Successful use of fondaparinux in a patient with a mechanical heart valve replacement and a history of heparin-induced thrombocytopenia

Abstract

The development of heparin-induced thrombocytopenia (HIT) is an antibody-mediated clinicopathologic syndrome. The resultant thrombocytopenia and thrombosis can be severe and life-threatening. Fondaparinux is a parenteral factor Xa inhibitor used for venous thromboembolism prevention and treatment. Fondaparinux has minimal affinity for platelet factor 4, making it an alternative agent to unfractionated heparin (UFH) and low-molecular weight heparin (LMWH) and a plausible consideration for patients with a history of HIT. The use of fondaparinux in patients with mechanical heart valve replacement and a history of HIT has never been discussed in the literature. We report on the case of a patient with a mechanical aortic heart valve replacement and a history of HIT who was successfully bridged postoperatively with fondaparinux. While there is currently no literature to support the use of fondaparinux in patients with mechanical heart valves, this drug may offer an option for management of such patients who cannot use heparin products. However, further clinical investigations are warranted to confirm both the safety and efficacy of this agent in the mechanical heart valve population.

Chemoenzymatic Synthesis of Heparin Oligosaccharides with both Anti-factor Xa and Anti-factor IIa Activities

“…It should be noted that ULMW heparin 1 did not bind to PF4, consistent with the previous finding indicating that the minimum size of HS oligosaccharides that bind to PF4 is an octasaccharide (24,25). Furthermore, the use of fondaparinux, a synthetic ULMW heparin, effectively eliminates the risk of heparin-induced thrombocytopenia (26,27).…”

Successful Use of Fondaparinux Early After Mechanical Aortic Valve Replacement in a Patient with a History of Heparin‐Induced Thrombocytopenia

“…The first published case report involved a woman with a history of HIT and a mechanical aortic valve who required interruption of long-term warfarin therapy due to hemoperitoneum and resultant surgical evacuation. 10 The patient's weight was 79.5 kg. Fondaparinux 7.5 mg subcutaneously daily was initiated on the first postoperative day and was overlapped with warfarin for at least 14 days.…”

“…8,9 Human data consist of four case reports of fondaparinux use in patients with mechanical valves. [10][11][12][13] Only two of these reports describe the early use of fondaparinux after valve replacement (within 3 mo), 12,13 and only one describes use in a patient with a history of HIT. 10 To date, there have been no reports of the use of fondaparinux within 24-48 hours after mechanical valve replacement as guidelines suggest for early postoperative bridging to prevent early thrombosis while awaiting a therapeutic international normalized ratio (INR).…”

Is there a role for fondaparinux in perioperative bridging?

“…23 The first case described a patient with a history of DVT and antithrombin III deficiency who received fondaparinux sodium 2.5 mg subcutaneously daily for four days before carpal tunnel surgery on cessation of phenprocoumon (not commercially available in the United States), a phytonadione antagonist. 21 The last fondaparinux dose was received the morning before surgery.…”