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Xu H, Fu XY, Bao YX, Zhu SY, Xu Z, Song M, Qi YK, Li Z, Du SS. d-type peptides based fluorescent probes for "turn on" sensing of heparin. Bioorg Chem 2024; 147:107356. [PMID: 38604021 DOI: 10.1016/j.bioorg.2024.107356] [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: 02/14/2024] [Revised: 03/26/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024]
Abstract
Developing "turn on" fluorescent probes was desirable for the detection of the effective anticoagulant agent heparin in clinical applications. Through combining the aggregation induced emission (AIE) fluorogen tetraphenylethene (TPE) and heparin specific binding peptide AG73, the promising "turn on" fluorescent probe TPE-1 has been developed. Nevertheless, although TPE-1 could achieve the sensitive and selective detection of heparin, the low proteolytic stability and undesirable poor solubility may limit its widespread applications. In this study, seven TPE-1 derived fluorescent probes were rationally designed, efficiently synthesized and evaluated. The stability and water solubility were systematically estimated. Especially, to achieve real-time monitoring of proteolytic stability, the novel Abz/Dnp-based "turn on" probes that employ the internally quenched fluorescent (IQF) mechanism were designed and synthesized. Moreover, the detection ability of synthetic fluorescent probes for heparin were systematically evaluated. Importantly, the performance of d-type peptide fluorescent probe XH-6 indicated that d-type amino acid substitutions could significantly improve the proteolytic stability without compromising its ability of heparin sensing, and attaching solubilizing tag 2-(2-aminoethoxy) ethoxy) acid (AEEA) could greatly enhance the solubility. Collectively, this study not only established practical strategies to improve both the water solubility and proteolytic stability of "turn on" fluorescent probes for heparin sensing, but also provided valuable references for the subsequent development of enzymatic hydrolysis-resistant d-type peptides based fluorescent probes.
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Affiliation(s)
- Huan Xu
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao 266042, China
| | - Xing-Yan Fu
- School of Pharmacy, Qingdao University Medical College, Qingdao University, Qingdao 266073, China; Institute of Innovative Drugs, Qingdao University, Qingdao 266021, China
| | - Yong-Xin Bao
- Department of Anesthesiology, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, Shandong 266034, China
| | - Shu-Ya Zhu
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao 266042, China
| | - Zi Xu
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao 266042, China
| | - Min Song
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao 266042, China
| | - Yun-Kun Qi
- School of Pharmacy, Qingdao University Medical College, Qingdao University, Qingdao 266073, China; Institute of Innovative Drugs, Qingdao University, Qingdao 266021, China.
| | - Zhibo Li
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao 266042, China.
| | - Shan-Shan Du
- State Key Laboratory Base for Eco-Chemical Engineering in College of Chemical Engineering, Qingdao University of Science and Technology, Qingdao 266042, China; School of Pharmacy, Qingdao University Medical College, Qingdao University, Qingdao 266073, China; Institute of Innovative Drugs, Qingdao University, Qingdao 266021, China.
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Nadtochiy SM, Stefanos T, Wissler R, Gu Y, Feng C, Lebedko N, Eaton MP. Effect of bivalirudin on coagulation in neonatal (cord) and adult human blood in vitro. Paediatr Anaesth 2024; 34:415-421. [PMID: 38055634 DOI: 10.1111/pan.14814] [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: 07/19/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Bivalirudin is recommended as an alternative to heparin in cardiac surgery with cardiopulmonary bypass. Although it has been used in infants and children for this indication, there is a paucity of data on the pharmacologic effects of bivalirudin in neonates. Given the immaturity of the hemostatic system in neonates, we hypothesized that coagulation responses to bivalirudin in this population would be different than in adults. METHODS Blood samples were drawn from placenta-cord units and from healthy adult donors. The study was carried out in two steps. First, bivalirudin was added to cord and adult blood samples at concentrations of 0, 5, 10, 15, and 20 μg/mL. Activated clotting time and thromboelastographic variables were recorded. Next, we used a Chandler loop system to assess the efficacy of bivalirudin in a simple model of cardiopulmonary bypass. The loops were primed with cord or adult blood and were run until thrombus was detected. Plasma bivalirudin concentrations were measured at 1, 15, 30, 45, 60, and 75 min after initiating rotation of the loops using liquid chromatography/mass spectrometry. RESULTS Bivalirudin elicited a dose-dependent prolongation inhibition of coagulation in both cord and adult blood samples with greater potency in cord blood in comparison to adult blood (activated clotting time: 627 ± 50 vs. 452 ± 22 s at 15 μg/mL bivalirudin, p < .0001). This relative potency was also demonstrated in the Chandler loop system, but interestingly, cord blood appeared to inactivate bivalirudin more rapidly than adult blood with earlier clotting in loops containing cord blood. CONCLUSIONS This study demonstrates that bivalirudin has greater potency in cord blood in vitro than in adult blood. Plasma degradation appears to proceed more rapidly in cord blood than in adults. Both of these findings should be considered when planning dosing regimens in neonatal patients.
