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Management of heparin-induced thrombocytopenia: systematic reviews and meta-analyses. Blood Adv 2021; 4:5184-5193. [PMID: 33095876 DOI: 10.1182/bloodadvances.2020002963] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/22/2020] [Indexed: 01/01/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic adverse drug reaction occurring in <0.1% to 7% of patients receiving heparin products depending on the patient population and type of heparin. Management of HIT is highly dependent on a sequence of tests for which clinicians may or may not have the results when care decisions need to be made. We conducted systematic reviews of the effects of management strategies in persons with acute HIT, subacute HIT A or B, and remote HIT. We searched Medline, EMBASE, and the Cochrane Database through July 2019 for previously published systematic reviews and primary studies. Two investigators independently screened and extracted data and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. We found primarily noncomparative studies and case series assessing effects of treatments, which led to low to very low certainty evidence. There may be little to no difference in the effects between nonheparin parenteral anticoagulants and direct oral anticoagulants in acute HIT. The benefits of therapeutic-intensity may be greater than prophylactic-intensity anticoagulation. Using inferior vena cava filters or platelet transfusion may result in greater harm than not using these approaches. Evidence for management in special situations, such as for patients undergoing cardiovascular interventions or renal replacement therapy, was also low to very low certainty. Additional research to evaluate nonheparin anticoagulants is urgently needed, and the development of novel treatments that reduce thrombosis without increasing hemorrhage should be a priority.
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GTH 2021 State of the Art-Cardiac Surgery: The Perioperative Management of Heparin-Induced Thrombocytopenia in Cardiac Surgery. Hamostaseologie 2021; 41:59-62. [PMID: 33588456 DOI: 10.1055/a-1336-6116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
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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Scala E, Gerschheimer C, Gomez FJ, Alberio L, Marcucci C. Potential and Limitations of the New P2Y12 Inhibitor, Cangrelor, in Preventing Heparin-Induced Platelet Aggregation During Cardiac Surgery: An In Vitro Study. Anesth Analg 2020; 131:622-630. [PMID: 32102014 DOI: 10.1213/ane.0000000000004700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) can put cardiac surgery patients at a high risk of lethal complications. If anti-PF4/heparin antibodies (anti-PF4/Hep Abs) are present, 2 strategies exist to prevent intraoperative aggregation during bypass surgery: first, using an alternative anticoagulant, and second, using heparin combined with an antiaggregant. The new P2Y12 inhibitor, cangrelor, could be an attractive candidate for the latter strategy; several authors have reported its successful use. The present in vitro study evaluated cangrelor's ability to inhibit heparin-induced platelet aggregation in the presence of anti-PF4/Hep Abs. METHODS Platelet-poor plasma (PPP) from 30 patients with functional anti-PF4/Hep Abs was mixed with platelet-rich plasma (PRP) from 5 healthy donors.Light transmission aggregometry was used to measure platelet aggregation after adding 0.5 IU·mL of heparin (HIT) to the plasma, and this was compared with samples spiked with normal saline (control) and samples spiked with cangrelor 500 ng·mL and heparin 0.5 IU·mL (treatment). Friedman test with post hoc Dunn-Bonferroni test was used for between-group comparisons. RESULTS Heparin 0.5 IU·mL triggered aggregation in 22 of 44 PPP-PRP mixtures, with a median aggregation of 86% (interquartile range [IQR], 69-91). The median aggregation of these 22 positive samples' respective control tests was 22% (IQR, 16-30) (P < .001). Median aggregation in the cangrelor-treated samples was 29% (IQR, 19-54) and significantly lower than the HIT samples (P < .001). Cangrelor inhibited heparin-induced aggregation by a median of 91% (IQR, 52-100). Cangrelor only reduced heparin-induced aggregation by >95% in 10 of the 22 positive samples (45%). Cangrelor inhibited heparin-induced aggregation by <50% in 5 of the 22 positive samples (22%) and by <10% in 3 samples (14%). CONCLUSIONS This in vitro study found that cangrelor was an unreliable inhibitor of heparin-induced aggregation in the presence of anti-PF4/Hep Abs. We conclude that cangrelor should not be used as a standard antiaggregant for cardiac patients affected by HIT during surgery. Unless cangrelor's efficacy in a particular patient has been confirmed in a presurgery aggregation test, other strategies should be chosen.
