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Gómez-Alonso J, Martínez Martínez M, Bonilla Rojas CA, García Díaz HC, Riera Del Brio J, Gorgas Torner MQ, Doménech-Moral L. Management of heparin-induced thrombocytopenia during extracorporeal membrane oxygenation support: a case of neutropenia caused by argatroban anticoagulation. Eur J Hosp Pharm 2024:ejhpharm-2023-003914. [PMID: 38272648 DOI: 10.1136/ejhpharm-2023-003914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
We present the case of a man in his 70s admitted to the intensive care unit (ICU) after mitral valve replacement and coronary artery bypass graft surgery requiring extracorporeal membrane oxygenation support due to haemodynamic instability. He received anticoagulation therapy with heparin sodium and, after 5 days, the patient presented with thrombocytopenia and deep venous thrombosis. Heparin-induced thrombocytopenia was suspected based on a positive 4T score and confirmed by antiplatelet factor 4/heparin antibodies, so argatroban was initiated as an alternative anticoagulation therapy. In the following days the patient developed severe neutropenia requiring discontinuation of argatroban and the administration of granulocyte colony-stimulating factor. According to the Naranjo Adverse Drug Reaction Probability Scale, this event would be classified as a 'probable' argatroban-related adverse event. Argatroban should be conisdered as a possible cause of neutropenia and appropriate interventions need to be implemented due to the gravity of this adverse event in the ICU.
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2
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Graboyes SDT, Owen PS, Evans RA, Berei TJ, Hryniewicz KM, Hollis IB. Review of anticoagulation considerations in extracorporeal membrane oxygenation support. Pharmacotherapy 2023; 43:1339-1363. [PMID: 37519116 DOI: 10.1002/phar.2857] [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] [Received: 01/27/2023] [Revised: 06/10/2023] [Accepted: 06/16/2023] [Indexed: 08/01/2023]
Abstract
Since its first success in 1975, extracorporeal membrane oxygenation (ECMO) has been used with increasing frequency for pulmonary and cardiopulmonary bypass. Use in adults has increased exponentially since the early 2000s, but despite thousands of international cannulations using both veno-arterial (VA) and veno-venous (VV) ECMO, there are still significant hemocompatibility-related adverse events. Current management of anticoagulation has been based on the Extracorporeal Life Support Organization guidance published in 2014 with recent updates published in 2022. Despite this guidance, there is still limited international consensus on how to manage anticoagulation in ECMO. For this review, we completed a comprehensive search of multiple electronic databases to identify studies pertaining to anticoagulation of adult patients on VV or VA-ECMO. The highest priority was given to sources that were prospective, randomized, controlled studies, but in the absence of such resources, observational studies, retrospective uncontrolled studies, and case series/reports were considered for inclusion. This document serves to provide a comprehensive review of the current understanding of management pertaining to anticoagulation relating to ECMO.
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Affiliation(s)
- Sydney D T Graboyes
- Department of Pharmacy, University of California, Davis Medical Center, Sacramento, California, USA
| | - Phillip S Owen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Rickey A Evans
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Theodore J Berei
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Katarzyna M Hryniewicz
- Heart Failure Section, Minneapolis Heart Institute at Abbot Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Ian B Hollis
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
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3
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Tang S, Xu L, Li H, Wu Z, Wen Q. Anticoagulants in adult extracorporeal membrane oxygenation: alternatives to standardized anticoagulation with unfractionated heparin. Eur J Clin Pharmacol 2023; 79:1583-1594. [PMID: 37740749 DOI: 10.1007/s00228-023-03568-3] [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] [Received: 06/21/2023] [Accepted: 09/14/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a vital technique for severe respiratory or heart failure patients. Bleeding and thrombotic events are common during ECMO and negatively impact patient outcomes. Unfractionated heparin is the primary anticoagulant, but its adverse effects limit its use, necessitating alternative anticoagulants. OBJECTIVE Review available alternative anticoagulants for adult ECMO patients. Explore potential novel anticoagulants for future ECMO use. Aim to reduce complications (bleeding and thrombosis) and improve safety and efficacy for critically ill ECMO patients. METHODS Comprehensive literature review of existing and emerging anticoagulants for ECMO. RESULTS Identified a range of alternative anticoagulants beyond unfractionated heparin. Evaluated their potential utility in mitigating ECMO-related complications. CONCLUSION Diverse anticoagulant options are available and under investigation for ECMO. These alternatives may enhance patient safety and outcomes during ECMO support. Further research and clinical studies are warranted to determine their effectiveness and safety profiles.
