Prevalence and outcome of heparin-induced thrombocytopenia diagnosed under veno-arterial extracorporeal membrane oxygenation: a retrospective nationwide study

Kimmoun, Antoine; Oulehri, Walid; Sonneville, Romain; Grisot, Paul Henri; Zogheib, Élie; Amour, Julien; Aïssaoui, Nadia; Mégarbane, Bruno; Mongardon, Nicolas; Renou, Amélie; Schmidt, Matthieu; Besnier, Emmanuel; Delmas, Clément; Dessertaine, Géraldine; Guidon, C.; Nesseler, Nicolas; Labro, Guylaine; Rozec, Bertrand; Pierrot, Marc; Boisramé-Helms, Julie; Bougon, David; Chardonnal, Laurent; Médard, Anne; Ouattara, Alexandre; Girerd, Nicolas; Lamiral, Zohra; Borie, Marc; Ajzenberg, Nadine; Lévy, Bruno

doi:10.1007/s00134-018-5346-y

Cited by 51 publications

(79 citation statements)

References 21 publications

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“…A retrospective study found no difference in terms of thrombotic complications, but a significant decrease in severe bleeding complications (11.5% vs. 32%, p=0.01), in 52 VA-ECMO patients treated without continuous heparin infusion compared to 50 patients treated with heparin aiming an activated clotting time between 180 to 220 seconds (44). A national French multicenter study reported a very low frequency of heparin-induced thrombocytopenia (0.36%, n=21/5797) in VA-ECMO with no impact on patient's survival (45).…”

Section: Hematologic Complicationsmentioning

confidence: 96%

Venoarterial extracorporeal membrane oxygenation in cardiogenic shock: indications, mode of operation, and current evidence

Chambrun

Bréchot

Combes

2019

Current Opinion in Critical Care

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Purpose of review: Temporary circulatory support (TCS) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of VA-ECMO principles, indications, management, complications and discusses the results of recent case series and trials. Recent findings: VA-ECMO is utilized as a bridge to "decision" that includes weaning after cardiac function recovery, transplantation, long-term mechanical circulatory support and withdrawal in case of futility. VA-ECMO is considered the first-line TCS since it allows rapid improvement in oxygenation, is less expensive, and is also suitable for patients with biventricular failure. Combining Impella or intra-aortic balloon pump support with VA-ECMO might decrease left ventricular pressure and improve outcomes. Massive pulmonary embolism, sepsis-associated cardiomyopathy, refractory cardiac arrest are among emerging indications for TCS. Summary: TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the place VA-ECMO in cardiogenic shock treatment strategies.

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Section: Hematologic Complicationsmentioning

confidence: 96%

Venoarterial extracorporeal membrane oxygenation in cardiogenic shock: indications, mode of operation, and current evidence

Chambrun

Bréchot

Combes

2019

Current Opinion in Critical Care

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“…There were 6.698 V-A ECMO patients, of whom 459 were post-cardiotomy. In 6 studies, authors did not report about the ECMO setting (post-cardiotomy, post-acute myocardial infarction, or other aetiologies) [8,16,25,26,28,39]. V-V ECMO was present in 477 patients.…”

Section: Study Descriptionmentioning

confidence: 99%

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

et al. 2020

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Despite increasing improvement in extracorporeal membrane oxygenation (ECMO) technology and knowledge, thrombocytopenia and impaired platelet function are usual findings in ECMO patients and the underlying mechanisms are only partially elucidated. The purpose of this meta-analysis and systematic review was to thoroughly summarize and discuss the existing knowledge of platelet profile in adult ECMO population. All studies meeting the inclusion criteria (detailed data about platelet count and function) were selected, after screening literature from July 1975 to August 2019. Twenty-one studies from 1.742 abstracts were selected. The pooled prevalence of thrombocytopenia in ECMO patients was 21% (95% CI 12.9-29.0; 14 studies). Thrombocytopenia prevalence was 25.4% (95% CI 10.6-61.4; 4 studies) in veno-venous ECMO, whereas it was 23.2% (95% CI 11.8-34.5; 6 studies) in veno-arterial ECMO. Heparin-induced thrombocytopenia prevalence was 3.7% (95% CI 1.8-5.5; 12 studies). Meta-regression revealed no significant association between ECMO duration and thrombocytopenia. Platelet function impairment was described in 7 studies. Impaired aggregation was shown in 5 studies, whereas loss of platelet receptors was found in one trial, and platelet activation was described in 2 studies. Platelet transfusions were needed in up to 50% of the patients. Red blood cell transfusions were administered from 46 to 100% of the ECMO patients. Bleeding events varied from 16.6 to 50.7%, although the cause and type of haemorrhage was not consistently reported. Thrombocytopenia and platelet dysfunction are common in ECMO patients, regardless the type of ECMO mode. The underlying mechanisms are multifactorial, and understanding and management are still limited. Further research to design appropriate strategies and protocols for its monitoring, management, or prevention should be matter of thorough investigations.

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“…It is important to clarify that not all cases were confirmed by functional assays. Kimmoun et al 62 Once laboratory confirmation of the diagnosis is made, the patient is said to have acute HIT 29 The proposed HIT management algorithm for ECMO patients is presented in Figure 2.…”

Section: Hit and Ecmomentioning

confidence: 99%

Heparin‐induced thrombocytopenia complicating extracorporeal membrane oxygenation support: Review of the literature and alternative anticoagulants

Pollak

2019

Journal of Thrombosis and Haemostasis

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Heparin‐induced thrombocytopenia (HIT) is a life‐threatening prothrombotic, immune‐mediated complication of unfractionated heparin and low molecular weight heparin therapy. HIT is characterized by moderate thrombocytopenia 5‐10 days after initial heparin exposure, detection of platelet‐activating anti‐platelet factor 4/heparin antibodies and an increased risk of venous and arterial thrombosis. Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support used in critically ill patients with respiratory or cardiac failure. Systemic anticoagulation is used to alleviate the thrombotic complications that may occur when blood is exposed to artificial surfaces within the ECMO circuit. Therefore, when HIT complicates patients on ECMO support, it is associated with a high thrombotic morbidity and mortality. The risk for HIT correlates with the accumulative dosage of heparin exposure. In ECMO patients receiving continuous infusion of heparin for circuit patency, the risk for HIT is not neglected and must be thought of in the differential diagnosis of the appropriate clinical and laboratory circumstances. The following article reviews the current knowledge in HIT complicating ECMO patients and the alternative anticoagulation options in the presence of HIT.

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Prevalence and outcome of heparin-induced thrombocytopenia diagnosed under veno-arterial extracorporeal membrane oxygenation: a retrospective nationwide study

Cited by 51 publications

References 21 publications

Venoarterial extracorporeal membrane oxygenation in cardiogenic shock: indications, mode of operation, and current evidence

Venoarterial extracorporeal membrane oxygenation in cardiogenic shock: indications, mode of operation, and current evidence

Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis

Heparin‐induced thrombocytopenia complicating extracorporeal membrane oxygenation support: Review of the literature and alternative anticoagulants

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