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Affiliation(s)
- Emmanuelle Scala
- From the Department of Anesthesiology.,Division of Hematology, Department of Oncology and Central Hematology Laboratory, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois [CHUV]) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Christiane Gerschheimer
- Division of Hematology, Department of Oncology and Central Hematology Laboratory, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois [CHUV]) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Francisco J Gomez
- Division of Hematology, Department of Oncology and Central Hematology Laboratory, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois [CHUV]) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology, Department of Oncology and Central Hematology Laboratory, Department of Laboratory Medicine and Pathology, Lausanne University Hospital (Centre Hospitalier Universitaire Vaudois [CHUV]) and University of Lausanne (UNIL), Lausanne, Switzerland
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Cuker A, Arepally GM, Chong BH, Cines DB, Greinacher A, Gruel Y, Linkins LA, Rodner SB, Selleng S, Warkentin TE, Wex A, Mustafa RA, Morgan RL, Santesso N. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv 2018; 2:3360-3392. [PMID: 30482768 PMCID: PMC6258919 DOI: 10.1182/bloodadvances.2018024489] [Citation(s) in RCA: 351] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/14/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction mediated by platelet-activating antibodies that target complexes of platelet factor 4 and heparin. Patients are at markedly increased risk of thromboembolism. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about diagnosis and management of HIT. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 33 recommendations. The recommendations address screening of asymptomatic patients for HIT, diagnosis and initial management of patients with suspected HIT, treatment of acute HIT, and special situations in patients with acute HIT or a history of HIT, including cardiovascular surgery, percutaneous cardiovascular intervention, renal replacement therapy, and venous thromboembolism prophylaxis. CONCLUSIONS Strong recommendations include use of the 4Ts score rather than a gestalt approach for estimating the pretest probability of HIT and avoidance of HIT laboratory testing and empiric treatment of HIT in patients with a low-probability 4Ts score. Conditional recommendations include the choice among non-heparin anticoagulants (argatroban, bivalirudin, danaparoid, fondaparinux, direct oral anticoagulants) for treatment of acute HIT.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Beng H Chong
- Department of Haematology, University of New South Wales, Sydney, NSW, Australia
| | - Douglas B Cines
- Department of Medicine and
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andreas Greinacher
- Institute of Immunology and Transfusion Medicine, University of Greifswald, Greifswald, Germany
| | - Yves Gruel
- Department of Haematology-Haemostasis, Trousseau Hospital, Tours, France
| | - Lori A Linkins
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Sixten Selleng
- Department of Anaesthesiology, University of Greifswald, Greifswald, Germany
| | - Theodore E Warkentin
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada; and
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The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines ∗ —Anticoagulation During Cardiopulmonary Bypass. Ann Thorac Surg 2018; 105:650-662. [DOI: 10.1016/j.athoracsur.2017.09.061] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/09/2017] [Indexed: 01/01/2023]
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Shore-Lesserson L, Baker RA, Ferraris VA, Greilich PE, Fitzgerald D, Roman P, Hammon JW. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology. Anesth Analg 2018; 126:413-424. [DOI: 10.1213/ane.0000000000002613] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Palatianos G, Michalis A, Alivizatos P, Lacoumenda S, Geroulanos S, Karabinis A, Iliopoulou E, Soufla G, Kanthou C, Khoury M, Sfyrakis P, Stavridis G, Astras G, Vassili M, Antzaka C, Marathias K, Kriaras I, Tasouli A, Papadopoulos K, Katafygioti M, Matoula N, Angelidis A, Melissari E. 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. Am J Hematol 2015; 90:608-17. [PMID: 25808486 DOI: 10.1002/ajh.24017] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 03/16/2015] [Accepted: 03/16/2015] [Indexed: 11/09/2022]
Abstract
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 three-point heparin-induced platelet aggregation assay (HIPAG). The screening identified 110 patients with HIT-reactive 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 HIT-negative 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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Affiliation(s)
- George Palatianos
- 3rd Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - Alkiviadis Michalis
- 2nd Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - Petros Alivizatos
- 1st Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | | | | | | | - Eugenia Iliopoulou
