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Abstract
A newly created antibody to the active site of Factor XIIa protects against clotting of extracorporeal bypass circuitry without bleeding risk in vivo, obviating the need for heparin (Larsson et al., this issue).
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Affiliation(s)
- Alvin H Schmaier
- Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH 44106, USA
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2
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Makris M, Van Veen JJ, Tait CR, Mumford AD, Laffan M. Guideline on the management of bleeding in patients on antithrombotic agents. Br J Haematol 2012; 160:35-46. [PMID: 23116425 DOI: 10.1111/bjh.12107] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Mike Makris
- Department of Cardiovascular Science, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK.
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3
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Anticoagulant therapy during cardiopulmonary bypass. J Thromb Thrombolysis 2008; 26:218-28. [DOI: 10.1007/s11239-008-0280-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Accepted: 09/19/2008] [Indexed: 10/21/2022]
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4
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Bauer C, Vichova Z, Ffrench P, Hercule C, Jegaden O, Bastien O, Lehot JJ. Extracorporeal membrane oxygenation with danaparoid sodium after massive pulmonary embolism. Anesth Analg 2008; 106:1101-3, table of contents. [PMID: 18349178 DOI: 10.1213/ane.0b013e31816794d9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
During extracorporeal membrane oxygenation, anticoagulation therapy is usually achieved with unfractionated heparin. We report on an extracorporeal membrane oxygenation with danaparoid sodium for a patient with severe respiratory failure due to massive pulmonary embolism and suspected type 2 heparin-induced thrombocytopenia. Danaparoid, a low molecular weight heparinoid, is an alternative to heparin for patients who develop type 2 heparin-induced thrombocytopenia. Danaparoid was given at 400 IU/h with an objective of antifactor Xa activity of 0.6-0.8 U/mL, which was monitored twice a day. No excessive bleeding or clotting of the circuit was noted. The patient was weaned from extracorporeal membrane oxygenation after 9 days of treatment.
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5
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Chong BH, Magnani HN. Danaparoid for the Treatment of Heparin-Induced?Thrombocytopenia. HEPARIN-INDUCED THROMBOCYTOPENIA 2007. [DOI: 10.3109/9781420045093.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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6
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Murphy GS, Marymont JH. Alternative Anticoagulation Management Strategies for the Patient With Heparin-Induced Thrombocytopenia Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2007; 21:113-26. [PMID: 17289495 DOI: 10.1053/j.jvca.2006.08.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Glenn S Murphy
- Department of Anesthesiology, Evanston Northwestern Healthcare, Northwestern University Feinberg School of Medicine, Evanston, IL 60201, USA.
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7
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Riess FC. Anticoagulation management and cardiac surgery in patients with heparin-induced thrombocytopenia. Semin Thorac Cardiovasc Surg 2005; 17:85-96. [PMID: 16104366 DOI: 10.1053/j.semtcvs.2004.12.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Unfractionated heparin (UFH) is the gold standard for anticoagulation during cardiopulmonary bypass (CPB). Of patients undergoing CPB operations, 25% to 50% develop heparin-dependent antibodies during the postoperative period, typically between day 5 and 10, if UFH is continued during the postoperative course. In 1% to 3% of all patients undergoing CPB operation with UFH anticoagulation, these antibodies activate platelets causing a prothrombotic disorder, known as heparin-induced thrombocytopenia (HIT), which can lead to life-threatening thromboembolic complications. If urgent cardiac operation with the use of CPB in patients with positive antibody titer is required, different anticoagulatory approaches are available, such as lepirudin, bivalirudin, and danaparoid or UFH in combination with platelet antagonists, such as epoprostenol or tirofiban. In patients with previous HIT but no detectable antibodies, UFH alone can be used only during CPB, but alternative anticoagulation has to be used pre- and postoperatively.
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8
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Affiliation(s)
- Mark E Comunale
- Department of Anesthesia and Critical Care, St. Louis University, MO 63110-0250, USA
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9
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Abstract
Unfractionated heparin given during cardiopulmonary bypass is remarkably immunogenic, as 25% to 50% of postcardiac surgery patients develop heparin-dependent antibodies during the next 5 to 10 days. Sometimes, these antibodies strongly activate platelets and coagulation, thereby causing the prothrombotic disorder, heparin-induced thrombocytopenia. The risk of heparin-induced thrombocytopenia is 1% to 3% if unfractionated heparin is continued beyond the first postoperative week. When cardiac surgery is urgently needed for a patient with acute or subacute heparin-induced thrombocytopenia, options include an alternative anticoagulant (bivalirudin, lepirudin, or danaparoid) or combining unfractionated heparin with a platelet antagonist (epoprostenol or tirofiban). As heparin-induced thrombocytopenia antibodies are transient, unfractionated heparin alone is appropriate in a patient with previous heparin-induced thrombocytopenia whose antibodies have disappeared.