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Affiliation(s)
- Shu Tang
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Liqing Xu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hui Li
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhanshen Wu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiang Wen
- Institute of Clinical Pharmacology, Zhengzhou University, Zhengzhou, China
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Lüsebrink E, Scherer C, Binzenhöfer L, Hoffmann S, Höpler J, Kellnar A, Thienel M, Joskowiak D, Peterß S, Petzold T, Deseive S, Hein R, Brunner S, Kääb S, Braun D, Theiss H, Hausleiter J, Hagl C, Massberg S, Orban M. Heparin-Induced Thrombocytopenia in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation. J Clin Med 2023; 12:jcm12010362. [PMID: 36615162 PMCID: PMC9821297 DOI: 10.3390/jcm12010362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/17/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
Background: Heparin-induced thrombocytopenia (HIT) is a serious, immune-mediated adverse drug reaction to unfractionated heparin (UFH) affecting also patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO). Although the association between VA-ECMO support and the development of thrombocytopenia has long been known and discussed, HIT as one underlying cause is still insufficiently understood. Therefore, the purpose of this study was to further investigate the epidemiology, mortality, diagnosis, and clinical management of HIT occurring in VA-ECMO patients treated with UFH. Methods: We conducted a retrospective single-center study including adult patients (≥18 years) with VA-ECMO support in the cardiac intensive care unit (ICU) of the University Hospital of Munich (LMU) between January 2013 and May 2022, excluding patients with a known history of HIT upon admission. Differences in baseline characteristics and clinical outcome between excluded HIT (positive anti-platelet factor 4 (PF4)/heparin antibody test but negative functional assay) and confirmed HIT (positive anti-PF4/heparin antibody test and positive functional assay) VA-ECMO patients as well as diagnosis and clinical management of HIT were analysed. Results: Among the 373 patients included, anti-PF4/heparin antibodies were detected in 53/373 (14.2%) patients. Functional HIT testing confirmed HIT in 13 cases (3.5%) and excluded HIT in 40 cases (10.7%), corresponding to a prevalence of confirmed HIT of 13/373 (3.5%) [1.6, 5.3] and a positive predictive value (PPV) of 24.5% for the antibody screening test. The platelet course including platelet recovery following argatroban initiation was similar between all groups. One-month mortality in patients with excluded HIT was 14/40 (35%) and 3-month mortality 17/40 (43%), compared to 5/13 (38%) (p > 0.999), and 6/13 (46%) (p > 0.999) in patients with confirmed HIT. Neurological outcome in both groups measured by the cerebral performance category of survivors on hospital discharge was similar, as well as adverse events during VA-ECMO therapy. Conclusions: With a prevalence of 3.5%, HIT is a non-frequent complication in patients on VA-ECMO and was not associated with a higher mortality rate. HIT was ultimately excluded by functional essay in 75% of VA-ECMO patients with clinical suspicion of HIT and positive anti-PF4/heparin antibody test. Argatroban seems to be an appropriate and safe therapeutic option for confirmed HIT-positive patients on VA-ECMO support.
