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Meshulami N, Murthy R, Meyer M, Meyer AD, Kaushik S. Bivalirudin anticoagulation for cardiopulmonary bypass during cardiac surgery. Perfusion 2023:2676591231221708. [PMID: 38084653 DOI: 10.1177/02676591231221708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Heparin is the primary anticoagulant for cardiopulmonary bypass (CPB) support during cardiac surgery. While widely used, ∼2% of cardiac surgery patients develop heparin-induced thrombocytopenia (HIT) and 4-26% develop heparin resistance. Bivalirudin is an alternative anticoagulant mainly used for percutaneous coronary interventions. Given the challenges associated with heparin anticoagulation, we conducted a review to explore the use of bivalirudin for CPB surgery. METHODS PubMed and Embase scoping review included 2 randomized controlled trials, a retrospective comparison study, 3 pilot studies, and 30 case reports. To provide a contemporary series, we searched for articles published from 2010 to 2023. Our review included studies from both adult and pediatric populations. RESULTS While data is limited, bivalirudin seems to supply similar effectiveness and safety as heparin for CPB anticoagulation. Across the three comparative studies, the heparin cohorts had a 0-9% mortality rate and 0-27% rate of major bleeding/reoperation compared to a 0-3% mortality and 0-6% major bleeding/reoperation rate for the bivalirudin cohorts. Bivalirudin was successfully used as an anticoagulant in a wide range of CPB surgeries (e.g., heart transplants, ventricular assisted device placements, and valve repairs). Successful patient outcomes were reported with bivalirudin infusion of ∼2 mg/kg/hour, activated clotting time monitoring (target >400 s or 2.5× baseline), use of cardiotomy suctions, minimization of stagnant blood, and post-bypass modified ultrafiltration. CONCLUSION Bivalirudin is a safe and effective anticoagulant for CPB, especially for patients with HIT or heparin resistance. Further comparative research is called for to optimize bivalirudin utilization for CPB during cardiac surgery.
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Affiliation(s)
- Noy Meshulami
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raghav Murthy
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Pediatric Cardiac Surgery, Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maisy Meyer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew D Meyer
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Shubhi Kaushik
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Pediatric Critical Care, Department of Pediatrics, Kravis Children's Hospital at Mount Sinai, Icahn School of Medicine, New York, NY, USA
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2
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Pong T, Cyr K, Aparicio-Valenzuela J, Carlton C, Lee AM. A Modified 4Ts Score for Heparin-Induced Thrombocytopenia in the Mechanical Circulatory Support Population. J Cardiothorac Vasc Anesth 2023; 37:2499-2507. [PMID: 37407329 DOI: 10.1053/j.jvca.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE To identify risk factors and develop a pretest scoring system to differentiate patients with heparin-induced thrombocytopenia (HIT) in the mechanical circulatory support (MCS) population. The authors present a modified "4TMCS" scoring system, which considers the "type of mechanical circulatory support" that may help identify patients at risk for developing postoperative HIT. DESIGN A retrospective cohort study. Patients who underwent cardiac surgery were categorized into 3 groups: (1) normal platelet count, (2) thrombocytopenia with a negative HIT test, and (3) thrombocytopenia with a positive HIT test. A comparison of diagnostic accuracy between the 4Ts and 4TMCS probability scores was performed. SETTING At a single adult tertiary-care center. PARTICIPANTS A total of 5,314 patients who underwent cardiac surgery between May 1, 2008 and December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 125 out of 5,314 patients (2.4%) were diagnosed with HIT, of whom 75 out of 5,314 (1.4%) had clinical evidence of thrombosis. Overall, in-hospital mortality was 25.6%, 11.7%, and 1.5% in the HIT(+), HIT(-), and control groups, respectively (p < 0.001). Mechanical circulatory support was associated with a significantly increased risk for HIT, with an incidence of 5.9% in patients receiving MCS versus 1.9% in those without (p < 0.001). Area under the receiver operator curve (AUC) analysis demonstrated improved diagnostic accuracy of the 4TMCS score compared with the 4Ts (AUC = 0.83 v 0.77, p < 0.044). The 4TMCS score had higher sensitivity than the 4Ts, using the guideline-recommended score cutoff of ≥4 (95.2% v 85.7%). CONCLUSION Heparin-induced thrombocytopenia is associated with worse outcomes and increased morbidity and mortality in the MCS population. Awareness of patient risk factors and the application of a modified 4TMCS probability score may allow for more accurate screening and treatment of HIT in the MCS population.
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Affiliation(s)
- Terrence Pong
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Kevin Cyr
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Joy Aparicio-Valenzuela
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Cody Carlton
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Anson M Lee
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA.
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Pishko A, Cuker A. Early-onset heparin-induced thrombocytopenia after cardiac surgery: Should we lose sleep? J Thromb Haemost 2022; 20:2491-2493. [PMID: 36271465 DOI: 10.1111/jth.15840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Allyson Pishko
- Division of Hematology & Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam Cuker
- Division of Hematology & Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Draxler DF, Brodard J, Zante B, Jakob SM, Wiegand J, Kremer Hovinga JA, Angelillo-Scherrer A, Rovo A. The potential impact of Covid-19 on the capacity of routine laboratory tests to detect heparin-induced thrombocytopenia. Thromb J 2022; 20:55. [PMID: 36163073 PMCID: PMC9510722 DOI: 10.1186/s12959-022-00411-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/04/2022] [Indexed: 11/24/2022] Open
Abstract
In Covid-19, anticoagulation with heparin is often administered to prevent or treat thromboembolic events. Heparin-induced thrombocytopenia (HIT) is a severe complication of heparin treatment, caused by heparin-dependent, platelet activating anti-platelet factor 4 (PF4)/heparin antibodies. Diagnosis of HIT is based on the combination of clinical parameters, allowing to determine the pretest probability, and laboratory testing for anti-PF4/heparin antibodies and confirmatory functional assays, such as the heparin-induced platelet activation (HIPA) test. We report the case of a patient with severe Covid-19 pneumonia requiring ECMO treatment, who developed recurrent clotting of the ECMO filter and a drop in platelet count under heparin treatment. He was therefore suspected to have HIT and the anticoagulation was switched to argatroban. Despite high clinical probability and high titres of anti-PF4/heparin antibodies, the functional HIPA test was negative. Nevertheless, argatroban was continued rather than to reinstate anticoagulation with heparin. Reevaluation 7 days later then demonstrated a strongly positive functional HIPA test and confirmed the diagnosis of HIT. Under anticoagulation with argatroban the patient gradually improved and was finally weaned off the ECMO. In conclusion, this case highlights the critical importance of clinical judgement, exploiting the 4 T score, given that Covid-19 patients may present a different pattern of routine laboratory test results in HIT diagnostics. The possibility of a false negative HIPA test has to be considered, particularly in early phases of presentation. In cases of a discrepancy with high clinical probability of HIT and/or high titre anti-PF4/heparin antibodies despite a negative HIPA test, a reevaluation within 3 to 5 days after the initial test should be considered in order to avoid precipitant reestablishment of unfractionated heparin, with potentially fatal consequences.
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Affiliation(s)
- Dominik F Draxler
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Bern Center for Precision Medicine, Bern, Switzerland.
| | - Justine Brodard
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Björn Zante
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Wiegand
- Department of Intensive Care Medicine, Lindenhofspital, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Bern Center for Precision Medicine, Bern, Switzerland
| | - Alicia Rovo
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Lee JH, Park JH, Jang JH, Kim SH, Hong SY, Heo W, Lee DH, Choi HS, Kim KH, Jang HJ. The role of nafamostat mesilate as a regional anticoagulant during extracorporeal membrane oxygenation. Acute Crit Care 2022; 37:177-184. [PMID: 35545240 PMCID: PMC9184977 DOI: 10.4266/acc.2021.01312] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022] Open
Abstract
Background Anticoagulation during extracorporeal membrane oxygenation (ECMO) usually is required to prevent thrombosis. The aim of this study was to investigate the usefulness of nafamostat mesilate (NM) as a regional anticoagulant during veno-arterial ECMO (VA-ECMO) treatment. Methods We retrospectively reviewed the medical records of 16 patients receiving VA-ECMO and NM from January 2017 to June 2020 at Haeundae Paik Hospital. We compared clinical and laboratory data, including activated partial thromboplastin time (aPTT), which was measured simultaneously in patients and the ECMO site, to estimate the efficacy of regional anticoagulation. Results The median patient age was 68.5 years, and 56.3% of patients were men. Cardiovascular disease was the most common primary disease (75.0%) requiring ECMO treatment, followed by respiratory disease (12.5%). The median duration of ECMO treatment was 7.5 days. Among 16 patients, seven were switched to NM after first using heparin as an anticoagulation agent, and nine received only NM. When comparing aPTT values in the NM group between patients and the ECMO site, that in patients was significantly lower than that at the ECMO site (73.57 vs. 79.25 seconds; P=0.010); in contrast, no difference was observed in the heparin group. Conclusions NM showed efficacy as a regional anticoagulation method by sustaining a lower aPTT value compared to that measured at the ECMO site. NM should be considered as a safer regional anticoagulation method in VA-ECMO for patients at high risk of bleeding.
