Novel Use of Cangrelor With Heparin During Cardiopulmonary Bypass in Patients With Heparin-Induced Thrombocytopenia Who Require Cardiovascular Surgery: A Case Series

Gernhofer, Yan K.; Banks, Dalia A.; Golts, Eugene; Pretorius, Victor

doi:10.1053/j.semtcvs.2019.10.002

Cited by 16 publications

(13 citation statements)

References 15 publications

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“…For such a patient who requires urgent cardiac surgery, nonheparin anticoagulation for cardiopulmonary bypass (CPB) can be performed with bivalirudin, a short‐acting direct thrombin inhibitor; however, this strategy is primarily used for lower‐risk patients, 2 as its use in higher‐risk patients carries risk of severe bleeding 3 . Other options include administering heparin after reducing HIT antibody titers using therapeutic plasma exchange, 4 or with inhibition of HIT‐associated platelet activation with concomitant intraoperative administration of a short‐acting antiplatelet agent (“platelet anesthesia”) 1,5 . However, rebound HIT‐associated hypercoagulability could occur once the intraoperative anticoagulant and antiplatelet effects wear off.…”

Section: Introductionmentioning

confidence: 99%

“…3 Other options include administering heparin after reducing HIT antibody titers using therapeutic plasma exchange, 4 or with inhibition of HIT-associated platelet activation with concomitant intraoperative administration of a short-acting antiplatelet agent ("platelet anesthesia"). 1,5 However, rebound HITassociated hypercoagulability could occur once the intraoperative anticoagulant and antiplatelet effects wear off.…”

Section: Introductionmentioning

confidence: 99%

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High‐dose IVIG plus cangrelor platelet “anesthesia” during urgent heparin‐CPB in a patient with recent SRA‐negative HIT‐thrombosis with persisting platelet‐activating antibodies

Koster

Nazy

Birschmann

et al. 2020

Research and Practice in Thrombosis and Haemostasis

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In a high‐risk patient with subacute heparin‐induced thrombocytopenia (HIT) type A (platelet count recovery following acute HIT but with persisting platelet‐activating antibodies), in whom urgent cardiac surgery was required, a key clinical question arose: could intraoperative heparin be given safely with “platelet anesthesia” provided with high‐dose intravenous immunoglobulin (IVIG) plus cangrelor (ultra‐short‐acting antiplatelet agent)? This approach proved successful, without unexpected postoperative thrombocytopenia or thromboembolism. In vitro studies confirmed that both IVIG and cangrelor contributed to perioperative inhibition of HIT antibody‐induced platelet activation. Interestingly, despite the patient testing strongly positive in 4 HIT immunoassays (latex immunoturbidimetric assay and 3 enzyme‐immunoassays), the serotonin‐release assay (SRA) was consistently negative. Nevertheless, platelet‐activating HIT antibodies were detectable using modified (platelet factor 4–enhanced) SRA. Our protocol of heparin rechallenge following IVIG/cangrelor provides both intraoperative and early postoperative inhibition of HIT antibody‐induced platelet activation and is applicable to patients with circulating functional HIT antibodies requiring urgent heart surgery, including those with “SRA‐negative HIT.”

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

High‐dose IVIG plus cangrelor platelet “anesthesia” during urgent heparin‐CPB in a patient with recent SRA‐negative HIT‐thrombosis with persisting platelet‐activating antibodies

Koster

Nazy

Birschmann

et al. 2020

Research and Practice in Thrombosis and Haemostasis

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“…The newer, ultra-short-acting P2Y12 receptor antagonist cangrelor has been proposed as an alternative to tirofiban, but, to date, its use has been reported only in four case reports on HIT patients undergoing cardiac surgery. [31][32][33][34] Although no major bleeding requiring reoperation 31 and even possibly decreased postoperative bleeding 34 were reported, no conclusion on its efficacy can be drawn from these reports. 33 One patient with persistent HITabs 8 years following HIT was treated with this strategy during coronary artery bypass surgery and exhibited a huge rise in HITabs with a positive functional assay in the postoperative period, putting her at risk of developing recurrent HIT.…”

Section: Alternative Anticoagulation Strategies During Cardiac Surgerymentioning

confidence: 96%

GTH 2021 State of the Art—Cardiac Surgery: The Perioperative Management of Heparin-Induced Thrombocytopenia in Cardiac Surgery

Ranta

Scala

2021

Hamostaseologie

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Heparin-induced thrombocytopenia (HIT) is a severe, immune-mediated, adverse drug reaction that paradoxically induces a prothrombotic state. Particularly in the setting of cardiac surgery, where full anticoagulation is required during cardiopulmonary bypass, the management of HIT can be highly challenging, and requires a multidisciplinary approach. In this short review, the different perioperative strategies to run cardiopulmonary bypass will be summarized.