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Affiliation(s)
- Enzo Lüsebrink
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
- Correspondence:
| | - Clemens Scherer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Leonhard Binzenhöfer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Sabine Hoffmann
- Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Klinikum der Universität München, 81377 Munich, Germany
| | - Julia Höpler
- Institut für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Klinikum der Universität München, 81377 Munich, Germany
| | - Antonia Kellnar
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Manuela Thienel
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Dominik Joskowiak
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Sven Peterß
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Tobias Petzold
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Simon Deseive
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Ralph Hein
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Stefan Brunner
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Stefan Kääb
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Daniel Braun
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Hans Theiss
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Martin Orban
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
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Lubnow M, Berger J, Schneckenpointner R, Zeman F, Lunz D, Philipp A, Foltan M, Lehle K, Heimerl S, Hart C, Schmid C, Fisser C, Müller T. Prevalence and outcomes of patients developing heparin-induced thrombocytopenia during extracorporeal membrane oxygenation. PLoS One 2022; 17:e0272577. [PMID: 35939484 PMCID: PMC9359525 DOI: 10.1371/journal.pone.0272577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/21/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives Unfractionated heparin (UFH) is the commonly used anticoagulant to prevent clotting of the ECMO circuit and thrombosis of the cannulated vessels. A side effect of UFH is heparin-induced thrombocytopenia (HIT). Little is known about HIT during ECMO and the impact of changing anticoagulation in ECMO patients with newly diagnosed HIT. The aim of the study was to determine the prevalence, complications, impact of switching anticoagulation to argatroban and outcomes of patients developing heparin-induced thrombocytopenia (HIT) during either veno-venous (VV) or veno-arterial (VA) ECMO. Methods Retrospective observational single centre study of prospectively collected data of consecutive patients receiving VV ECMO therapy for severe respiratory failure and VA ECMO for circulatory failure from January 2006 to December 2016 of the Medical intensive care unit (ICU) of the University Hospital of Regensburg. Treatment of HIT on ECMO was done with argatroban. Results 507 patients requiring ECMO were included. Further HIT-diagnostic was conducted if HIT-4T-score was ≥4. The HIT-confirmed group had positive HIT-enzyme-linked-immunosorbent-assay (ELISA) and positive heparin-induced-platelet-activation (HIPA) test, the HIT-suspicion group a positive HIT-ELISA and missing HIPA but remained on alternative anticoagulation until discharge and the HIT-excluded group a negative or positive HIT-ELISA, however negative HIPA. These were compared to group ECMO-control without any HIT suspicion. The prevalence of HIT-confirmed was 3.2%, of HIT-suspicion 2.0% and HIT-excluded 10.8%. Confirmed HIT was trendwise more frequent in VV than in VA (3.9 vs. 1.7% p = 0.173). Compared to the ECMO control group, patients with confirmed HIT were longer on ECMO (median 13 vs. 8 days, p = 0.002). Different types of complications were higher in the HIT-confirmed than in the ECMO-control group, but in-hospital mortality was not different (31% vs. 41%, p = 0.804). Conclusion HIT is rare on ECMO, should be suspected, if platelets are decreasing, but seems not to increase mortality if treated promptly.
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Affiliation(s)
- Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
- * E-mail:
| | - Johannes Berger
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Roland Schneckenpointner
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Bavaria, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Karla Lehle
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Susanne Heimerl
- Department of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Christina Hart
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Bavaria, Germany
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6
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Abstract
DISCLAIMER These guidelines for adult and pediatric anticoagulation for extracorporeal membrane oxygenation are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing ECLS / ECMO and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Elliott A, Dahyia G, Kalra R, Alexy T, Bartos J, Kosmopoulos M, Yannopoulos D. Extracorporeal Life Support for Cardiac Arrest and Cardiogenic Shock. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The rising incidence and recognition of cardiogenic shock has led to an increase in the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). As clinical experience with this therapy has increased, there has also been a rapid growth in the body of observational and randomized data describing the clinical and logistical considerations required to institute a VA-ECMO program with successful clinical outcomes. The aim of this review is to summarize this contemporary data in the context of four key themes that pertain to VA-ECMO programs: the principles of patient selection; basic hemodynamic and technical principles underlying VA-ECMO; contraindications to VA-ECMO therapy; and common complications and intensive care considerations that are encountered in the setting of VA-ECMO therapy.
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Affiliation(s)
- Andrea Elliott
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Garima Dahyia
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Rajat Kalra
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Tamas Alexy
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Jason Bartos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Department of Medicine, Division of Cardiology, Center for Resuscitation Medicine, University of Minnesota, Minneapolis, MN
| | - Demetri Yannopoulos
- Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN
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Páramo JA, Lozano ML, González-Porras JR, Mateo J. Current status of diagnosis and treatment of heparin-induced thrombocytopenia (HIT). Med Clin (Barc) 2021; 158:82-89. [PMID: 34311973 DOI: 10.1016/j.medcli.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 12/01/2022]
Affiliation(s)
- José A Páramo
- Servicio de Hematología Clínica, Universidad de Navarra, Pamplona, España; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, España; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, España.