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Keles E, Bilen C, Aygun H, Gencpinar T, Catalyurek H. Non-heparin-induced thrombocytopenia in patients after open-heart surgery. Perfusion 2022; 38:781-790. [PMID: 35377248 DOI: 10.1177/02676591221082496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Thrombocytopenia (platelet count below 150 x 103/μL) is a common finding after open-heart surgery and can lead to various complications, including patient death. This study aimed to determine the extent of non-heparin-induced thrombocytopenia in open-heart surgery and to highlight the associated factors. MATERIALS AND METHODS In this cohort study, 842 patients who underwent valve and/or coronary bypass surgery over a 5-year period were retrospectively analyzed. After open-heart surgery, patients whose platelet count was less than 150 x 103/μL on a complete blood count 12 and 24 h after surgery were classified as thrombocytopenic. Three hundred twenty patients without thrombocytopenia and 21 patients with a high probability of heparin-induced thrombocytopenia were excluded from the study. Logistic regression analysis was used to assess the association of independent variables in moderate-severe thrombocytopenia: Age groups, sex, underlying disease, symptoms, type of surgery, pump time, pulsatile or non-pulsatile duration, degree of hypothermia, hemodilution, oxygenator type, use of an intra-aortic balloon, and erythrocyte transfusion counts were included in the analysis. RESULTS A total of 501 patients were diagnosed as having non-heparin-induced thrombocytopenia, and 64.3% were male. Three hundred seventy-seven (75.2%) patients had mild thrombocytopenia and 124 (24.7%) had moderate-severe thrombocytopenia. The postoperative platelet count was significantly lower than the preoperative platelet count (213 x 103 vs.117 x 103/μL; p < 0.001). Moderate-severe thrombocytopenia was associated with age ≥80 years odds (OR = 9.026, 95% CI: [1.757-46.363]; p = 0.008), isolated valve surgery (OR = 3.090, 95% CI: [1.867-5.114]; p < 0.001), and valve surgery with coronary bypass (OR = 4.938, 95% CI: [1.638-14.889]; p = 0.005) compared to isolated coronary bypass, type of oxygenator (Nipro vital compared with Affinity OR = 11.097, 95% CI: [1.923-64.023]; p = 0.007), erythrocyte transfusion count (OR = 1.219, 95%CI: [1.046-1.420]; p = 0.011). CONCLUSION Age 80 years or older, surgical procedures including heart-valve surgery, and the number of red blood cell transfusions are associated with the risk of moderate-to-severe thrombocytopenia. This study provides a guide in terms of risk factors that may lead to moderate-to-severe thrombocytopenia after open-heart surgery. However, future multicentre prospective randomized studies may provide more detailed information on this subject.
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Affiliation(s)
- Ercan Keles
- Bakırcay University Cigli Training and Research Hospital, Izmir, Turkey
| | - Cagatay Bilen
- Health Sciences University Dr Behcet Uz Training and Research Hospital, Izmir, Turkey
| | - Hakan Aygun
- Bakırcay University Cigli Training and Research Hospital, Izmir, Turkey
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Antibodies against Platelet Factor 4 and Their Associated Pathologies: From HIT/HITT to Spontaneous HIT-Like Syndrome, to COVID-19, to VITT/TTS. Antibodies (Basel) 2022; 11:antib11010007. [PMID: 35225866 PMCID: PMC8883896 DOI: 10.3390/antib11010007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/20/2021] [Accepted: 01/19/2022] [Indexed: 02/06/2023] Open
Abstract
Antibodies against platelet factor 4 (PF4), a protein released from alpha-granules of activated platelets, may cause a number of pathophysiological conditions. The most commonly known is heparin-induced thrombocytopenia (HIT), which develops in a small proportion of people treated with the anticoagulant drug heparin. Notably, PF4 binds with high affinity to heparin, and in HIT, complexes of PF4/H may, in a small proportion of susceptible patients, trigger the development of anti-PF4 antibodies and subsequent platelet activation and aggregation, ultimately leading to the development of pathological thrombosis at sites of vessel occlusion. Of more modern interest, antibodies against PF4 may also arise in patients with COVID-19 (Coronavirus Disease 2019) or in patients who have been vaccinated against COVID-19, especially in recipients of adenovirus-based vaccines. For this latter group of patients, the terms VITT (vaccine-induced [immune] thrombotic thrombocytopenia) and TTS (thrombotic thrombocytopenia syndrome) have been coined. Another category associated with this pathophysiology comprises those in whom a precipitating event is not clear; this category is referred to as ‘spontaneous HIT-like syndrome’. Despite its name, it arises as an HIT-mimicking disorder but without antecedent heparin exposure. In this narrative review, we describe the development of antibodies against PF4, and associated pathophysiology, in such conditions.
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Pishko AM. Heparin-induced thrombocytopenia and cardiovascular surgery. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:536-544. [PMID: 34889428 PMCID: PMC8791147 DOI: 10.1182/hematology.2021000289] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Clinicians generally counsel patients with a history of heparin-induced thrombocytopenia (HIT) to avoid heparin products lifelong. Although there are now many alternative (nonheparin) anticoagulants available, heparin avoidance remains challenging for cardiac surgery. Heparin is often preferred in the cardiac surgery setting based on the vast experience with the agent, ease of monitoring, and reversibility. To "clear" a patient with a history of HIT for cardiac surgery, hematologists must first confirm the diagnosis of HIT, which can be challenging due to the ubiquity of heparin exposure and frequency of thrombocytopenia in patients in the cardiac intensive care unit. Next, the "phase of HIT" (acute HIT, subacute HIT A/B, or remote HIT) should be established based on platelet count, immunoassay for antibodies to platelet factor 4/heparin complexes, and a functional assay (eg, serotonin release assay). As long as the HIT functional assay remains positive (acute HIT or subacute HIT A), cardiac surgery should be delayed if possible. If surgery cannot be delayed, an alternative anticoagulant (preferably bivalirudin) may be used. Alternatively, heparin may be used with either preoperative/intraoperative plasma exchange or together with a potent antiplatelet agent. The optimal strategy among these options is not known, and the choice depends on institutional experience and availability of alternative anticoagulants. In the later phases of HIT (subacute HIT B or remote HIT), brief intraoperative exposure to heparin followed by an alternative anticoagulant as needed in the postoperative setting is recommended.
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Affiliation(s)
- Allyson M. Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Correspondence Allyson M. Pishko, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 3rd Floor Dulles, Philadelphia, PA 19104; e-mail:
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Radu RI, Ben Gal T, Abdelhamid M, Antohi E, Adamo M, Ambrosy AP, Geavlete O, Lopatin Y, Lyon A, Miro O, Metra M, Parissis J, Collins SP, Anker SD, Chioncel O. Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature. ESC Heart Fail 2021; 8:4717-4736. [PMID: 34664409 PMCID: PMC8712803 DOI: 10.1002/ehf2.13643] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 01/09/2023] Open
Abstract
Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non-acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short-term or long-term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi-organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.