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“…Cangrelor, a novel intravenous, short‐acting, reversible P2Y 12 antagonist that does not require hepatic activation has been approved for use during percutaneous coronary intervention. There are case reports demonstrating its short‐term use in adults with heparin‐induced thrombocytopenia who are undergoing cardiopulmonary bypass or VAD placement 26‐28 . Additional studies in adults have demonstrated cangrelor as a relatively safe and effective bridge when oral antiplatelet agents are contraindicated 29‐31 .…”

Section: Introductionmentioning

confidence: 99%

Novel use of cangrelor in pediatrics: A pilot cohort study demonstrating use in ventricular assist devices

et al. 2020

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Thromboembolic events and bleeding are major sources of morbidity among pediatric patients supported on a ventricular assist device (VAD). Pharmacokinetics and pharmacodynamics of enteral antiplatelet agents are affected and variable due to erratic enteral absorption in end‐stage heart failure and VAD circulation. Additionally, 20%‐40% of the population are poor metabolizers of clopidogrel, a prodrug, making cangrelor an alternative when antiplatelet therapy is crucial. Cangrelor has been used effectively and safely for short durations in adults during percutaneous coronary interventions, but the use of cangrelor is still under investigation in pediatrics. This case series utilized cangrelor, a novel short‐acting, reversible, intravenous P2Y12 platelet inhibitor in managing pediatric patients supported with a VAD. We performed a retrospective, single‐center review of patients admitted to a tertiary medical center with end‐stage heart failure requiring mechanical circulatory support and concomitant cangrelor administration between January 2019 and March 2020. Platelet function testing, cangrelor dose, bleeding complications, thromboembolic events, and frequency of circuit interventions during the use of cangrelor were recorded. Optimal platelet reactivity, defined as P2Y12 < 180 platelet reaction units (PRU), was measured with serial point‐of‐care testing (VerifyNow). Seven patients, median age of 4.9 years, met the above criteria. Three patients had a diagnosis of complex congenital heart disease. Four patients had dilated or restrictive cardiomyopathy. All patients were on continuous flow VADs. The median VAD duration was 84.5 days (IQR 61.5‐103). The median duration on cangrelor was 43 days (IQR 8‐70). The median cangrelor dose to reach the therapeutic threshold was 0.75 μg/kg/min with the mean P2Y12, while on cangrelor of 164.75 PRU. Bleeding complications included mild gastrointestinal bleeding and hematuria. There was one patient with pump thrombosis requiring intervention. There were no cerebrovascular events while on cangrelor. We report the first successful long‐term use of cangrelor in pediatric patients. The reversibility and short half‐life of cangrelor make it a feasible antiplatelet agent in selected patients. This data supports the use of cangrelor in children as a viable antiplatelet option; with minimal bleeding complications and no cerebrovascular events demonstrated in this cohort.

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Novel Use of Cangrelor With Heparin During Cardiopulmonary Bypass in Patients With Heparin-Induced Thrombocytopenia Who Require Cardiovascular Surgery: A Case Series

Cited by 16 publications

References 15 publications

High‐dose IVIG plus cangrelor platelet “anesthesia” during urgent heparin‐CPB in a patient with recent SRA‐negative HIT‐thrombosis with persisting platelet‐activating antibodies

High‐dose IVIG plus cangrelor platelet “anesthesia” during urgent heparin‐CPB in a patient with recent SRA‐negative HIT‐thrombosis with persisting platelet‐activating antibodies

GTH 2021 State of the Art—Cardiac Surgery: The Perioperative Management of Heparin-Induced Thrombocytopenia in Cardiac Surgery

Novel use of cangrelor in pediatrics: A pilot cohort study demonstrating use in ventricular assist devices

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