| | - Mª Luisa Lozano
- Departmento de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Murcia, España; Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Murcia, España
| | | | - José Mateo
- Unidad de Hemostasia y Trombosis, Servicio de Hematología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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9
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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. 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] [MESH Headings] [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
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10
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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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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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12
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Lüsebrink E, Orban M, Kupka D, Scherer C, Hagl C, Zimmer S, Luedike P, Thiele H, Westermann D, Massberg S, Schäfer A, Orban M. Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock. Eur Heart J 2021; 41:3753-3761. [PMID: 33099278 DOI: 10.1093/eurheartj/ehaa547] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/07/2020] [Accepted: 06/15/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiogenic shock is still a major driver of mortality on intensive care units and complicates ∼10% of acute coronary syndromes with contemporary mortality rates up to 50%. In the meantime, percutaneous circulatory support devices, in particular venoarterial extracorporeal membrane oxygenation (VA-ECMO), have emerged as an established salvage intervention for patients in cardiogenic shock. Venoarterial extracorporeal membrane oxygenation provides temporary circulatory support until other treatments are effective and enables recovery or serves as a bridge to ventricular assist devices, heart transplantation, or decision-making. In this critical care perspective, we provide a concise overview of VA-ECMO utilization in cardiogenic shock, considering rationale, critical care management, as well as weaning aspects. We supplement previous literature by focusing on therapeutic issues related to the vicious circle of retrograde aortic VA-ECMO flow, increased left ventricular (LV) afterload, insufficient LV unloading, and severe pulmonary congestion limiting prognosis in a relevant proportion of patients receiving VA-ECMO treatment. We will outline different modifications in percutaneous mechanical circulatory support to meet this challenge. Besides a strategy of running ECMO at lowest possible flow rates, novel therapeutic options including the combination of VA-ECMO with percutaneous microaxial pumps or implementation of a venoarteriovenous-ECMO configuration based on an additional venous cannula supplying towards pulmonary circulation are most promising among LV unloading and venting strategies. The latter may even combine the advantages of venovenous and venoarterial ECMO therapy, providing potent respiratory and circulatory support at the same time. However, whether VA-ECMO can reduce mortality has to be evaluated in the urgently needed, ongoing prospective randomized studies EURO-SHOCK (NCT03813134), ANCHOR (NCT04184635), and ECLS-SHOCK (NCT03637205). These studies will provide the opportunity to investigate indication, mode, and effect of LV unloading in dedicated sub-analyses. In future, the Heart Teams should aim at conducting a dedicated randomized trial comparing VA-ECMO support with vs. without LV unloading strategies in patients with cardiogenic shock.
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Affiliation(s)
- Enzo Lüsebrink
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Danny Kupka
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Clemens Scherer
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Sebastian Zimmer
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53127 Bonn, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45122 Essen, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology, Leipzig Heart Institute, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Dirk Westermann
- Klinik für Allgemeine und Interventionelle Kardiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Steffen Massberg
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Andreas Schäfer
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Martin Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
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13
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New challenges in cardiac intensive care units. Clin Res Cardiol 2021; 110:1369-1379. [PMID: 33966127 DOI: 10.1007/s00392-021-01869-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
Critical care cardiology is a steadily and rapidly developing sub-specialization within cardiovascular medicine, since the first emergence of a coronary care unit in the early 1960s. Today, modern cardiac intensive care units (CICU) serve a complex patient population with a high burden of cardiovascular and non-cardiovascular critical illnesses. Treatment of these patients requires a multidisciplinary approach, with a combination of highly specialized knowledge and skills in cardiovascular diseases, as well as emergency, critical-care and internal medicine. The CICU has always posed special challenges to both experienced intensivists as well as fellows-in-training (FIT) and is certainly one of the most demanding training phases. In recent years, these challenges have grown significantly owing to technological innovations, with new and steadily rising numbers of complex interventional procedures and new options for temporary circulatory support for critically ill patients, such as venoarterial extracorporeal membrane oxygenation (VA-ECMO). Herein, we focus on the successful CICU management of these special patient cohorts, which must become an integral part of critical-care training.