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10
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Abstract
Unfractionated heparin given during cardiopulmonary bypass is remarkably immunogenic, as 25% to 50% of postcardiac surgery patients develop heparin-dependent antibodies during the next 5 to 10 days. Sometimes, these antibodies strongly activate platelets and coagulation, thereby causing the prothrombotic disorder, heparin-induced thrombocytopenia. The risk of heparin-induced thrombocytopenia is 1% to 3% if unfractionated heparin is continued throughout the postoperative period. When cardiac surgery is urgently needed for a patient with acute or subacute heparin-induced thrombocytopenia, options include an alternative anticoagulant (bivalirudin, lepirudin, or danaparoid) or combining unfractionated heparin with a platelet antagonist (epoprostenol or tirofiban). As heparin-induced thrombocytopenia antibodies are transient, unfractionated heparin alone is appropriate in a patient with previous heparin-induced thrombocytopenia whose antibodies have disappeared.
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.
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11
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Affiliation(s)
- Richard M Green
- Division of Vascular Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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12
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Dworschak M, Hiesmayr JM, Lassnigg A. Lifesaving citrate anticoagulation to bridge ineffective danaparoid [correction of to bridge to danaparoid] treatment. Ann Thorac Surg 2002; 73:1626-7. [PMID: 12022563 DOI: 10.1016/s0003-4975(01)03438-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A case of successful regional anticoagulation with trisodium citrate in a patient who developed heparin-induced thrombocytopenia while on continuous hemofiltration is described. Immediate citrate anticoagulation allowed for maintenance of extracorporeal circulation until effective danaparoid therapy could be established. Recommended plasma antifactor Xa levels for hemodialysis may be inadequate in some cases. Values similar to those in use during cardiopulmonary bypass could be required.
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Affiliation(s)
- Martin Dworschak
- Department of Cardiothoracic Anesthesia and Intensive Care, University Hospital Vienna, Austria.
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13
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Fedullo PF, Auger WR, Channick RN, Kerr KM, Rubin LJ. Chronic thromboembolic pulmonary hypertension. Clin Chest Med 2001; 22:561-81. [PMID: 11590849 DOI: 10.1016/s0272-5231(05)70292-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Remarkable advances have occurred over the past 2 decades in the diagnostic approach, surgical management, and postoperative care of patients afflicted with chronic thromboembolic pulmonary hypertension. Despite these advances, a great deal needs to be achieved if the morbidity and mortality of the disease process are to be reduced further. First, the preliminary insights that have been achieved into the natural history of the disease must be defined further. The level of pulmonary hypertension encountered in most patients with chronic thromboembolic pulmonary hypertension at the time of initial clinical recognition cannot be reached on an acute basis. Gradual hemodynamic progression, therefore, must occur over time. The basis for this progression, why it occurs in certain patients and not others, following an acute thromboembolic event and why it seems to occur over months in certain patients and over decades in others, remain entirely speculative. It is possible that the overall extent of central pulmonary vascular obstruction represents the primary pathophysiologic determinant of disease progression. Given the lack of correlation between the degree of central thromboembolic obstruction and hemodynamic impairment in certain patients, however, it is also possible that other factors, such as the circulating vasoconstrictors, the development of a hypertensive pulmonary arteriopathy, an individual genetic predisposition to pulmonary hypertension, or the compensatory adaptations of the right ventricle, contribute to the extent and rate of disease progression. By identifying and sequentially evaluating patients with persistent pulmonary vascular obstruction or pulmonary hypertension following an acute thromboembolic event, valuable insights into the natural history of thromboembolic pulmonary hypertension and other variants of pulmonary hypertension might be achieved. It is also important to recognize that the development of chronic thromboembolic pulmonary hypertension represents a failure in the long-term management or follow-up surveillance of those with documented acute thromboembolic disease. Recent insights into the recurrent nature of acute thromboembolic disease and its potential for only partial resolution in a number of afflicted individuals suggest that a repeat perfusion scan and, if abnormal, an echocardiogram be performed at the time of anticipated discontinuation of anticoagulation in patients with documented pulmonary embolic disease. Although the cost-effectiveness of this approach has been questioned in the past, recent data suggest that doing so would help identify that subset of patients