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Affiliation(s)
- Razvan I. Radu
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Center (Beilinson Campus), Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Magdy Abdelhamid
- Cardiology Department, Kasr Alainy School of MedicineCairo UniversityCairoEgypt
| | - Elena‐Laura Antohi
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
| | - Marianna Adamo
- Cardiothoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Andrew P. Ambrosy
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
- Division of Research, Kaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Oliviana Geavlete
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
| | - Yuri Lopatin
- Cardiology CentreVolgograd Medical UniversityVolgogradRussian Federation
| | - Alexander Lyon
- Cardio‐Oncology ServiceRoyal Brompton Hospital and Imperial College LondonLondonUK
| | - Oscar Miro
- Emergency Department, Hospital Clínic de BarcelonaUniversity of BarcelonaBarcelonaSpain
| | - Marco Metra
- Cardiology, Cardiothoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - John Parissis
- Second Department of Cardiology, Attikon University HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Sean P. Collins
- Department of Emergency Medicine; Vanderbilt University Medical CentreNashvilleTNUSA
| | - Stefan D. Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site BerlinCharité—Universitätsmedizin BerlinBerlinGermany
| | - Ovidiu Chioncel
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
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13
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Zaaqoq AM, Brammer RC, Chan CM, Shorr AF. Heparin-induced thrombocytopenia in extra-corporeal membrane oxygenation: epidemiology, outcomes, and diagnostic challenges. J Thromb Thrombolysis 2021; 53:499-505. [PMID: 34341895 PMCID: PMC8327895 DOI: 10.1007/s11239-021-02546-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2021] [Indexed: 11/17/2022]
Abstract
To describe the prevalence of heparin-induced thrombocytopenia (HIT) in patients on extracorporeal membrane oxygenation (ECMO) and to explore ways to improve the diagnostic accuracy of the HIT enzyme-linked immunosorbent assay (ELISA). Retrospective review of all patients needing ECMO between September 2011 and September 2020 who underwent evaluation for HIT while on ECMO. The diagnosis of HIT required a confirmatory serotonin release assay (SRA). Various break points for the optical density (OD) that defines a positive HIT ELISA were examined to estimate their utility as screening tests for HIT. Patient outcomes served as a secondary endpoint. Among 417 ECMO patients, 162 (38.8%) had a HIT ELISA. Of these, 114 (70.4%) had a subsequent SRA. Although the HIT ELISA was positive at an OD ≥ 0.4 in 1/3rd of subjects, only 15 subjects met criteria for HIT by SRA. Hence, the prevalence of HIT equaled 3.6%. At an OD ≥ 0.4 the ELISA had both poor specificity (71.7%) and accuracy (74.6%). Changing the definition of the ELISA to an OD ≥ 1.2 improved both specificity and accuracy with only a limited impact on sensitivity. Nearly 60% of those with HIT developing during ECMO died. HIT is infrequent in persons requiring ECMO. However, HIT remains associated with substantial mortality. The HIT ELISA as currently implemented performs poorly as a screening test and likely results in the unnecessary overuse of alternatives to unfractionated heparin. Altering the definition of a positive OD improves the HIT ELISA’s accuracy.
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Affiliation(s)
- Akram M Zaaqoq
- Pulmonary and Critical Care Medicine Service, Medstar Washington Hospital Center, Washington, DC, USA
| | - Robert C Brammer
- Pulmonary and Critical Care Medicine Service, Medstar Washington Hospital Center, Washington, DC, USA
| | - Chee M Chan
- Pulmonary and Critical Care Medicine Service, Medstar Washington Hospital Center, Washington, DC, USA
| | - Andrew F Shorr
- Pulmonary and Critical Care Medicine Service, Medstar Washington Hospital Center, Washington, DC, USA.
- Medstar Washington Hospital Center, Room 2A-68D, 110 Irving St., NW, Washington, DC, 20010, USA.
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14
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Chieffo A, Dudek D, Hassager C, Combes A, Gramegna M, Halvorsen S, Huber K, Kunadian V, Maly J, Møller J, Pappalardo F, Tarantini G, Tavazzi G, Thiele H, Vandenbriele C, Van Mieghem NM, Vranckx P, Werner N, Price S. Joint EAPCI/ACVC expert consensus document on percutaneous ventricular assist devices. EUROINTERVENTION 2021; 17:e274-e286. [PMID: 34057071 PMCID: PMC9709772 DOI: 10.4244/eijy21m05_01] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
There has been a significant increase in the use of short-term percutaneous ventricular assist devices (pVADs) as acute circulatory support in cardiogenic shock and to provide haemodynamic support during interventional procedures, including high-risk percutaneous coronary interventions. Although frequently considered together, pVADs differ in their haemodynamic effects, management, indications, insertion techniques, and monitoring requirements. This consensus document summarizes the views of an expert panel by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Association for Acute Cardiovascular Care (ACVC) and appraises the value of short-term pVAD. It reviews the pathophysiological context and possible indications for pVAD in different clinical settings and provides guidance regarding the management of pVAD based on existing evidence and best current practice.
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Affiliation(s)
- Alaide Chieffo
- Interventional Cardiology Unit San Raffaele Scientific Institute - Milan, Italy
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, and Department of Medical Intensive Care Unit, Cardiology Institute, Pitié Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, F-75013 Paris, France
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål and University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna, and Sigmund Freud University, Medical School, Freudplatz 3, A-1020 Vienna, Austria
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - Jiri Maly
- Cardiac Center, IKEM Prague, Videnska 1958/9, 14021 Prague 4, Czech Republic
| | - Jacob Møller
- Department of Cardiology, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Via Ernesto Triconi 5, 94100 Palermo, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Unit of Anaesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Piazzale Golgi 19, 27100 Pavia, Italy
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Struempellstr 30, 04289 Leipzig, Germany
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium,Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
| | - Nicolas M. Van Mieghem
- Department of Interventional Cardiology, Erasmus University Medical Centre, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium, and Faculty of Medicine and Life Sciences University of Hasselt Martelarenplein 42, 3500 Hasselt, Belgium
| | - Nikos Werner
- Heart Center Trier,Department of Internal Medicine III, Krankenhaus der Barmherzigen Brüder, Nordallee 1, 54292 Trier, Germany
| | - Susanna Price
- Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
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15
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Welker C, Huang J, Ramakrishna H. Analysis of the 2020 EACTS/ELSO/STS/AATS Expert Guidelines on the Management of Adult Postcardiotomy Extracorporeal Life Support. J Cardiothorac Vasc Anesth 2021; 36:2207-2219. [PMID: 34332842 DOI: 10.1053/j.jvca.2021.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation (ECMO), increasingly is used in postcardiotomy (PC) shock to facilitate a bridge to sustained recovery, long-term mechanical support, or heart transplantation. Given increasing prevalence and complexity of PC-ECLS, a joint expert consensus guideline was created in 2020 for management of adult PC-ECLS by the European Association for Cardio-Thoracic Surgery (EACTS), the Extracorporeal Life Support Organization (ELSO), the Society of Thoracic Surgeons (STS), and the American Association of Thoracic Surgery (AATS). The aim of this analysis was to comprehensively review the expert consensus guidelines, with particular emphasis on PC-ECLS candidacy, timing, cannula configuration, left ventricular distention, anticoagulation, ECLS weaning, and intensive care unit complications. This analysis finds the expert consensus guideline to be timely, pertinent, and clinically valuable, although there remains the need for larger clinical trials to codify best practices.
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Affiliation(s)
- Carson Welker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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16
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Chieffo A, Dudek D, Hassager C, Combes A, Gramegna M, Halvorsen S, Huber K, Kunadian V, Maly J, Møller JE, Pappalardo F, Tarantini G, Tavazzi G, Thiele H, Vandenbriele C, van Mieghem N, Vranckx P, Werner N, Price S. Joint EAPCI/ACVC expert consensus document on percutaneous ventricular assist devices. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:570-583. [PMID: 34057173 DOI: 10.1093/ehjacc/zuab015] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/11/2021] [Indexed: 11/12/2022]
Abstract
There has been a significant increase in the use of short-term percutaneous ventricular assist devices (pVADs) as acute circulatory support in cardiogenic shock and to provide haemodynamic support during interventional procedures, including high-risk percutaneous coronary interventions. Although frequently considered together, pVADs differ in their haemodynamic effects, management, indications, insertion techniques, and monitoring requirements. This consensus document summarizes the views of an expert panel by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Association for Acute Cardiovascular Care (ACVC) and appraises the value of short-term pVAD. It reviews the pathophysiological context and possible indications for pVAD in different clinical settings and provides guidance regarding the management of pVAD based on existing evidence and best current practice.