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14
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Kumar G, Maskey A. Anticoagulation in ECMO patients: an overview. Indian J Thorac Cardiovasc Surg 2021; 37:241-247. [PMID: 33967447 DOI: 10.1007/s12055-021-01176-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 12/16/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of cardiorespiratory support, and is being increasingly used to support refractory heart and respiratory failure. It involves draining blood from the vascular system, which is then circulated outside the body by a mechanical pump and then later reinfused back into the circulation. The blood that is circulated outside the body comes in contact with a large surface area of non-endothelial biosurface. This exposure leads to a pro-thrombotic state, and hence anticoagulation is required. Unfractionated heparin is the most commonly used anticoagulation in most ECMO centers, but it does require close monitoring. Despite the advances made, hemostasis remains a challenge for physicians who manage patients on ECMO.
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Affiliation(s)
- Gaurav Kumar
- Department of Pulmonary Critical Care and Sleep Medicine, University of Kentucky, 740 S. Limestone, Second Floor, Wing C, Room 211, Lexington, KY 40536 USA
| | - Ashish Maskey
- Department of Pulmonary Critical Care and Sleep Medicine, Kentucky Clinic, University of Kentucky, 740 S. Limestone, 5th Floor L543, Lexington, KY 40536 USA
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15
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Geli J, Capoccia M, Maybauer DM, Maybauer MO. Argatroban Anticoagulation for Adult Extracorporeal Membrane Oxygenation: A Systematic Review. J Intensive Care Med 2021; 37:459-471. [PMID: 33653194 DOI: 10.1177/0885066621993739] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Heparin is the widely used anti-coagulation strategy for patients on extracorporeal membrane oxygenation (ECMO). Nevertheless, heparin-induced thrombocytopenia (HIT) and acquired anti-thrombin (AT) deficiency preclude the use of heparin requiring utilization of an alternative anticoagulant agent. Direct thrombin inhibitors are being proposed as potential alternatives with argatroban as one of the main agents. We aimed to review the evidence with regard to safety and efficacy of argatroban as a potential definitive alternative to heparin in the adult patient population undergoing ECMO support. METHODS A web-based systematic literature search was performed in Medline (PubMed) and Embase from inception until June 18, 2020. RESULTS The search identified 13 publications relevant to the target (4 cohort studies and 9 case series). Case reports and case series with less than 3 cases were not included in the qualitative synthesis. The aggregate number of argatroban treated patients on ECMO was n = 307. In the majority of studies argatroban was used as a continuous infusion without loading dose. Starting doses on ECMO varied between 0.05 and 2 μg/kg/min and were titrated to achieve the chosen therapeutic target range. The activated partial thormboplastin time (aPTT) was the anticoagulation parameter used for monitoring purposes in most studies, whereas some utilized the activated clotting time (ACT). Optimal therapeutic targets varied between 43-70 and 60-100 seconds for aPTT and between 150-210 and 180-230 seconds for ACT. Bleeding and thromboembolic complication rates were comparable to patients treated with unfractionated heparin (UFH). CONCLUSIONS Argatroban infusion rates and anticoagulation target ranges showed substantial variations. The rational for divergent dosing and monitoring approaches are discussed in this paper. Argatroban appears to be a potential alternative to UFH in patients requiring ECMO. To definitively establish its safety, efficacy and ideal dosing strategy, larger prospective studies on well-defined patient populations are warranted.