with unresolved embolism, provide additional information regarding the optimal duration of anticoagulation, and provide a new baseline study for patients in whom anticoagulation is discontinued and who subsequently present with suspected embolic recurrence. Improved diagnostic techniques are also necessary if the mortal risk of thromboendarterectomy is to be reduced. Even in the setting of a broad experiential base, prognostic uncertainty exists in approximately 10% of patients before operative intervention. Because many of these patients will benefit from the procedure, and because many are ineligible for transplantation for reason of age or other restriction, it has been the authors' practice to offer surgery to these patients, although at an assumed higher risk. To not do so would be to deny a potentially lifesaving procedure to many who would benefit and who might be left without an effective therapeutic alternative. The ability to better define the group of patients who will not benefit from surgery, however, would spare those patients the morbid and mortal risks of the procedure and provide a basis for the investigation of other therapeutic alternatives such as pulmonary vasodilating agents. Finally, this patient population offers a unique opportunity to enhance understanding of the pathophysiologic mechanisms involved in acute lung injury. The population involved is uniform, the predisposing event is consistent, the time of onset is predictable, and, compared with other populations at risk for acute lung injury, the presence of confounding variables is negligible. It also provides a unique opportunity to evaluate pharmacologic interventions designed to prevent or diminish the occurrence of acute lung injury and postoperative management strategies designed to minimize its impact.
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Affiliation(s)
- P F Fedullo
- Division of Pulmonary and Critical Care, University of California, San Diego Medical Center, San Diego, California, USA.
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14
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McCrae KR, Bussel JB, Mannucci PM, Remuzzi G, Cines DB. Platelets: an update on diagnosis and management of thrombocytopenic disorders. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2001; 2001:282-305. [PMID: 11722989 DOI: 10.1182/asheducation-2001.1.282] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Thrombocytopenia in the pregnant patient may result from a number of causes, most of which involve either immune-mediated platelet destruction or platelet consumption. Many of these disorders share clinical and laboratory features, making accurate diagnosis difficult. Moreover, uterine evacuation is indicated in the therapy of some disorders, while in others alternative interventions may allow the pregnancy to be carried to term. These and other issues are discussed as part of a comprehensive review of the differential diagnosis and management of thrombocytopenia in pregnancy. The term "refractory ITP" is used with reference to two distinct groups of patients: 1) patients in whom the platelet count cannot be easily increased, including those who are poorly responsive to initial single agent treatment, and 2) those with persistent thrombocytopenia despite the use of conventional therapies. An approach to management of the former group will be presented, followed by a discussion of patients with chronic refractory ITP. The latter will include presentation of new data on the role of Helicobacter pylori in ITP and whether its treatment ameliorates thrombocytopenia, as well as the use of rituximab and other modalities. Thrombotic microangiopathies such as thrombotic thrombocytopenic purpura (TTP) are rare, but life threatening causes of thrombocytopenia. Ultra-large multimers of von Willebrand factor (vWF) aggregate platelets intravascularly, and congenital or immune-mediated deficiencies of a metalloprotease that cleaves these ultra-large multimers may cause TTP. However, little information exists concerning the behavior of this protease in other physiological and pathological conditions. Levels of this protease have now been measured in healthy individuals of different ages, full-term newborns, pregnant women and a patients with variety of pathologic conditions, and these data will be reviewed herein. Heparin-induced thrombocytopenia/thrombosis (HIT/T) remains the most common antibody-mediated, drug-induced thrombocytopenic disorder, and a leading cause of morbidity and mortality. Based on clinical correlations and murine models, there is increasing evidence that antibodies to complexes between platelet factor 4 (PF4) and heparin cause HIT/T, and the molecular composition of the relevant antigen has also become better defined. However, the introduction of sensitive ELISAs to measure anti-PF4/heparin antibodies has complicated diagnosis in some settings in which the incidence of such antibodies in unaffected patients exceeds the incidence of the disease. In addition, the FDA approval of Lepirudin and Argatroban has expanded the repertoire of agents available for therapy of HIT/T and may change the approach to management of asymptomatic patients with thrombocytopenia. However, the optimal use of these drugs in commonly encountered settings remains in evolution, and a need for alternative approaches to prevention and treatment is evident.