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Affiliation(s)
- Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland and Maria Cecilia Hospital GVM, Cotignola, Ravenna, Italy
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, and Department of Medical Intensive Care Unit, Cardiology Institute, Pitieé Salpeêtrieère Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University Medical School, F-75013 Paris, France
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål and University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna, and Sigmund Freud University, Medical School, Freudplatz 3, A-1020 Vienna, Austria
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, NE2 4HH, United Kingdom
| | - Jiri Maly
- Cardiac Center, IKEM Prague, Videnska 1958/9, 14021 Prague 4, Czech Republic
| | - Jacob Eifer Møller
- Department of Cardiology, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Via Ernesto Triconi 5, 94100 Palermo, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padua, Italy
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Unit of Anaesthesia and Intensive Care, Fondazione Policlinico San Matteo Hospital IRCCS, Piazzale Golgi 19, 27100 Pavia, Italy
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Struempellstr 30, 04289 Leipzig, Germany
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.,Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
| | - Nicolas van Mieghem
- Department of Interventional Cardiology, Erasmus University Medical Centre, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium, and Faculty of Medicine and Life Sciences University of Hasselt Martelarenplein 42, 3500 Hasselt, Belgium
| | - Nikos Werner
- Heart Center Trier, Department of Internal Medicine III, Krankenhaus der Barmherzigen Brüder, Nordallee 1, 54292 Trier, Germany
| | - Susanna Price
- Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK
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17
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Frequency of Thrombocytopenia and Heparin-Induced Thrombocytopenia in Patients Receiving Extracorporeal Membrane Oxygenation Compared With Cardiopulmonary Bypass and the Limited Sensitivity of Pretest Probability Score. Crit Care Med 2021; 48:e371-e379. [PMID: 32058356 DOI: 10.1097/ccm.0000000000004261] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To ascertain: 1) the frequency of thrombocytopenia and heparin-induced thrombocytopenia; 2) positive predictive value of the Pretest Probability Score in identifying heparin-induced thrombocytopenia; and 3) clinical outcome of heparin-induced thrombocytopenia in adult patients receiving venovenous- or venoarterial-extracorporeal membrane oxygenation, compared with cardiopulmonary bypass. DESIGN A single-center, retrospective, observational cohort study from January 2016 to April 2018. SETTING Tertiary referral center for cardiac and respiratory failure. PATIENTS Patients who received extracorporeal membrane oxygenation for more than 48 hours or had cardiopulmonary bypass during specified period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical and laboratory data were collected retrospectively. Pretest Probability Score and heparin-induced thrombocytopenia testing results were collected prospectively. Mean age (± SD) of the extracorporeal membrane oxygenation and cardiopulmonary bypass cohorts was 45.4 (± 15.6) and 64.9 (± 13), respectively (p < 0.00001). Median duration of cardiopulmonary bypass was 4.6 hours (2-16.5 hr) compared with 170.4 hours (70-1,008 hr) on extracorporeal membrane oxygenation. Moderate and severe thrombocytopenia were more common in extracorporeal membrane oxygenation compared with cardiopulmonary bypass throughout (p < 0.0001). Thrombocytopenia increased in cardiopulmonary bypass patients on day 2 but was normal in 83% compared with 42.3% of extracorporeal membrane oxygenation patients at day 10. Patients on extracorporeal membrane oxygenation also followed a similar pattern of platelet recovery following cessation of extracorporeal membrane oxygenation. The frequency of heparin-induced thrombocytopenia in extracorporeal membrane oxygenation and cardiopulmonary bypass were 6.4% (19/298) and 0.6% (18/2,998), respectively (p < 0.0001). There was no difference in prevalence of heparin-induced thrombocytopenia in patients on venovenous-extracorporeal membrane oxygenation (8/156, 5.1%) versus venoarterial-extracorporeal membrane oxygenation (11/142, 7.7%) (p = 0.47). The positive predictive value of the Pretest Probability Score in identifying heparin-induced thrombocytopenia in patients post cardiopulmonary bypass and on extracorporeal membrane oxygenation was 56.25% (18/32) and 25% (15/60), respectively. Mortality was not different with (6/19, 31.6%) or without (89/279, 32.2%) heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation (p = 0.79). CONCLUSIONS Thrombocytopenia is already common at extracorporeal membrane oxygenation initiation. Heparin-induced thrombocytopenia is more frequent in both venovenous- and venoarterial-extracorporeal membrane oxygenation compared with cardiopulmonary bypass. Positive predictive value of Pretest Probability Score in identifying heparin-induced thrombocytopenia was lower in extracorporeal membrane oxygenation patients. Heparin-induced thrombocytopenia had no effect on mortality.
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18
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Wajih N, Alipour E, Rigal F, Zhu J, Perlegas A, Caudell DL, Kim-Shapiro D. Effects of nitrite and far-red light on coagulation. Nitric Oxide 2021; 107:11-18. [PMID: 33271226 PMCID: PMC7855911 DOI: 10.1016/j.niox.2020.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/18/2020] [Accepted: 11/26/2020] [Indexed: 01/14/2023]
Abstract
Nitric oxide, NO, has been explored as a therapeutic agent to treat thrombosis. In particular, NO has potential in treating mechanical device-associated thrombosis due to its ability to reduce platelet activation and due to the central role of platelet activation and adhesion in device thrombosis. Nitrite is a unique NO donor that reduces platelet activation in that it's activity requires the presence of red blood cells whereas NO activity of other NO donors is blunted by red blood cells. Interestingly, we have previously shown that red blood cell mediated inhibition of platelet activation by adenosine diphosophate (ADP) is dramatically enhanced by illumination with far-red light that is likely due to photolysis of red cell surface bound NO congeners. We now report the effects of nitrite, far-red light, and their combination on several measure of blood coagulation using a variety of agonists. We employed turbidity assays in platelet rich plasma, platelet activation using flow cytometry analysis of a fluorescently labeled antibody to the activated platelet fibrinogen binding site, multiplate impedance-based platelet aggregometry, and assessment of platelet adhesion to collagen coated flow-through microslides. In all cases, the combination of far-red light and nitrite treatment decreased measures of coagulation, but in some cases mono-treatment with nitrite or light alone had no effect. Perhaps most relevant to device thrombosis, we observed that platelet adhesions was inhibited by the combination of nitrite and light treatment while nitrite alone and far-red light alone trended to decrease adhesion, but the results were mixed. These results support the potential of combined far-red light and nitrite treatment for preventing thrombosis in extra-corporeal or shallow-tissue depth devices where the far-red light can penetrate. Such a combined treatment could be advantageous due to the localized treatment afforded by far-red light illumination with minimal systemic effects. Given the role of thrombosis in COVID 19, application to treatment of patients infected with SARS Cov-2 might also be considered.
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Affiliation(s)
- Nadeem Wajih
- Department of Physics, Wake Forest University, Winston-Salem, NC, 27109, United States; Translational Science Center, Wake Forest University, Winston-Salem, NC, 27109, United States.
| | - Elmira Alipour
- Department of Physics, Wake Forest University, Winston-Salem, NC, 27109, United States.
| | - Fernando Rigal
- Department of Physics, Wake Forest University, Winston-Salem, NC, 27109, United States.
| | - Jiqing Zhu
- Department of Physics, Wake Forest University, Winston-Salem, NC, 27109, United States.
| | - Andreas Perlegas
- Department of Physics, Wake Forest University, Winston-Salem, NC, 27109, United States
| | - David L Caudell
- Department of Pathology,-Section on Comparative Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, United States.
| | - Daniel Kim-Shapiro
- Department of Physics, Wake Forest University, Winston-Salem, NC, 27109, United States; Translational Science Center, Wake Forest University, Winston-Salem, NC, 27109, United States.