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
| | - Giannoula Soufla
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
| | - Chryso Kanthou
- Department of Oncology, School of Medicine; University of Sheffield; Sheffield United Kingdom
| | - Mazen Khoury
- 2nd Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - Petros Sfyrakis
- 1st Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - George Stavridis
- 1st Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - George Astras
- 3rd Department of Cardiothoracic Surgery; Onassis Cardiac Surgery Center; Athens Greece
| | - Maria Vassili
- Department of Anaesthesiology; Onassis Cardiac Surgery Center; Athens Greece
| | - Christina Antzaka
- Department of Anaesthesiology; Onassis Cardiac Surgery Center; Athens Greece
| | | | - Ioannis Kriaras
- Intensive Care Unit, Onassis Cardiac Surgery Center; Athens Greece
| | | | | | - Marina Katafygioti
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
| | - Nikoletta Matoula
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
| | - Antonios Angelidis
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
| | - Euthemia Melissari
- Department of Haematology/Blood Transfusion; Onassis Cardiac Surgery Center; Athens Greece
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Mishra PK, Chnaris A, Mohammed F, Luckraz H. A novel method for the management of patients with heparin-induced thrombocytopaenia during cardiac surgery: Figure 1. Interact Cardiovasc Thorac Surg 2014; 18:850-852. [DOI: 10.1093/icvts/ivu030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Patel PA, Lane B, Augoustides JGT. Progress in platelet blockers: the target is the P2Y12 receptor. J Cardiothorac Vasc Anesth 2013; 27:620-4. [PMID: 23672863 DOI: 10.1053/j.jvca.2013.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Indexed: 11/11/2022]
Abstract
The considerable progress in P2Y12-platelet blockers has important perioperative implications due to a family of novel agents beyond clopidogrel. Although prasugrel is more potent than clopidogrel due to more efficient hepatic metabolism, it is limited clinically by its irreversibility and bleeding risks. Ticagrelor, as the first approved direct and reversible oral P2Y12 blocker, still is limited clinically by its novel side-effect profile. Intravenous reversible P2Y12 blockade is possible now with both cangrelor and elinogrel, although both agents are still in clinical development. Furthermore, elinogrel offers the possibility of both oral and parenteral P2Y12 blockade with a single agent. Future trials likely will continue to evaluate and compare the safety and efficacy of these agents in multiple clinical settings, including the perioperative period.
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Affiliation(s)
- Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Darcin OT, Zor MH, Sahin V, Kara I, Bekmezci M, Sahsivar O. Effect of iloprost on renal function in patients undergoing coronary artery bypass grafting: a clinical study. Ann Thorac Cardiovasc Surg 2012; 19:12-7. [PMID: 22785552 DOI: 10.5761/atcs.oa.11.01827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Renal dysfunction remains a serious complication of coronary artery bypass grafting (CABG) surgery and is associated with increased mortality and morbidity. To date, a number of different strategies, including new pharmacologic agents, off-pump and cardiopulmonary bypass techniques have been used to avoid it, but none of them proves the excellent result. METHODS Between April 2009 to September 2011, 185 consecutive patients with multivessel coronary artery disease undergoing elective CABG were included the study. Iloprost was given with the onset of rewarming period at a dose of 1.25-2.5 ng/kg/min and it was ended together with the ending of CPB in 94 patients and remaining were in the control group. Creatinine clearance (CCr) and GFR were measured at the time of hospitalisation and on day first and fifth postoperatively. Serum potassium level was determined every 6 hours, during the first 24 hours postoperatively, and every 12 hours for the next 72 hours, and glomerular filtration rate was estimated. RESULTS There was no statistically significant difference in preoperative comorbidity. There were no significant differences in postoperative morbidity or mortality between either of the two groups that completed the study. However, urine output during the operation was significantly higher in the study group. An increase in creatine levels was more common in the control group. Development of a new CCr less than 50 ml/min was also significantly higher in the control group, postoperatively. CONCLUSION Our study demonstrates that prophylactic intravenous iloprost administration after initiation of a rewarming period during CPB in patients undergoing CABG surgery is associated with improved renal function, compared with conventional treatment in well-hydrated patients. It also has a good safety profile and is generally well tolerated.
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Affiliation(s)
- Osman Tansel Darcin
- Konya Education and Research Hospital, Clinic of Cardiovascular Surgery, Konya, Turkey.
