Therapeutic plasma exchange in heart transplantation: role of coagulation assessment with thromboelastometry

Viscoelastic Haemostatic Assays in Cardiovascular Critical Care

The initiation and management of anticoagulation is a fundamental practice for a wide variety of indications in cardiovascular critical care, including the management of patients with acute MI, stroke prevention in patients with AF or mechanical valves, as well as the prevention of device thrombosis and thromboembolic events with the use of mechanical circulatory support and ventricular assist devices. The frequent use of antiplatelet and anticoagulation therapy, in addition to the presence of concomitant conditions that may lead to a propensity to bleed, such as renal and liver dysfunction, present unique challenges. The use of viscoelastic haemostatic assays provides an additional tool allowing clinicians to strike a delicate balance of attaining adequate anticoagulation while minimising the risk of bleeding complications. In this review, the authors discuss the role that viscoelastic haemostatic assay plays in cardiac populations (including cardiac surgery, heart transplantation, extracorporeal membrane oxygenation, acute coronary syndrome and left ventricular assist devices), and identify areas in need of further study.

Literature review of apheresis procedures performed perioperatively in cardiac surgery for ASFA category indications

BACKGROUND

Perioperative therapeutic plasma exchange in patients with cardiovascular diseases poses several challenges, including alterations in intravascular volume, serum electrolytes, the coagulation cascade, and drug pharmacokinetics.

METHODS

This review article summarizes different indications of plasma exchange for patients requiring cardiac surgery based on reported case reports and case series.

RESULTS

The most common reported indication is plasma exchange for the management of allosensitized cardiac transplant candidate patients in combination with immunosuppressive regimens, which increases the likelihood of obtaining a cross-match-negative allograft, improving post-transplant clinical outcome. The second most common indication is for patients with a history of heparin-induced thrombocytopenia syndrome that permits the use of heparin in cardiopulmonary bypass in an urgent cardiac surgery. Less common indications are restoration of clotting factors for patients with congenital bleeding disorders or removal of cold agglutinins. No severe complications were described in reported cases.

CONCLUSION

Therapeutic plasma exchange is an effective and safe procedure that could be performed preoperatively and intraoperatively in urgent cardiac surgery for the management of antibody-mediated disorders including allosensitized cardiac transplant candidate patients or patients with heparin-induced thrombocytopenia syndrome.