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19
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Zhong H, Zhu ML, Yu YT, Li W, Xing SP, Zhao XY, Wang WJ, Gu ZC, Gao Y. Management of Bivalirudin Anticoagulation Therapy for Extracorporeal Membrane Oxygenation in Heparin-Induced Thrombocytopenia: A Case Report and a Systematic Review. Front Pharmacol 2020; 11:565013. [PMID: 33013402 PMCID: PMC7516194 DOI: 10.3389/fphar.2020.565013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/18/2020] [Indexed: 02/05/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) can provide respiratory and cardiac support to patients in reversible devastated conditions. Heparin is the mainstay for anticoagulation during ECMO. Bivalirudin, a direct thrombin blocker, may represent an effective alternative for patients suffering from heparin-induced thrombocytopenia (HIT). We present the first case of a Chinese patient who experienced HIT and received bivalirudin anticoagulation during ECMO. In addition, we present a systematic review for this topic. We searched PubMed, EMBASE, and Cochrane Library (up to April 20, 2020) for studies that included patients undergoing ECMO, presenting with HIT, requiring bivalirudin treatment, and reporting relevant outcomes. The literature review yielded 15 studies involving 123 patients, amongst whom 58 patients were confirmed or suspected HIT patients, and 76 patients received bivalirudin as an anticoagulant for ECMO. Twelve studies were included for quantitative synthesis, and 46 patients were retrieved. The mean age of these patients was 46 years, and 30 patients were males. The average maintenance rate of bivalirudin was 0.27 ± 0.37 mg/kg/h, in order to maintain a target of activated clotting time (ACT) of 160–220 s. Additionally, bivalirudin doses in patients with continuous renal replacement therapies (CRRT) and patients without CRRT were 0.15 ± 0.06 mg/kg/h vs 0.28 ± 0.36 mg/kg/h, respectively (p=0.15). Most of the patients with confirmed HIT improved platelet counts in 3.3 ± 2.8 days after switching to bivalirudin anticoagulation. The patient-level data showed that 29 cases survived, 1 reported major bleeding, and 4 reported thrombotic events. Bivalirudin might be a promising optimal choice for ECMO anticoagulation in patients with HIT. A tailored protocol for management of bivalirudin treatment during ECMO should be developed with caution. Further prospective studies are necessary to standardise the use of bivalirudin.
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Affiliation(s)
- Han Zhong
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ming-Li Zhu
- Department of Critical Care, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yue-Tian Yu
- Department of Critical Care, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Wen Li
- Department of Critical Care, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shun-Peng Xing
- Department of Critical Care, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xian-Yuan Zhao
- Department of Critical Care, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Wei-Jun Wang
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yuan Gao
- Department of Critical Care, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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20
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Li JF, Wu LJ, Wen GY, Zhou RR, Liu F, Wang W, Yang SQ, Gong JN, Miao R, Gu S, Liu Y, Yang YH. Platelet count trends and response to fondaparinux in a cohort of heparin-induced thrombocytopenia suspected patients after pulmonary endarterectomy. J Thromb Thrombolysis 2020; 51:703-710. [PMID: 32894400 DOI: 10.1007/s11239-020-02260-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A definitive diagnosis of heparin-induced thrombocytopenia (HIT) is difficult to make, especially in patients undergoing cardiac surgery. In this retrospective cohort study, we assessed the platelet count trends and the response to fondaparinux in a population of patients of suspected HIT after pulmonary endarterectomy (PEA). Patients enrolled in this study were over the age of 18 years, and survived longer than 7 days after PEA between January 1, 2011 and December 31, 2015. HIT likelihood was assessed by the 4 T's score and interpreted by our institutional algorithm. 54 patients were operated, and 49 patients met the inclusion criteria. Six patients met the criteria for suspected HIT and were treated with fondaparinux until the platelet recovered. No significant difference was observed of clinical characteristics between intermediate to high HIT likelihood patients (HIT SUSPECTED) and low HIT likelihood patients (NO HIT SUSPECTED). HIT SUSPECTED patients reached platelet count lowest later (about 5.5 days after PEA), while NO HIT SUSPECTED patients is about 4.0 days after PEA. Percentage of platelet counts decrease (> 50%) was larger than NO HIT SUSPECTED patients (< 50%). There was no difference in mortality or residual pulmonary hypertension between HIT SUSPECTED and NO HIT SUSPECTED patients. Two HIT SUSPECTED patients who used heparin after PEA died, the other four survived by replacing heparin or low molecular weight heparin with fondaparinux. Suspected HIT patients should be surveilled carefully. Platelet counts trends may have some hints in the prevention of HIT. Fondaparinux may be effective for patients with suspected HIT.
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Affiliation(s)
- Ji-Feng Li
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China
- Department of Respiratory Disease, Capital Medical University, 100069, Beijing, P.R. China
| | - Li-Juan Wu
- School of Public Health, Capital Medical University, 100020, Beijing, P.R. China
- Beijing Key Laboratory of Epidemilology, Capital Medical University, 100020, Beijing, P.R. China
| | - Ge-Yi Wen
- Department of Respiratory Disease, Capital Medical University, 100069, Beijing, P.R. China
| | - Rong-Rong Zhou
- Department of Respiratory Disease, Capital Medical University, 100069, Beijing, P.R. China
| | - Fang Liu
- Department of Respiratory Medicine, The Branch of Tangshan Gongren Hospital, 063000, Tangshan, P.R. China
| | - Wei Wang
- Department of Respiratory Disease, Capital Medical University, 100069, Beijing, P.R. China
| | - Su-Qiao Yang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China
- Department of Respiratory Disease, Capital Medical University, 100069, Beijing, P.R. China
| | - Juan-Ni Gong
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China
- Department of Respiratory Disease, Capital Medical University, 100069, Beijing, P.R. China
| | - Ran Miao
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China
- Department of Respiratory Disease, Capital Medical University, 100069, Beijing, P.R. China
| | - Song Gu
- Department of Cardiac Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China
| | - Yan Liu
- Department of Cardiac Surgery, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China.
| | - Yuan-Hua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, 100020, Beijing, P.R. China.
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China.
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 100020, Beijing, P.R. China.
- Department of Respiratory Disease, Capital Medical University, 100069, Beijing, P.R. China.
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21
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Karangwa SA, Lisman T, Porte RJ. Anticoagulant Management and Synthesis of Hemostatic Proteins during Machine Preservation of Livers for Transplantation. Semin Thromb Hemost 2020; 46:743-750. [DOI: 10.1055/s-0040-1715452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractLiver transplantation remains the only curative treatment for patients with end-stage liver disease. Despite a steadily increasing demand for suitable donor livers, the current pool of donor organs fails to meet this demand. To resolve this discrepancy, livers traditionally considered to be of suboptimal quality and function are increasingly utilized. These marginal livers, however, are less tolerant to the current standard cold preservation of donor organs. Therefore, alternative preservation methods have been sought and are progressively applied into clinical practice. Ex situ machine perfusion is a promising alternative preservation modality particularly for suboptimal donor livers as it provides the ability to resuscitate, recondition, and test the viability of an organ prior to transplantation. This review addresses the modalities of machine perfusion currently being applied, and particularly focuses on the hemostatic management employed during machine perfusion. We discuss the anticoagulant agents used, the variation in dosage, and administration, as well as the implications of perfusion for extended periods of time in terms of coagulation activation associated with production of coagulation factors during perfusion. Furthermore, in regard to viability testing of an organ prior to transplantation, we discuss the possibilities and limitations of utilizing the synthesis of liver-derived coagulation factors as potential viability markers.
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Affiliation(s)
- Shanice A. Karangwa
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J. Porte
- Section of HPB Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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22
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Neethling E, Moreno Garijo J, Mangalam TK, Badiwala MV, Billia P, Wasowicz M, Van Rensburg A, Slinger P. Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications. J Cardiothorac Vasc Anesth 2020; 34:2189-2206. [DOI: 10.1053/j.jvca.2019.09.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/07/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
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23
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Klompas AM, Albright RC, Maltais S, Demirci O. Acute renal failure due to bilateral renal vein thromboses: A rare complication of heparin-induced thrombocytopenia. Ann Card Anaesth 2020; 22:204-206. [PMID: 30971604 PMCID: PMC6489386 DOI: 10.4103/aca.aca_114_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Heparin-induced thrombocytopenia type II is a rare but devastating complication of heparin exposure. We review a case of a 66-year-old female who underwent aortic valve surgery requiring venoarterial extracorporeal membranous oxygenation (ECMO) support postoperatively. She subsequently developed acute renal failure due to bilateral renal vein thromboses and thrombocytopenia and was found to have platelet factor 4/heparin antibodies and was diagnosed with heparin-induced thrombocytopenia (HIT). She was transitioned to nonheparin anticoagulation and her thrombocytopenia improved. Although a rare complication of anticoagulation, diagnosing HIT in a patient on ECMO requires a high index of suspicion and should be considered.
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Affiliation(s)
- Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert C Albright
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Simon Maltais
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Onur Demirci
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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24
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Jiritano F, Serraino GF, Ten Cate H, Fina D, Matteucci M, Mastroroberto P, Lorusso R. Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis. Intensive Care Med 2020; 46:1154-1169. [PMID: 32328725 PMCID: PMC7292815 DOI: 10.1007/s00134-020-06031-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/28/2020] [Indexed: 12/24/2022]
Abstract
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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Affiliation(s)
- Federica Jiritano
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands.