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Sakr Y, Haetscher F, Gonsalves MD, Hoffman M, Theis B, Barz D, Reinhart K, Kortgen A. Heparin-induced thrombocytopenia type II in a surgical intensive care unit. J Crit Care 2012; 27:232-41. [DOI: 10.1016/j.jcrc.2011.06.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 06/19/2011] [Accepted: 06/26/2011] [Indexed: 11/26/2022]
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Bärthel E, Rauchfuss F, Hoyer H, Habrecht O, Jandt K, Götz M, Voigt R, Heise M, Marx G, Settmacher U. Impact of stable PGI₂ analog iloprost on early graft viability after liver transplantation: a pilot study. Clin Transplant 2011; 26:E38-47. [PMID: 21919966 DOI: 10.1111/j.1399-0012.2011.01516.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ischemia/reperfusion injury after liver transplantation (LT) may be associated with primary graft dysfunction (PDF) or non-function. Prostaglandins were demonstrated to be beneficial in reducing ischemic injury by improving microcirculation and protecting endothelial cells. The aim of this study was to analyze the effect of the continuously administered prostaglandin I(2) analog iloprost on allograft function after LT. METHODS Eighty patients were prospectively randomized and assigned to two groups. Patients in the treatment group received iloprost for seven d after transplantation, and those in the control group did not. The primary end point was graft dysfunction. RESULTS The incidence of PDF was 20% (n = 8) in the control group and 5% (n = 2) in the treatment group, respectively (p = 0.087). Four patients in the control group underwent re-transplantation for initial non-function (INF). There was no evidence for INF in the treatment group. Iloprost was associated with improved allograft function. Clinical course and outcome were comparable. CONCLUSIONS We suggest iloprost to be beneficial for early post-transplant liver function. If the rate of PDF can be significantly reduced with this treatment concept, it should be analyzed in a larger number of patients (ISRCTN95672167).
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Affiliation(s)
- Erik Bärthel
- Department of General, Visceral and Vascular Surgery, Friedrich-Schiller-University, Jena, Germany.
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Gates R, Yost P, Parker B. The Use of Bivalirudin for Cardiopulmonary Bypass Anticoagulation in Pediatric Heparin-Induced Thrombocytopenia Patients. Artif Organs 2010; 34:667-9. [DOI: 10.1111/j.1525-1594.2009.00961.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Kroupis C, Theodorou M, Kounavi M, Oliveira SC, Iliopoulou E, Mavri-Vavayanni M, Melissari EN, Degiannis D. Development of a real-time PCR detection method for a FCGR2A polymorphism in the LightCycler and application in the heparin-induced thrombocytopenia syndrome. Clin Biochem 2009; 42:1685-93. [PMID: 19664613 DOI: 10.1016/j.clinbiochem.2009.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2009] [Revised: 07/14/2009] [Accepted: 07/25/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The FcgammaRIIa receptor is responsible for the activation of platelets by antibodies in heparin-induced thrombocytopenia (HIT). The c.497G>A polymorphism in the corresponding FCG2RA gene (H131R) has been implicated in the HIT syndrome and we aimed at its rapid and reliable determination. DESIGN AND METHODS We designed a novel asymmetric real-time PCR method in the LightCycler that uses two hybridization probes and is followed by melting curve analysis. Seventy-one post-cardiac-surgery HIT Greek patients well ascertained by clinical data, immunological and functional tests (PAT, CD62P-selectin and microparticle flow cytometric detection) were studied, along with a clinically relevant group of 49 thrombocytopenic control patients and 119 healthy subjects. RESULTS The developed method has excellent analytical characteristics (linear and efficient amplification, precision), has wide DeltaT(m) between the two alleles H and R (11.53 degrees C), and is in 100% concordance with validated controls and another commonly used screening method. The RR percentage increased from 10% in the control populations to 24% in the HIT patient group. CONCLUSION The described method is technically simple, robust, fast, and accurate. A statistically significant difference was found in the comparison between the groups of HIT patients and healthy subjects [RR vs. RH+ HH, chi(2) test, p=0.01, OR (95% C.I.) 2.81 (1.21-4.68)]. The RR frequency in the Greek population was found to be the lowest among Caucasians.