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Affiliation(s)
- Janos Geli
- Department of Cardiothoracic Anaesthesia and Critical Care, 59562Karolinska University Hospital, Stockholm, Sweden
| | - Massimo Capoccia
- Department of Aortic and Cardiac Surgery, 156726Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Dirk M Maybauer
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
| | - Marc O Maybauer
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany.,Department of Anaesthesia, 105551Manchester Royal Infirmary, Manchester University NHS Foundation Trust, The University of Manchester and Manchester Academic Health Science Centre, Manchester, United Kingdom.,Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Queensland, Australia.,Nazih Zuhdi Transplant Institute, Advanced Critical Care, Integris Baptist Medical Centre, Oklahoma City, and Oklahoma State University, Tulsa, Oklahoma, USA
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16
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Phan XT, Nguyen TH, Tran TT, Huynh THT, Hoang THT, Nguyen VCV, Pham TNT. Suspected heparin-induced thrombocytopenia in a COVID-19 patient on extracorporeal membrane oxygenation support: a case report. Thromb J 2020; 18:37. [PMID: 33317566 PMCID: PMC7734386 DOI: 10.1186/s12959-020-00252-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/09/2020] [Indexed: 12/20/2022] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) support can be life-saving in critically ill COVID-19 patients. However, there are many complications associated with this procedure, including Heparin-induced thrombocytopenia (HIT.) Despite its rarity in ECMO cases, HIT can lead to devastating consequences and is difficult to manage. Case presentation In this report, we present a case of a COVID-19 patient on ECMO support who was diagnosed with HIT and required intensive treatment. Initially, HIT was only suspected due to newly-developed thrombocytopenia and oxygenator dysfunction, with thrombi observed later. Regarding his treatment, since there was no recommended replacement to heparin available to us at the time of diagnosis, we decided to use rivaroxaban temporarily. No adverse events were recorded during that period. The patient was able to make a full recovery. Conclusion HIT may jeopardize patient’s care during ECMO. As COVID-19 may bring about a surge in the number of patients requiring ECMO support, we need consented guidance to optimize treatment in this specific situation.
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Affiliation(s)
- Xuan T Phan
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Tuan H Nguyen
- Department of Hematology, Cho Ray Hospital, 201B Nguyen Chi Thanh Street, Ward 12, District 5, Ho Chi Minh City, Vietnam.
| | - Tung T Tran
- Department of Hematology, Cho Ray Hospital, 201B Nguyen Chi Thanh Street, Ward 12, District 5, Ho Chi Minh City, Vietnam
| | - Thu-Hien T Huynh
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Thuy-Ha T Hoang
- Department of Hematology, Cho Ray Hospital, 201B Nguyen Chi Thanh Street, Ward 12, District 5, Ho Chi Minh City, Vietnam
| | - Vinh-Chau V Nguyen
- Hospital for Tropical Diseases in Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Thao N T Pham
- Intensive Care Unit, Cho Ray Hospital, Ho Chi Minh City, Vietnam
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17
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Nei SD, Pope HE. Part I: Anticoagulation for unique situations. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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18
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Dingman JS, Smith ZR, Coba VE, Peters MA, To L. Argatroban dosing requirements in extracorporeal life support and other critically ill populations. Thromb Res 2020; 189:69-76. [DOI: 10.1016/j.thromres.2020.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/22/2020] [Accepted: 02/26/2020] [Indexed: 12/27/2022]
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19
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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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20
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Burstein B, Wieruszewski PM, Zhao YJ, Smischney N. Anticoagulation with direct thrombin inhibitors during extracorporeal membrane oxygenation. World J Crit Care Med 2019; 8:87-98. [PMID: 31750086 PMCID: PMC6854393 DOI: 10.5492/wjccm.v8.i6.87] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 08/13/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
Use of extracorporeal membrane oxygenation to support patients with critical cardiorespiratory illness is increasing. Systemic anticoagulation is an essential element in the care of extracorporeal membrane oxygenation patients. While unfractionated heparin is the most commonly used agent, unfractionated heparin is associated with several unique complications that can be catastrophic in critically ill patients, including heparin-induced thrombocytopenia and acquired antithrombin deficiency. These complications can result in thrombotic events and subtherapeutic anticoagulation. Direct thrombin inhibitors (DTIs) are emerging as alternative anticoagulants in patients supported by extracorporeal membrane oxygenation. Increasing evidence supports DTIs use as safe and effective in extracorporeal membrane oxygenation patients with and without heparin-induced thrombocytopenia. This review outlines the pharmacology, dosing strategies and available protocols, monitoring parameters, and special use considerations for all available DTIs in extracorporeal membrane oxygenation patients. The advantages and disadvantages of DTIs in extracorporeal membrane oxygenation relative to unfractionated heparin will be described.