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy.
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dario Fina
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands
- IRCCS San Donato, University of Milan, Milan, Italy
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Pasquale Mastroroberto
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), P. Debeylaan, 26, 6220 AZ, Maastricht, The Netherlands
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25
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Zhai Z, Li C, Chen Y, Gerotziafas G, Zhang Z, Wan J, Liu P, Elalamy I, Wang C. Prevention and Treatment of Venous Thromboembolism Associated with Coronavirus Disease 2019 Infection: A Consensus Statement before Guidelines. Thromb Haemost 2020; 120:937-948. [PMID: 32316065 PMCID: PMC7295267 DOI: 10.1055/s-0040-1710019] [Citation(s) in RCA: 250] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Coronavirus disease 2019 (COVID-19) has caused a global pandemic in just a few months, causing millions infected. Nearly 20% of COVID-19 patients present severe coagulation abnormalities, which may occur in almost all of the severe and critical ill COVID-19 cases. Concomitant venous thromboembolism (VTE), a potential cause of unexplained deaths, has been frequently reported in COVID-19 cases, but its management is still challenging due to the complexity between antithrombotic therapy and coagulation disorders. Based on frontline practical experience and comprehensive literature review, here a panel of experts and physicians from China and Europe developed an evidence and opinion-based consensus on the prophylaxis and management of VTE associated with COVID-19. This statement aims for clinicians treating COVID-19 and provides practical recommendations in detailed situations, for example, how to choose thromboprophylactic measures for patients with diverse severity of disease and bleeding risk, or which kind of anticoagulant should be prescribed. With limited experience on COVID19-associated VTE, this expert consensus statement should be helpful for clinicians worldwide with specific suggestions.
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Affiliation(s)
- Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Chenghong Li
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jianghan University, Wuhan, China
| | - Yaolong Chen
- Evidence-based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Grigorios Gerotziafas
- Hematology and Thrombosis Center, Tenon University Hospital, INSERM UMRS 938, Sorbonne University, Paris, France
| | - Zhenlu Zhang
- Department of Clinical Laboratory, Wuhan Asia Heart Hospital, Wuhan, China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Ismaïl Elalamy
- Hematology and Thrombosis Center, Tenon University Hospital, INSERM UMRS 938, Sorbonne University, Paris, France.,Department of Obstetrics and Gynaecology, the First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Respiratory Diseases, Beijing, China.,Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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26
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Hogan M, Berger JS. Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management. Vasc Med 2020; 25:160-173. [PMID: 32195628 DOI: 10.1177/1358863x19898253] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. Here, we review the pathogenesis, incidence, diagnosis, and management of HIT. The first step in thwarting devastating complications from this entity is to maintain a high index of clinical suspicion, followed by an accurate clinical scoring assessment using the 4Ts. Next, appropriate stepwise laboratory testing must be undertaken in order to rule out HIT or establish the diagnosis. In the interim, all heparin must be stopped immediately, and the patient administered alternative anticoagulation. Here we review alternative anticoagulation choice, therapy alternatives in the difficult-to-manage patient with HIT, and the problem of overdiagnosis.
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Affiliation(s)
- Marie Hogan
- Department of Pediatrics, Division of Hematology Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology and Hematology, New York University School of Medicine, New York, NY, USA
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27
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Vandenbriele C, Vanassche T, Price S. Why we need safer anticoagulant strategies for patients on short-term percutaneous mechanical circulatory support. Intensive Care Med 2020; 46:771-774. [PMID: 31974917 DOI: 10.1007/s00134-019-05897-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/06/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Adult Intensive Care, Royal Brompton NHS Foundation Trust, Imperial College London, Sydney Street, London, SW36NP, UK.
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Susanna Price
- Department of Adult Intensive Care, Royal Brompton NHS Foundation Trust, Imperial College London, Sydney Street, London, SW36NP, UK
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28
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Joseph J, Rabbolini D, Enjeti AK, Favaloro E, Kopp M, McRae S, Pasalic L, Tan CW, Ward CM, Chong BH. Diagnosis and management of heparin‐induced thrombocytopenia: a consensus statement from the Thrombosis and Haemostasis Society of Australia and New ZealandHITWriting Group. Med J Aust 2019; 210:509-516. [DOI: 10.5694/mja2.50213] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Joanne Joseph
- St Vincent's Hospital Sydney NSW
- St Vincent's Clinical SchoolUniversity of New South Wales Sydney NSW
| | - David Rabbolini
- Royal North Shore Hospital Sydney NSW
- Northern Blood Research CentreKolling Institute of Medical Research Sydney NSW
| | | | - Emmanuel Favaloro
- Institute of Clinical Pathology and Medical Research Sydney NSW
- Westmead Hospital Sydney NSW
| | | | | | - Leonardo Pasalic
- Institute of Clinical Pathology and Medical Research Sydney NSW
- Westmead Hospital Sydney NSW
| | | | - Christopher M Ward
- Royal North Shore Hospital Sydney NSW
- Northern Blood Research CentreKolling Institute of Medical Research Sydney NSW
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29
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Malalur P, Greenberg C, Lim MY. Limited impact of clinician education on reducing inappropriate PF4 testing for heparin-induced thrombocytopenia. J Thromb Thrombolysis 2019; 47:287-291. [PMID: 30612329 DOI: 10.1007/s11239-018-01803-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A high frequency of PF4-ELISA testing in patients suspected to have heparin-induced thrombocytopenia (HIT) despite low 4T scores has been observed in multiple medical centers. Education of clinicians has been suggested to reduce inappropriate testing. We determined trends of PF4-ELISA testing in our institution after the introduction of a HIT education program for clinicians. A HIT Program was developed that included ongoing education, individual feedback, and continuous clinical audit of PF4-ELISA utilization. To assess the impact of education on PF4-ELISA testing trends, we conducted a prospective cohort review of all adult patients who had a PF4-ELISA ordered over a 3 month period (the last quarter of the academic year). 72 PF4-ELISA tests were ordered during the study period. Prospectively calculated 4T scores by investigators revealed 60 low-risk (83.3%), 9 intermediate-risk (12.5%), and 3 high-risk (4.16%). We observed divergent 4T scores with the ordering clinician calculating a higher 4T score compared to the Hematology Quality Improvement (QI) team. The majority of PF4-ELISA testing was ordered by the intensive care units (ICUs) (n = 32, 44.44%). Our study revealed that the frequency of calculation of 4T scores remains poor with the majority inappropriately performed in the ICU setting, with ordering clinicians calculating higher 4T scores than the Hematology QI team. This suggests that clinician education alone is insufficient. Introducing mandatory 4T score calculation prior to PF4-ELISA testing may not be helpful as ordering clinicians can bypass the restriction through inaccurate 4T score calculation.
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Affiliation(s)
- Pannaga Malalur
- Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, 39 Sabin St, MSC 635, Charleston, SC, 29425, USA.
| | - Charles Greenberg
- Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, 39 Sabin St, MSC 635, Charleston, SC, 29425, USA
| | - Ming Y Lim
- Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, 39 Sabin St, MSC 635, Charleston, SC, 29425, USA
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30
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Hirasaki Y, Yamamoto Y, Nakamura T, Higa Y, Honda M, Yoshida S. Rotational Thromboelastometry for Coagulation Management During Cardiopulmonary Bypass Using Argatroban. J Cardiothorac Vasc Anesth 2018; 33:1977-1982. [PMID: 30529181 DOI: 10.1053/j.jvca.2018.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Yuji Hirasaki
- Department of Anesthesia, IMS Tokyo Katsushika General Hospital, Tokyo, Japan.