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Affiliation(s)
- Christos Kroupis
- Department of Clinical Biochemistry, Attikon University Hospital, University of Athens Medical School, 1 Rimini Street, Haidari, Greece.
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Choi S, Brull R. Neuraxial Techniques in Obstetric and Non-Obstetric Patients with Common Bleeding Diatheses. Anesth Analg 2009; 109:648-60. [DOI: 10.1213/ane.0b013e3181ac13d1] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Levy JH, Tanaka KA, Hursting MJ. Reducing thrombotic complications in the perioperative setting: an update on heparin-induced thrombocytopenia. Anesth Analg 2007; 105:570-82. [PMID: 17717208 DOI: 10.1213/01.ane.0000277497.70701.47] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Heparins are widely used in the perioperative setting. Immune heparin-induced thrombocytopenia (HIT) is a serious, antibody-mediated complication of heparin therapy that occurs in approximately 0.5%-5% of patients treated with heparin for at least 5 days. An extremely prothrombotic disorder, HIT confers significant risks of thrombosis and devastating consequences on affected patients: approximately 38%-76% develop thrombosis, approximately 10% with thrombosis require limb amputation, and approximately 20%-30% die within a month. HIT antibodies are transient and typically disappear within 3 mo. In patients with lingering antibodies, however, re-exposure to heparin can be catastrophic. In the perioperative setting, heightened awareness is important for the prompt recognition, diagnosis, and treatment of HIT. HIT should be considered if the platelet count decreases 50% and/or thrombosis occurs 5-14 days after starting heparin, with other diagnoses excluded. On strong clinical suspicion of HIT, heparin should be discontinued and a parenteral alternative anticoagulant initiated, even before laboratory confirmation of HIT is obtained. Subsequent laboratory test results may help with the decision to continue with nonheparin therapy or switch back to heparin. Heparin avoidance in patients with current or previous HIT is feasible in most clinical situations, except perhaps in cardiovascular surgery. If the surgery cannot be delayed until HIT antibodies have disappeared, intraoperative alternative anticoagulation is recommended.
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Affiliation(s)
- Jerrold H Levy
- Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Dyke CM, Aldea G, Koster A, Smedira N, Avery E, Aronson S, Spiess BD, Lincoff AM. Off-Pump Coronary Artery Bypass With Bivalirudin for Patients With Heparin-Induced Thrombocytopenia or Antiplatelet Factor Four/Heparin Antibodies. Ann Thorac Surg 2007; 84:836-9. [PMID: 17720385 DOI: 10.1016/j.athoracsur.2007.04.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2006] [Revised: 03/29/2007] [Accepted: 04/02/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND This study assessed the use of bivalirudin as an alternative anticoagulant in patients with heparin-induced thrombocytopenia-thrombotic syndrome (HIT/TS) or antiplatelet factor four-heparin (anti-PF4/H) antibodies undergoing off-pump coronary artery bypass (OPCAB). METHODS In a prospective, open-label, multicenter study, fifty-one patients with documented anti-PF4/H antibodies and (or) HIT/TS underwent OPCAB with bivalirudin anticoagulation (0.75 mg/kg i.v. bolus, 1.75 mg/kg/hour infusion). Procedural success (absence of death, Q-wave myocardial infarction, repeat revascularization, and stroke), bleeding, and transfusion at day seven/discharge, thirty days, and twelve weeks were assessed. RESULTS Thirty-five patients (67%) were included with positive anti-PF4/H antibodies and no thrombocytopenia or thrombosis, eleven patients (22%) had thrombocytopenia, and five patients had clinical HIT/TS (10%). Procedural success at seven days/discharge was achieved in forty-seven patients (92%), while procedural success at thirty days and twelve weeks was 88%. There were no deaths. Chest tube output over the first twenty-four hours was 936 +/- 525 mL and twenty-five patients received a red blood cell transfusion during their hospitalization. Two patients required reexploration for persistent postoperative hemorrhage. CONCLUSIONS Bivalirudin was an effective alternative anticoagulant for patients with HIT/TS or circulating anti-PF4/H antibodies undergoing OPCAB, with high rates of procedural success and an acceptable incidence of bleeding or transfusions.
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Affiliation(s)
- Cornelius M Dyke
- Department of Cardiovascular and Thoracic Surgery, Gaston Memorial Hospital, Gastonia, North Carolina 28054, USA.
