Clinical outcomes of cardiac surgery patients undergoing therapeutic plasma exchange for heparin‐induced thrombocytopenia

Abstract

Background and Objectives Heparin‐induced thrombocytopenia (HIT) is an antibody‐mediated condition that leads to thrombocytopenia and possible thrombosis. Patients with HIT who require cardiac surgery pose a challenge as high doses of heparin or heparin alternatives are required to permit cardiopulmonary bypass (CPB). Intraoperative therapeutic plasma exchange (TPE) is a valuable adjunct in the management of antibody‐mediated syndromes including HIT. The clinical impact of TPE on thromboembolic events, bleeding and mortality after heparin re‐exposure is not well established. We hypothesized that TPE with heparin re‐exposure will not lead to HIT‐related thromboembolic events, bleeding or increased mortality after cardiac surgery with CPB. Materials and Methods We reviewed 330 patients who received perioperative TPE between September 2012 and September 2017. Results Twenty four patients received TPE for HIT before anticipated heparin use for CPB. Most patients were males (79%) scheduled for advanced heart failure therapies. Three patients (12·5%) died within 30 days after surgery but none of the deaths were considered HIT‐related. Thromboembolic events (TE) occurred in 3 patients within 7 days of surgery; of those, two were possibly HIT‐related. Conclusion Therapeutic plasma exchange with heparin re‐exposure was not strongly associated with HIT‐related thrombosis/death after cardiac surgery with CPB.

Coagulation and Transfusion Updates From 2021

“…Authors from Duke presented safety data in 2021 for intraoperative therapeutic plasma exchange in 24 patients with HIT. 66 Preoperative antibody titers only were available in about half of these patients, and postoperative titers were demonstrably lower. Some patients did have postoperative thrombotic events; however, many were high-risk advanced heart failure patients.…”

Research priorities for therapeutic plasma exchange in critically ill patients

“…Heparin-induced thrombocytopenia (HIT) is a pro-thrombotic complication of heparin where platelet-activating antibodies develop after exposure to heparin leading to thrombosis and thrombocytopenia [ 61 ]. TPE has been described for refractory HIT conditions to remove such specific antibodies [ 62 ].…”

Hemostatic effects of therapeutic plasma exchange: A concise review

“…surgery, the primary replacement fluid was plasma. 35 One bleeding complication (hemorrhagic stroke) occurred but was thought to be related to the underlying disorder not the TPE procedure. Among 30 patients with renal transplant acute humoral rejection, the replacement fluid was plasma, and no bleeding complications occurred.…”

“…As a result, there is an increased tendency to use plasma as a replacement fluid in the periprocedural setting 8 . In a study of 24 patients undergoing TPE for heparin‐induced thrombocytopenia prior to cardiopulmonary bypass surgery, the primary replacement fluid was plasma 35 . One bleeding complication (hemorrhagic stroke) occurred but was thought to be related to the underlying disorder not the TPE procedure.…”