| | - Yosuke Yamamoto
- Department of Cardiovascular Surgery, IMS Tokyo Katsushika General Hospital, Tokyo, Japan
| | - Tomokazu Nakamura
- Department of Cardiovascular Surgery, IMS Tokyo Katsushika General Hospital, Tokyo, Japan
| | - Yuki Higa
- Department of Anesthesia, IMS Tokyo Katsushika General Hospital, Tokyo, Japan
| | - Masahiro Honda
- Department of Anesthesia, IMS Tokyo Katsushika General Hospital, Tokyo, Japan
| | - Shigehiko Yoshida
- Department of Cardiovascular Surgery, IMS Tokyo Katsushika General Hospital, Tokyo, Japan
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31
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Cho JH, Parilla M, Treml A, Wool GD. Plasma exchange for heparin-induced thrombocytopenia in patients on extracorporeal circuits: A challenging case and a survey of the field. J Clin Apher 2018; 34:64-72. [DOI: 10.1002/jca.21671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Joseph H. Cho
- Department of Pathology; The University of Chicago; Chicago Illinois
| | - Megan Parilla
- Department of Pathology; The University of Chicago; Chicago Illinois
| | - Angela Treml
- BloodCenter of Wisconsin, Department of Pathology; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Geoffrey D. Wool
- Department of Pathology; The University of Chicago; Chicago Illinois
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32
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Kimmoun A, Oulehri W, Sonneville R, Grisot PH, Zogheib E, Amour J, Aissaoui N, Megarbane B, Mongardon N, Renou A, Schmidt M, Besnier E, Delmas C, Dessertaine G, Guidon C, Nesseler N, Labro G, Rozec B, Pierrot M, Helms J, Bougon D, Chardonnal L, Medard A, Ouattara A, Girerd N, Lamiral Z, Borie M, Ajzenberg N, Levy B. Prevalence and outcome of heparin-induced thrombocytopenia diagnosed under veno-arterial extracorporeal membrane oxygenation: a retrospective nationwide study. Intensive Care Med 2018; 44:1460-1469. [PMID: 30136139 DOI: 10.1007/s00134-018-5346-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 08/10/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Thrombocytopenia is a frequent and serious adverse event in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. Similarly to postcardiac surgery patients, heparin-induced thrombocytopenia (HIT) could represent the causative underlying mechanism. However, the epidemiology as well as related mortality regarding HIT and VA-ECMO remains largely unknown. We aimed to define the prevalence and associated 90-day mortality of HIT diagnosed under VA-ECMO. METHODS This retrospective study included patients under VA-ECMO from 20 French centers between 2012 and 2016. Selected patients were hospitalized for more than 3 days with high clinical suspicion of HIT and positive anti-PF4/heparin antibodies. Patients were classified according to results of functional tests as having either Confirmed or Excluded HIT. RESULTS A total of 5797 patients under VA-ECMO were screened; 39/5797 met the inclusion criteria, with HIT confirmed in 21/5797 patients (0.36% [95% CI] [0.21-0.52]). Fourteen of 39 patients (35.9% [20.8-50.9]) with suspected HIT were ultimately excluded because of negative functional assays. Drug-induced thrombocytopenia tended to be more frequent in Excluded HIT at the time of HIT suspicion (p = 0.073). The platelet course was similar between Confirmed and Excluded HIT (p = 0.65). Mortality rate was 33.3% [13.2-53.5] in Confirmed and 50% [23.8-76.2] in Excluded HIT (p = 0.48). CONCLUSIONS Prevalence of HIT among patients under VA-ECMO is extremely low at 0.36% with an associated mortality rate of 33.3%, which appears to be in the same range as that observed in patients treated with VA-ECMO without HIT. In addition, HIT was ultimately ruled out in one-third of patients with clinical suspicion of HIT and positive anti-PF4/heparin antibodies.
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Affiliation(s)
- Antoine Kimmoun
- Medical Intensive Care Unit Brabois, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, INSERM U1116, Université de Lorraine, Vandoeuvre-les-Nancy, 54511, Nancy, France
| | - Walid Oulehri
- Department of Anesthesiology and Surgical Critical Care, Nouvel Hôpital Civil, CHU Strasbourg, Strasbourg, France
| | - Romain Sonneville
- Department of Intensive Care Medicine and Infectious Diseases, Hôpital Bichat Claude Bernard, Assistance Publique, Hôpitaux de Paris, INSERM, UMR 1148, Université Paris Diderot, Paris, France
| | - Paul-Henri Grisot
- Medical Intensive Care Unit Brabois, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, INSERM U1116, Université de Lorraine, Vandoeuvre-les-Nancy, 54511, Nancy, France
| | - Elie Zogheib
- Cardiothoracic and Vascular Intensive Care Unit, Amiens University Hospital, INSERM U1088, Jules Verne University of Picardy, Amiens, France
| | - Julien Amour
- Department of Anesthesiology and Surgical Critical Care, Institut Hospitalo-Universitaire de Cardiométabolisme et Nutrition, Hôpital Pitié-Salpêtrière, Assistance Publique, Hôpitaux de Paris, UMR INSERM 1166, Université Sorbonne, Paris, France
| | - Nadia Aissaoui
- Critical Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, INSERM U970, Université Paris-Descartes, Paris, France
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, INSERM UMRS-1144, Université Paris Diderot, Paris, France
| | - Nicolas Mongardon
- Department of Anesthesiology and Surgical Critical Care, CHU Henri Mondor, Assistance Publique-Hôpitaux de Paris, INSERM U955 Team 3, Université Paris Est, Paris, France
| | - Amelie Renou
- Department of Anesthesiology and Surgical Critical Care, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France
| | - Matthieu Schmidt
- Medical Intensive Care Unit, Institut Hospitalo-Universitaire de Cardiométabolisme et Nutrition, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, UMR INSERM 1166, Université Sorbonne, Paris, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Surgical Critical Care, Hôpital de Rouen, Université de Rouen, Rouen, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Hôpital de Rangueil, Université de Toulouse 3 Paul Sabatier, Toulouse, France
| | - Geraldine Dessertaine
- Intensive Cardiac Care Unit, Hôpital de Grenoble, Université de Grenoble Alpes, Grenoble, France
| | - Catherine Guidon
- Department of Cardiac Surgery, Hôpital La Timone, Marseille, France
| | - Nicolas Nesseler
- Department of Anesthesiology and Surgical Critical Care, Hôpital de Pontchaillou, INSERM, UMR 1214 and INSERM 1414, Université de Rennes 1, Rennes, France
| | - Guylaine Labro
- Medical Intensive Care Unit, Hôpital Jean Minjoz, Université de Franche-Comté, Besançon, France
| | - Bertrand Rozec
- Department of Anesthesiology and Surgical Critical Care, Hôpital Guillaume et René Laennec, CHRU Nantes, Institut du Thorax, Université de Nantes, Nantes, France
| | - Marc Pierrot
- Department of Medical Intensive Care and Hyperbaric Medicine, Hôpital d'Angers, Université d' Angers, Angers, France
| | - Julie Helms
- Medical Intensive Care Unit, Nouvel Hôpital Civil, CHU de Strasbourg, INSERM, UMR_S1109, Université de Strasbourg, Strasbourg, France
| | - David Bougon
- Intensive Care Unit, Hôpital Annecy Genevois, Annecy, France
| | - Laurent Chardonnal
- Department of Anesthesiology and Surgical Critical Care, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Anne Medard
- Department of Anesthesiology and Surgical Critical Care, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Alexandre Ouattara
- Department of Anesthesiology and Surgical Critical Care, Centre Médico-Chirurgical Magellan, CHU de Bordeaux, INSERM, UMR 1034, Université de Bordeaux, Bordeaux, France
| | - Nicolas Girerd
- INSERM CIC1433, CHRU de Nancy, Université de Lorraine, Nancy, France
| | - Zohra Lamiral
- INSERM CIC1433, CHRU de Nancy, Université de Lorraine, Nancy, France
| | | | - Nadine Ajzenberg
- Department of Hematology, Hôpital Bichat Claude Bernard, Assistance Publique, Hôpitaux de Paris, INSERM, UMR 1148, Université Paris Diderot, Paris, France
| | - Bruno Levy
- Medical Intensive Care Unit Brabois, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, INSERM U1116, Université de Lorraine, Vandoeuvre-les-Nancy, 54511, Nancy, France.