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Vasiliadis K, Pramateftakis MG, Blouhos K, Mantzoros I, Koliakos G, Zaraboukas T, Kanellos I, Demetriades H, Alamdari DH, Betsis D. Effect of iloprost on impaired anastomotic healing caused by 5-fluorouracil plus leucovorin. Dis Colon Rectum 2007; 50:899-907. [PMID: 17353975 DOI: 10.1007/s10350-006-0878-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This experimental study was designed to investigate whether iloprost can reverse impaired colonic healing caused by immediate postoperative intraperitoneal administration of 5-fluorouracil plus leucovorin. METHODS Eighty Wistar rats were randomized into four groups. After resection of a 1-cm segment of transverse colon, an end-to-end sutured anastomosis was generated. Rats received saline solution (Group 1), 5-fluorouracil plus leucovorin (Group 2), iloprost (Group 3), and 5-fluorouracil plus leucovorin plus iloprost (Group 4) intraperitoneally from the day of operation and once daily until killing. Each group was further randomized into two subgroups. Subjects were killed on the fifth (Subgroup a) and eighth (Subgroup b) postoperative days. After killing, anastomoses were examined macroscopically and graded histologically. Rats were measured for anastomotic bursting pressures and tissue hydroxyproline levels. RESULTS The leakage rate of the anastomoses was significantly higher in the 5-fluorouracil plus leucovorin group compared with the other groups (P = 0.049). Bursting pressure was significantly lower in 2a subgroup (5-fluorouracil plus leucovorin, postoperative Day 5) than in 4a (5-fluorouracil plus leucovorin plus iloprost, postoperative Day 5; P < 0.001). Adhesion formation was significantly higher in all b subgroups compared with the Control b subgroup. Neoangiogenesis was significantly higher in iloprost and iloprost plus 5-fluorouracil plus leucovorin subgroups compared with the 5-fluorouracil plus leucovorin subgroups. Hydroxyproline levels, collagen deposition, fibroblasts, and white cell count were significantly higher in the iloprost plus 5-fluorouracil plus leucovorin b subgroup (postoperative Day 8) compared with the 5-fluorouracil plus leucovorin b subgroup (postoperative Day 8). CONCLUSIONS The immediate postoperative, intraperitoneal administration of iloprost counteracts and reverses the negative effects of 5-fluorouracil plus leucovorin chemotherapy and protects colonic healing in rats.
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Affiliation(s)
- K Vasiliadis
- Fourth Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Koster A, Dyke CM, Aldea G, Smedira NG, McCarthy HL, Aronson S, Hetzer R, Avery E, Spiess B, Lincoff AM. Bivalirudin During Cardiopulmonary Bypass in Patients With Previous or Acute Heparin-Induced Thrombocytopenia and Heparin Antibodies: Results of the CHOOSE-ON Trial. Ann Thorac Surg 2007; 83:572-7. [PMID: 17257990 DOI: 10.1016/j.athoracsur.2006.09.038] [Citation(s) in RCA: 151] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Revised: 09/08/2006] [Accepted: 09/11/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND The coronary artery bypass grafting (CABG) heparin-induced thrombocytopenia thrombosis syndrome (HITTS) on- and off-pump safety and efficacy (CHOOSE-ON) trial was designed as a safety and efficacy trial of bivalirudin for use in anticoagulation during cardiopulmonary bypass (CPB) in patients with confirmed or suspected HIT and (or) antiplatelet factor 4/heparin (anti-PF4/H) antibodies. METHODS In an open-label, multicenter trial, 50 patients were enrolled prospectively. The primary study endpoint was in-hospital acute procedural success, defined as the absence of death, Q-wave myocardial infarction (MI), repeat operation for coronary revascularization, and stroke at day seven after surgery or hospital discharge, whichever occurred first. The secondary study endpoints were procedural success, defined as the absence of death, Q-wave MI, repeat operation for coronary revascularization, and stroke, at 30 days and 12 weeks after surgery. Perioperative blood loss, transfusions, and the incidence of major bleeding events were also captured. RESULTS There were 49 patients treated with bivalirudin of which 43 had acute HIT and thrombosis syndrome (HITTS) with antibodies at time of surgery. Procedural success in-hospital or at 7 days was achieved in 46 (94%) patients. At day 30 procedural success was achieved in 42 (86%) patients, and after 12 weeks in 40 (82%) patients. Mean intraoperative blood loss was 575 +/- 524 mL, and mean 24-hour postoperative blood loss was 998 +/- 595 mL. Forty-one (84%) patients received transfusions before day 7 or discharge with a mean of 5.6 +/- 3.8 units of red blood cells, 8.6 +/- 7.2 units of platelets, and 6.0 +/- 4.7 units of fresh frozen plasma. No differences in outcome among bivalirudin-treated patients were observed between those in the overall group and those with moderately impaired renal function (n = 10). CONCLUSIONS The current investigation expands the experience of safe and effective anticoagulation with bivalirudin during CPB to patients with confirmed or suspected HIT and anti-PF4/H antibodies, including in the setting of impaired renal function.
