no platelet activation), on-treatment platelet reactivity measured with the point-of-care VerifyNow-PRU was less than 25 PRU [6], whereas in STEMI patients, the median value was 94 PRU, with a large interindividual variability [7]. At the acute phase of HIT, characterized by intense platelet activation, Ta et al [3] reported on-treatment platelet reactivity more than 150 PRU during CPB, suggesting that the standard cangrelor dose is too low. As previously proposed [2,3], platelet function monitoring might help to adapt the dose of cangrelor.…”

Section: Discussionmentioning

confidence: 99%

“…The use of cangrelor for CPB has been reported in a few cases of suspected, subacute A/B, or remote HIT but only in four cases of acute HIT [2][3][4]. We reported here the use of cangrelor at the very acute phase, in a patient with a high titre of anti-PF4/heparin antibodies and deep thrombocytopenia.…”

Section: Introductionmentioning

confidence: 87%

“…For CPB management, we used the protocol of cangrelor (unlabelled use) previously reported [1,3]: a loading dose of 30 mg/kg cangrelor was administered over one minute, followed by a continuous infusion of 4 mg/kg/min throughout CPB. No platelet monitoring was available.…”

Section: Case Reportmentioning

confidence: 99%

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Cangrelor for cardiopulmonary bypass in patients with heparin-induced thrombocytopenia: it is not so easy

Godiér

Boucebci

Delhaye

et al. 2023

Blood Coagulation &Amp; Fibrinolysis

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Anticoagulation management for cardiopulmonary bypass (CPB) is challenging in patients with acute heparin-induced thrombocytopenia (HIT). The strategy of combining cangrelor intraoperatively with heparin for CPB anticoagulation is of increasing interest but exposes to specific unresolved problems. We report the case of a patient requiring surgical pulmonary embolectomy for pulmonary embolism at the very acute phase of HIT, with a high titre of anti-PF4/heparin antibodies and severe thrombocytopenia. For CPB management, cangrelor was administered in combination with heparin prescribed and monitored as usual. Surgery was successfully performed, but postoperatively, the patient developed a new thrombotic event. We discussed the specific problems associated with such strategy, including the dose of cangrelor and its monitoring, the management of the cell-saver, the risk of heparin rebound and the risk of platelet transfusion. These issues must be addressed before considering the combination of cangrelor and unfractionated heparin as a standard of care for CBP.

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