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Affiliation(s)
- K R McCrae
- Department of Hematology/Oncology, Case Western Reserve University, School of Medicine, Cleveland, OH 44107-4937, USA
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15
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Abstract
Seven anticoagulants besides unfractionated heparin have been used for human cardiopulmonary bypass (CPB), mainly in patients with heparin-induced thrombocytopenia. The collective experience with these alternative anticoagulants provides a perspective on current efforts aimed at improving CPB anticoagulation. Unfortunately, each alternative currently lacks a standard dosing schedule and a reliable method of monitoring the adequacy of its anticoagulant effect during CPB. Most also lack proven antidotes. Thus, unfractionated heparin remains the anticoagulant of choice for standard CPB.
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Affiliation(s)
- J W Frederiksen
- Department of Surgery, Northwestern University Medical School, Chicago, Illinois 60611, USA.
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16
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Pamboukian SV, Ignaszewski AP, Ross HJ. Management strategies for heparin-induced thrombocytopenia in heart-transplant candidates: case report and review of the literature. J Heart Lung Transplant 2000; 19:810-4. [PMID: 10967277 DOI: 10.1016/s1053-2498(00)00133-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Management of anticoagulation in patients with heparin-induced thrombocytopenia (HIT) undergoing surgery requiring cardiopulmonary bypass (CPB), such as cardiac transplantation, represents a difficult clinical problem and no clear management strategy exists. The cases of 2 patients with HIT who underwent cardiac transplantation using differing anticoagulation strategies are presented with a discussion of potential advantages and pitfalls of each approach used.
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Affiliation(s)
- S V Pamboukian
- Cardiac Transplant and Heart Failure fellow,a Rush Presbyterian St. Luke's Medical Center, Chicago, Illinois, USA
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17
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Morewood GH. Uncomplicated heparinization for cardiopulmonary bypass in a patient with antiheparin antibodies. J Cardiothorac Vasc Anesth 2000. [DOI: 10.1053/cr.2000.5845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Davies RR, Coady MA, Hammond GL, Elefteriades JA, Gusberg RJ. Low Molecular Weight Heparin: An Evaluation of Current and Potential Clinical Utility in Surgery. Int J Angiol 1999; 8:203-215. [PMID: 10559462 DOI: 10.1007/bf01616318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Heparin, a mixture of glycosaminoglycans of various sizes, is a potent natural anticoagulant. Low molecular weight heparins (LMWH) contain only the polymers of smaller size, which appear to possess most of the antithrombotic potential. Pharmacological differences between the two suggest a number of advantages with LMWH therapy. Our objective was to establish the utility of LMWHs in comparison to the current practice of anticoagulation in surgical patients. Articles were obtained through MEDLINE and CURRENT CONTENTS queries. The searches were limited to English and French-language articles and included published overviews containing relevant individual trials. We examined the current literature, consisting of 1,730 published reports from 1979-1998, regarding the biochemistry, pharmacology, physiology, and clinical applications of LMWH in comparison with current therapy. Studies were selected based on their relevance to LMWHs, the size and methods of trials, and their application to clinical care. Peer-reviewed published data were critically evaluated by independent extraction by several authors. Established rules for levels of evidence were used to objectively evaluate the strength of evidence supporting recommendations in each clinical area. LMWHs provide superior anticoagulation in the prophylaxis of DVT following orthopedic, general, and trauma surgery. Further studies should establish which other patients may benefit from such prophylaxis. Current evidence does not support the use of LMWHs in patients with mechanical heart valves or those on mechanical cardiac support devices; however, it may have a role in the maintenance of vascular graft patency. Further studies should examine the role of LMWHs in transplant atherosclerosis, and in patients requiring long-term anticoagulation at high risk for bleeding with warfarin therapy. The economic implications of LMWH administration remain unclear. On the basis of the information presented in this review, LMWHs are promising new agents in prophylaxis and treatment of both arterial and venous thrombosis. In the near future, LMWHs are likely to supplant UFH and perhaps warfarin in many applications.http://link.springer-ny.com/link/service/journals/00547/bibs/8n4p203.html</hea
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Affiliation(s)
- RR Davies
- Department of Surgery, Sections of Vascular and Cardiothoracic Surgery, Yale University School of Medicine
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