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Affiliation(s)
- Barry Burstein
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | | | - Yan-Jun Zhao
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, United States
| | - Nathan Smischney
- Department of Anesthesia, Mayo Clinic, Rochester, MN 55905, United States
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21
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Pollak U. Heparin-induced thrombocytopenia complicating extracorporeal membrane oxygenation support: Review of the literature and alternative anticoagulants. J Thromb Haemost 2019; 17:1608-1622. [PMID: 31313454 DOI: 10.1111/jth.14575] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/25/2019] [Accepted: 07/11/2019] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening prothrombotic, immune-mediated complication of unfractionated heparin and low molecular weight heparin therapy. HIT is characterized by moderate thrombocytopenia 5-10 days after initial heparin exposure, detection of platelet-activating anti-platelet factor 4/heparin antibodies and an increased risk of venous and arterial thrombosis. Extracorporeal membrane oxygenation (ECMO) is a form of mechanical circulatory support used in critically ill patients with respiratory or cardiac failure. Systemic anticoagulation is used to alleviate the thrombotic complications that may occur when blood is exposed to artificial surfaces within the ECMO circuit. Therefore, when HIT complicates patients on ECMO support, it is associated with a high thrombotic morbidity and mortality. The risk for HIT correlates with the accumulative dosage of heparin exposure. In ECMO patients receiving continuous infusion of heparin for circuit patency, the risk for HIT is not neglected and must be thought of in the differential diagnosis of the appropriate clinical and laboratory circumstances. The following article reviews the current knowledge in HIT complicating ECMO patients and the alternative anticoagulation options in the presence of HIT.
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Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Jerusalem, Israel
- Pediatric Cardiology, Hadassah University Medical Center, Jerusalem, Israel
- Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel
- The Hebrew University Hadassah Medical School, Jerusalem, Israel
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22
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Lunz D, Philipp A, Müller T, Pfister K, Foltan M, Rupprecht L, Schmid C, Lubnow M, Graf B, Sinner B. Ischemia-related vascular complications of percutaneously initiated venoarterial extracorporeal membrane oxygenation: Indication setting, risk factors, manifestation and outcome. J Crit Care 2019; 52:58-62. [DOI: 10.1016/j.jcrc.2019.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/18/2019] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
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23
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Pabst D, Boone JB, Soleimani B, Brehm CE. Heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation and the role of a heparin-bonded circuit. Perfusion 2019; 34:584-589. [DOI: 10.1177/0267659119842056] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: In patients supported with extracorporeal membrane oxygenation, and who develop heparin-induced thrombocytopenia, there is no clear evidence to support changing to a non-heparin-coated extracorporeal membrane oxygenation circuit. Our goal was to evaluate clinical outcomes of patients who were continued on heparin-bonded circuits despite diagnosed heparin-induced thrombocytopenia. Methods: We completed a single-center retrospective study of all patients who underwent extracorporeal membrane oxygenation support from July 2008 to July 2017 and were tested heparin-induced thrombocytopenia positive while on extracorporeal membrane oxygenation support. After diagnosis of heparin-induced thrombocytopenia, mean platelet count (k/µL) was measured on consecutive days for 14 days. Results: Out of 455 patients, 14 (3.1%) had a diagnosis of heparin-induced thrombocytopenia by serotonin release assay and systemic heparin treatment was discontinued in every case. In total, 11 of the heparin-induced thrombocytopenia patients (78.6%) survived to discharge. The overall survival of all 455 extracorporeal membrane oxygenation patients was 54.1%. Platelets counts after discontinuation of systemic heparin in the heparin-induced thrombocytopenia patients increased from a mean of 59.8 k/µL at time of heparin-induced thrombocytopenia diagnosis to a mean of 280.2 k/µL at 14 days after discontinuation of heparin despite continuation of the heparin-bonded circuit. Platelet count increased in heparin-induced thrombocytopenia patients on extracorporeal membrane oxygenation support after discontinuation of systemic heparin even if maintained on the heparin-bonded circuit. Conclusion: Discontinuation of systemic heparin but continuation of heparin-coated extracorporeal membrane oxygenation circuits appeared to be an appropriate response for our extracorporeal membrane oxygenation–supported patients who developed heparin-induced thrombocytopenia. Survival in this group was not significantly different to those patients on extracorporeal membrane oxygenation without heparin-induced thrombocytopenia. Larger studies should evaluate the safety of heparin-bonded extracorporeal membrane oxygenation systems in heparin-induced thrombocytopenia patients.