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Affiliation(s)
- Andreas Koster
- Department of Anesthesia, Deutsches Herzzentrum Berlin, Germany.
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Successful use of bivalirudin for cardiac transplantation in a child with heparin-induced thrombocytopenia. J Heart Lung Transplant 2006; 25:1376-9. [PMID: 17097505 DOI: 10.1016/j.healun.2006.08.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Revised: 06/22/2006] [Accepted: 08/20/2006] [Indexed: 01/19/2023] Open
Abstract
Bivalirudin, a direct thrombin inhibitor, has recently emerged as a promising option for anti-coagulation during cardiopulmonary bypass in patients who cannot receive heparin. There is limited experience with the use of bivalirudin in children. We present the case of a child with heparin-induced thrombocytopenia with thrombosis (HIT Type II) who underwent successful orthotopic cardiac transplantation using bivalirudin as the primary anti-coagulant for cardiopulmonary bypass.
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Abstract
Abstract
The diagnosis and management of thrombocytopenia is a growing component in the practice of hematology. The frequency with which hematologists are called in consultation for thrombocytopenia continues to increase with the advent of routine automated platelet determinations and the introduction of new medications. For most patients, such as those with inherited and auto-immune thrombocytopenia, emphasis is focused on efforts to treat or forestall bleeding without excess drug-induced toxicity or burden to the patient. However, in disorders such as heparin-induced thrombocytopenia (HIT), avoidance of thrombotic complications is the key to management. In this chapter, we provide the pediatric and adult hematologist with new insights into the pathogenesis and recognition of congenital inherited thrombocytopenias (CTP), a hitherto difficult to comprehend constellation of clinical entities. We also highlight new approaches to the diagnosis and treatment of two of the more common thrombocytopenic conditions encountered in practice, autoimmune or idiopathic thrombocytopenic purpura (ITP) and HIT.
In Section I, Dr. James Bussel discusses CTPs and their distinction from childhood ITP. He emphasizes the clinical features that enable the pediatrician and hematologist to suspect the diagnosis of CTP and those that are of use to subcategorize the various entities, where possible. He also emphasizes newer molecular markers that afford definitive diagnosis in some cases and provide insight into platelet production. This section highlights the characteristic associated findings and differences in the natural history and approaches to management of the various entities.
In Section II, Dr. Robert McMillan discusses adult chronic ITP. He revisits the utility of platelet antibody determination in diagnosis and review new insights into pathogenesis. The role of Helicobacter pylori infection and the timing of splenectomy in the management of acute and emergent ITP are examined. New insights into the natural history of ITP post-splenectomy and management strategies for patients with severe, chronic, refractory ITP are discussed.
In Section III, Dr. James Zehnder updates us on HIT. He emphasizes new insights into the clinical presentation and pathogenesis of this condition. He critically reviews the utility of laboratory testing for heparin-dependent antibodies. Recent studies on the use of direct thrombin inhibitors are examined and the management of cardiopulmonary bypass surgery in patients with HIT is discussed.
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MESH Headings
- Adult
- Child
- Child, Preschool
- Helicobacter Infections/drug therapy
- Helicobacter Infections/etiology
- Helicobacter pylori
- Humans
- Infant
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Purpura, Thrombocytopenic, Idiopathic/microbiology
- Purpura, Thrombocytopenic, Idiopathic/surgery
- Splenectomy
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