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Lee CL, Colombo PC, Eisenberger A, Diuguid D, Jennings DL, Han J, Salna MP, Takeda K, Kurlansky PA, Yuzefpolskaya M, Garan AR, Naka Y, Takayama H. Abciximab/Heparin Therapy for Left Ventricular Assist Device Implantation in Patients With Heparin-Induced Thrombocytopenia. Ann Thorac Surg 2018; 105:122-128. [DOI: 10.1016/j.athoracsur.2017.06.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/21/2017] [Accepted: 06/07/2017] [Indexed: 12/13/2022]
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Affiliation(s)
- Anna Vittoria Mattioli
- Department of Surgical, Medical and Dental, Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Via del pozzo, 71 41100, Modena, Italy.
| | - Antonio Manenti
- Department of Surgical, Medical and Dental, Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Via del pozzo, 71 41100, Modena, Italy
| | - Alberto Farinetti
- Department of Surgical, Medical and Dental, Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Via del pozzo, 71 41100, Modena, Italy
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Greinacher A, Warkentin TE, Bakchoul T. Heparin-induced thrombocytopenia in 2017 and beyond. Thromb Haemost 2017; 116:781-782. [DOI: 10.1160/th16-09-0742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 09/30/2016] [Indexed: 11/05/2022]
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Greinacher A, Selleng K, Warkentin TE. Autoimmune heparin-induced thrombocytopenia. J Thromb Haemost 2017; 15:2099-2114. [PMID: 28846826 DOI: 10.1111/jth.13813] [Citation(s) in RCA: 280] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Indexed: 01/18/2023]
Abstract
Autoimmune heparin-induced thrombocytopenia (aHIT) indicates the presence in patients of anti-platelet factor 4 (PF4)-polyanion antibodies that are able to activate platelets strongly even in the absence of heparin (heparin-independent platelet activation). Nevertheless, as seen with serum obtained from patients with otherwise typical heparin-induced thrombocytopenia (HIT), serum-induced platelet activation is inhibited at high heparin concentrations (10-100 IU mL-1 heparin). Furthermore, upon serial dilution, aHIT serum will usually show heparin-dependent platelet activation. Clinical syndromes associated with aHIT include: delayed-onset HIT, persisting HIT, spontaneous HIT syndrome, fondaparinux-associated HIT, heparin 'flush'-induced HIT, and severe HIT (platelet count of < 20 × 109 L-1 ) with associated disseminated intravascular coagulation (DIC). Recent studies have implicated anti-PF4 antibodies that are able to bridge two PF4 tetramers even in the absence of heparin, probably facilitated by non-heparin platelet-associated polyanions (chondroitin sulfate and polyphosphates); nascent PF4-aHIT-IgG complexes recruit additional heparin-dependent HIT antibodies, leading to the formation of large multimolecular immune complexes and marked platelet activation. aHIT can persist for several weeks, and serial fibrin, D-dimer, and fibrinogen levels, rather than the platelet count, may be helpful for monitoring treatment response. Although standard anticoagulant therapy for HIT ought to be effective, published experience indicates frequent failure of activated partial thromboplastin time (APTT)-adjusted anticoagulants (argatroban, bivalirudin), probably because of underdosing in the setting of HIT-associated DIC, known as 'APTT confounding'. Thus, non-APTT-adjusted therapies with drugs such as danaparoid and fondaparinux, or even direct oral anticoagulants, such as rivaroxaban or apixaban, are suggested therapies, especially for long-term management of persisting HIT. In addition, emerging data indicate that high-dose intravenous immunoglobulin can interrupt HIT antibody-induced platelet activation, leading to rapid platelet count recovery.
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MESH Headings
- Administration, Oral
- Animals
- Anticoagulants/administration & dosage
- Anticoagulants/adverse effects
- Anticoagulants/immunology
- Autoantibodies/blood
- Autoimmunity/drug effects
- Blood Coagulation/drug effects
- Blood Platelets/drug effects
- Blood Platelets/immunology
- Blood Platelets/metabolism
- Heparin/adverse effects
- Heparin/immunology
- Humans
- Immunoglobulins, Intravenous/administration & dosage
- Immunologic Factors/administration & dosage
- Partial Thromboplastin Time
- Platelet Activation/drug effects
- Platelet Factor 4/immunology
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/chemically induced
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/immunology
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Affiliation(s)
- A Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - K Selleng
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - T E Warkentin
- Department of Pathology and Molecular Medicine, Department of Medicine, and McMaster Centre for Transfusion Research, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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Implementation of a rapid HIT immunoassay at a university hospital - Retrospective analysis of HIT laboratory orders in patients with thrombocytopenia. Thromb Res 2017; 158:65-70. [PMID: 28843825 DOI: 10.1016/j.thromres.2017.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/19/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a rare cause of thrombocytopenia and a potentially life-threatening adverse drug reaction. Clinical overdiagnosis of HIT results in costly laboratory tests and anticoagulation. Criteria and algorithms for diagnosis are established, but their translation into clinical practice is still challenging. STUDY DESIGN AND METHODS In a retrospective approach we studied all HIT related laboratory test requests within four years and evaluated data before (1st period, 24month) and after (2nd period, 24month) replacing particle gel immunoassay (PaGIA) and enzyme-linked immunosorbent assay (ELISA) by a chemiluminescent immunoassay (CLIA). HIT was confirmed by heparin-induced platelet activation (HIPA) test. Clinical pretest probability for HIT using an implemented simplified 4Ts score and platelet count were evaluated. Costs for laboratory tests and alternative anticoagulation were calculated. RESULTS In 1850 patients with suspected HIT, 2327 laboratory orders were performed. In 87.2% of these orders an intermediate/high simplified 4Ts score was found. Thrombocytopenia was present in 87.1%. After replacing PaGIA and ELISA by CLIA the number of immunological and functional laboratory tests was reduced by 38.2%. The number of positive HIT immunoassays declined from 22.6% to 6.0%, while the number of positive HIPA tests among positive immunological tests increased by 19%. Altogether, acute HIT was confirmed in 59 patients. A decline in the use of alternative anticoagulants was observed in the 2nd period. CONCLUSION Our study shows that in a university hospital setting HIT is well-known, but diagnosis requires a precise laboratory confirmation. Replacing PaGIA and ELISA by CLIA did not influence laboratory order behavior but results in reduced overall costs for laboratory diagnostics and alternative anticoagulation.
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Stanzel RD, Gehron J, Wolff M, Striegl N, Roth P, Boedeker RH, Scheibelhut C, Herrmann J, Welters I, Mayer E, Scheffler M. International survey on the perioperative management of pulmonary endarterectomy: the perfusion perspective. Perfusion 2017; 33:53-61. [DOI: 10.1177/0267659117724865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Pulmonary endarterectomy (PEA) is the most effective treatment available for chronic thromboembolic pulmonary hypertension (CTEPH). Patient selection, surgical technique and perioperative management have improved patient outcomes, which are traditionally linked to surgical and center experience. However, optimal perfusion care has not been well defined. The goal of the international survey was to better characterize the contemporary perfusion management of PEA and highlight similarities and controversies. Method: The combined caseload of 15 participating centers was 5,066 cases. Topics queried included materials and types of cardiopulmonary bypass (CPB) equipment, choice of prime, fluid management, deep hypothermia strategy, temperature management, treatment of acid-base abnormalities and intraoperative hematocrit as well as anticoagulation management for heparin-induced thrombocytopenia. Conclusion: Our assessment could provide a base for further advancement and may help design future studies to elucidate the impact of perfusion in this challenging field.
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Affiliation(s)
- Roger D.P. Stanzel
- Perfusion Services, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Johannes Gehron
- Cardiovascular Surgery, Dept. of Perfusion, University Hospital Giessen and Marburg, Giessen, Germany
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Matthias Wolff
- Anesthesiology, Intensive Care, Pain Therapy, University Hospital Giessen and Marburg, Giessen, Germany
| | | | - Peter Roth
- Department of Cardiovascular Surgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - Rolf-Hasso Boedeker
- Institute for Medical Informatics, Justus-Liebig-University Giessen, Giessen, Germany
| | | | | | - Ingeborg Welters
- Institute of Ageing and Chronic Disease, Royal Liverpool University Hospital, Liverpool, UK
| | - Eckhard Mayer
- Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Matthias Scheffler
- Department of Anesthesia, Perioperative Medicine and Pain Therapy, Dalhousie University, QEII Health Sciences Centre, Halifax, Canada
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Wadowski PP, Felli A, Schiferer A, Panzer S, Opfermann P, Dworschak M, Holaubek C, Aliabadi-Zuckermann A, Steinlechner B. Argatroban in Thrombocytopenic Patients Sensitized to Circulating Protamine-Heparin Complexes. J Cardiothorac Vasc Anesth 2017; 31:1779-1783. [PMID: 28764988 DOI: 10.1053/j.jvca.2017.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Patricia Pia Wadowski
- Department of Internal Medicine II, Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - Alessia Felli
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Arno Schiferer
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Philipp Opfermann
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Martin Dworschak
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | - Caroline Holaubek
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria
| | | | - Barbara Steinlechner
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Medical University of Vienna, Vienna, Austria.
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