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Affiliation(s)
- Dirk Pabst
- Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
- Center for Emergency Medicine, University Hospital Essen, Essen, Germany
| | | | - Behzad Soleimani
- Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Christoph E Brehm
- Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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24
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Choi JH, Luc JGY, Weber MP, Reddy HG, Maynes EJ, Deb AK, Samuels LE, Morris RJ, Massey HT, Loforte A, Tchantchaleishvili V. Heparin-induced thrombocytopenia during extracorporeal life support: incidence, management and outcomes. Ann Cardiothorac Surg 2019; 8:19-31. [PMID: 30854309 DOI: 10.21037/acs.2018.12.02] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Heparin-induced thrombocytopenia (HIT) is a severe antibody-mediated reaction leading to transient prothrombosis. However, its incidence in patients on extracorporeal life support (ECLS) is not well described. The aim of this systematic review was to report the incidence of HIT in patients on ECLS, as well as compare the characteristics and outcomes of HIT in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and veno-venous ECMO (VV-ECMO). Methods An electronic search was performed to identify all studies in the English literature examining outcomes of patients with HIT on ECLS. All identified articles were systematically assessed using specific inclusion and exclusion criteria. Random effects meta-analysis as well as univariate analysis was performed. Results Of 309 patients from six retrospective studies undergoing ECLS, 83% were suspected, and 17% were confirmed to have HIT. Due to the sparsity of relevant retrospective data regarding patients with confirmed HIT on ECLS, patient-based data was subsequently collected on 28 patients from case reports and case series. Out of these 28 patients, 53.6% and 46.4% of them underwent VA-ECMO and VV-ECMO, respectively. Patients on VA-ECMO had a lower median platelet count nadir (VA-ECMO: 26.0 vs. VV-ECMO: 45.0 per µL, P=0.012) and were more likely to experience arterial thromboembolism (VA-ECMO: 53.3% vs. VV-ECMO: 0.0%, P=0.007), though there was a trend towards decreased likelihood of experiencing ECLS circuit oxygenator thromboembolism (VA-ECMO: 0.0% vs. VV-ECMO: 30.8%, P=0.075) and thromboembolism necessitating ECLS device or circuit exchange (VA-ECMO: 13.3% vs. VV-ECMO 53.8%, P=0.060). Kaplan-Meier survival plots including time from ECLS initiation reveal no significant differences in survival in patients supported on VA-ECMO as compared to VV-ECMO (P=0.300). Conclusions Patients who develop HIT on VA-ECMO are more likely to experience more severe thrombocytopenia and arterial thromboembolism than those on VV-ECMO. Further research in this area and development of standardized protocols for the monitoring, diagnosis and management of HIT in patients on ECLS support are warranted.
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Affiliation(s)
- Jae Hwan Choi
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jessica G Y Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew P Weber
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Haritha G Reddy
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elizabeth J Maynes
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Avijit K Deb
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Louis E Samuels
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rohinton J Morris
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Antonio Loforte
- Department of Cardiovascular Surgery and Transplantation, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Keebler ME, Haddad EV, Choi CW, McGrane S, Zalawadiya S, Schlendorf KH, Brinkley DM, Danter MR, Wigger M, Menachem JN, Shah A, Lindenfeld J. Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock. JACC-HEART FAILURE 2018; 6:503-516. [PMID: 29655828 DOI: 10.1016/j.jchf.2017.11.017] [Citation(s) in RCA: 149] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/13/2017] [Accepted: 11/13/2017] [Indexed: 01/19/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation has emerged as a viable treatment for patients in cardiogenic shock with biventricular failure and pulmonary dysfunction. Advances in pump and oxygenator technology, cannulation strategies, patient selection and management, and durable mechanical circulatory support have contributed to expanded utilization of this technology. However, challenges remain that require investigation to improve outcomes.
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Affiliation(s)
- Mary E Keebler
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Elias V Haddad
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chun W Choi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stuart McGrane
- Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandip Zalawadiya
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly H Schlendorf
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - D Marshall Brinkley
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew R Danter
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark Wigger
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan N Menachem
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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