Extracorporeal Circulation in a Patient with Heparin-induced Thrombocytopenia

Smith, Jill P.; Walls, Joseph T.; Muscato, Mary S.; McCord, E. Scott; Worth, Eugene R.; Curtis, Jennifer; Silver, Donald

doi:10.1097/00000542-198503000-00029

Cited by 39 publications

(8 citation statements)

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“…Olinger et al [15] in 1984 were the first to identify that the use of iloprost could inhibit heparin-dependent platelet activation in the presence of HIT serum. Since then, small studies referring to the UFH's deleterious effects being offset by iloprost administration in patients with HIT requiring cardiac surgery have been published [16][17][18][19][20]36,37]. The major drawback of iloprost is its effect on vasomotor tone, particularly the marked vasodilatation and lifethreatening hypotension that may result.…”

Section: Discussionmentioning

confidence: 99%

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Perioperative use of iloprost in cardiac surgery patients diagnosed with heparin‐induced thrombocytopenia‐reactive antibodies or with true HIT (HIT‐reactive antibodies plus thrombocytopenia): An 11‐year experience

et al. 2015

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*Thrombocytopenia and thromboembolism(s) may develop in heparin immune-mediated thrombocytopenia (HIT) patients after reexposure to heparin. At the Onassis Cardiac Surgery Center, 530 out of 17,000 patients requiring heart surgery over an 11-year period underwent preoperative HIT assessment by ELISA and a threepoint heparin-induced platelet aggregation assay (HIPAG). The screening identified 110 patients with HITreactive antibodies, out of which 46 were also thrombocytopenic (true HIT). Cardiac surgery was performed in HIT-positive patients under heparin anticoagulation and iloprost infusion. A control group of 118 HITnegative patients received heparin but no iloprost during surgery. For the first 20 patients, the dose of iloprost diminishing the HIPAG test to 5% was determined prior to surgery by in vitro titration using the patients' own plasma and donor platelets. In parallel, the iloprost "target dose" was also established for each patient intraoperatively, but before heparin administration. Iloprost was infused initially at 3 ng/kg/mL and further adjusted intraoperatively, until ex vivo aggregation reached 5%. As a close correlation was observed between the "target dose" identified before surgery and that established intraoperatively, the remaining 90 patients were administered iloprost starting at the presurgery identified "target dose." This process significantly reduced the number of intraoperative HIPAG reassessments needed to determine the iloprost target dose, and reduced surgical time, while maintaining similar primary clinical outcomes to controls. Therefore, infusion of iloprost throughout surgery, under continuous titration, allows cardiac surgery to be undertaken safely using heparin, while avoiding life-threatening iloprost-induced hypotension in patients diagnosed with HIT-reactive antibodies or true HIT.

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Section: Discussionmentioning

confidence: 99%

“…In a number of small studies and case reports, iloprost, a stable analogue of prostacyclin, has been used [15][16][17][18][19][20]. However, the use of iloprost is associated with severe hypotension [20,21].…”

Section: Introductionmentioning

confidence: 99%

Perioperative use of iloprost in cardiac surgery patients diagnosed with heparin‐induced thrombocytopenia‐reactive antibodies or with true HIT (HIT‐reactive antibodies plus thrombocytopenia): An 11‐year experience

et al. 2015

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“…A severe thrombocytopenia (27,000 platelets/mL) was discovered on June 2, compared with a preoperative platelet count of 260,000/mL. Her platelet count declined to a nadir of 13,000/mL, even after platelet transfusions (Figure 1).…”

Section: Case Reportmentioning

confidence: 97%

Heparin-Induced Thrombocytopenia: A Case Report

Damme¹,

Damas²,

David

et al. 1990

Angiology

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The authors report a case of heparin-induced thrombocytopenia, in whom massive pulmonary embolism occurred in spite of heparin anticoagulation. Successful pulmonary thrombectomy was carried out under cardiopulmonary bypass, with limitation of platelet clumping during bypass by aggregation inhibitors. This report is a comprehensive contribution to a better understanding of this rare immunoallergic complication of heparin administration, with a high incidence of serious thromboembolic events. The optimal management for cases of unavoidable reexposure to heparin is discussed.

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“…The practice of delaying CPB until the HIT antibody is no longer detectable and using heparin only during CPB remains controversial. Several case reports 17–20 and a recent case series 21 have shown that this is feasible. The use of heparin in the preoperative and postoperative period is absolutely contraindicated.…”

Section: Preoperative Assessmentmentioning

confidence: 99%