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Affiliation(s)
- Sergiy M Nadtochiy
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Tatsiana Stefanos
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Richard Wissler
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Yang Gu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Changyong Feng
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Natalie Lebedko
- School of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Michael P Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Moriguchi G, Umehara T, Yano Y, Fujita T, Kishima H. Paradoxical Worsening of Cerebral Venous Sinus Thrombosis Due to Heparin-Induced Thrombocytopenia: A Case Report and Literature Review. Cureus 2024; 16:e58124. [PMID: 38738156 PMCID: PMC11088870 DOI: 10.7759/cureus.58124] [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] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Development of cerebral venous sinus thrombosis (CVST) is a rare manifestation of heparin-induced thrombocytopenia (HIT). Herein, we present a case in which heparin administration for primary CVST caused paradoxical worsening of CVST secondary to HIT. A 53-year-old woman diagnosed with CVST was provided with intravenous unfractionated heparin therapy. After 12 days, the patient presented tonic convulsive seizures (TCS). Subsequent magnetic resonance image (MRI) scans revealed an exacerbation of cerebral edema with a subcortical hemorrhage on the left parietal lobe. Laboratory test results revealed a significant decline in platelet count. Heparin was immediately discontinued and replaced with argatroban. The definitive diagnosis of HIT was made through the presence of HIT antibodies. The present case, in which HIT caused the secondary CVST exacerbation, is distinctly rare. Our case provides an instructive example by highlighting the potential of TCS as the first sign of HIT development during CVST treatment.
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Affiliation(s)
- Gento Moriguchi
- Department of Neurosurgery, Hanwa Memorial Hospital, Osaka, JPN
| | - Toru Umehara
- Department of Neurosurgery, Hanwa Memorial Hospital, Osaka, JPN
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, JPN
| | - Yoshihiro Yano
- Department of Neurosurgery, Hanwa Memorial Hospital, Osaka, JPN
| | - Toshiaki Fujita
- Department of Neurosurgery, Hanwa Memorial Hospital, Osaka, JPN
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Suita, JPN
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Boldt D, Busse L, Chawla LS, Flannery AH, Khanna A, Neyra JA, Palmer P, Wilson J, Yessayan L. Anticoagulation practices for continuous renal replacement therapy: a survey of physicians from the United States. Ren Fail 2023; 45:2290932. [PMID: 38073554 PMCID: PMC11001369 DOI: 10.1080/0886022x.2023.2290932] [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: 09/11/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND During continuous renal replacement therapy (CRRT), anticoagulants are recommended for patients at low risk of bleeding and not already receiving systemic anticoagulants. Current anticoagulants used in CRRT in the US are systemic heparins or regional citrate. To better understand use of anticoagulants for CRRT in the US, we surveyed nephrologists and critical care medicine (CCM) specialists. METHODS The survey contained 30 questions. Respondents were board certified and worked in intensive care units of academic medical centers or community hospitals. RESULTS 150 physicians (70 nephrologists and 80 CCM) completed the survey. Mean number of CRRT machines in use increased ∼30% from the pre-pandemic era to 2022. Unfractionated heparin was the most used anticoagulant (43% of estimated patients) followed by citrate (28%). Respondents reported 29% of patients received no anticoagulant. Risk of hypocalcemia (52%) and citrate safety (42%) were the predominant reasons given for using no anticoagulant instead of citrate in heparin-intolerant patients. 84% said filter clogging was a problem when no anticoagulant was used, and almost 25% said increased transfusions were necessary. Respondents using heparin (n = 131) considered it inexpensive and easily obtainable, although of moderate safety, citing concerns of heparin-induced thrombocytopenia and bleeding. Anticoagulant citrate dextrose solution was the most used citrate. Respondents estimated that 37% of patients receiving citrate develop hypocalcemia and 17% citrate lock. CONCLUSIONS Given the increased use of CRRT and the lack of approved, safe, and effective anticoagulant choices for CRRT in the US, effective use of current and other anticoagulant options needs to be evaluated.
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Affiliation(s)
- David Boldt
- Department of Anesthesiology and Perioperative Medicine, UCLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA, USA
| | - Laurence Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
| | | | - Alexander H. Flannery
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Ashish Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Javier A. Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - James Wilson
- Department of Nephrology, UCLA Healthcare System and David Geffen School of Medicine, Los Angeles, CA, USA
| | - Lenar Yessayan
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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Warkentin TE. Autoimmune Heparin-Induced Thrombocytopenia. J Clin Med 2023; 12:6921. [PMID: 37959386 PMCID: PMC10649402 DOI: 10.3390/jcm12216921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/27/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
Autoimmune thrombocytopenia (aHIT) is a severe subtype of heparin-induced thrombocytopenia (HIT) with atypical clinical features caused by highly pathological IgG antibodies ("aHIT antibodies") that activate platelets even in the absence of heparin. The clinical features of aHIT include: the onset or worsening of thrombocytopenia despite stopping heparin ("delayed-onset HIT"), thrombocytopenia persistence despite stopping heparin ("persisting" or "refractory HIT"), or triggered by small amounts of heparin (heparin "flush" HIT), most cases of fondaparinux-induced HIT, and patients with unusually severe HIT (e.g., multi-site or microvascular thrombosis, overt disseminated intravascular coagulation [DIC]). Special treatment approaches are required. For example, unlike classic HIT, heparin cessation does not result in de-escalation of antibody-induced hemostasis activation, and thus high-dose intravenous immunoglobulin (IVIG) may be indicated to interrupt aHIT-induced platelet activation; therapeutic plasma exchange may be required if high-dose IVIG is ineffective. Also, aHIT patients are at risk for treatment failure with (activated partial thromboplastin time [APTT]-adjusted) direct thrombin inhibitor (DTI) therapy (argatroban, bivalirudin), either because of APTT confounding (where aHIT-associated DIC and resulting APTT prolongation lead to systematic underdosing/interruption of DTI therapy) or because DTI inhibits thrombin-induced protein C activation. Most HIT laboratories do not test for aHIT antibodies, contributing to aHIT under-recognition.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada; ; Tel.: +1-(905)-527-0271 (ext. 46139)
- Service of Benign Hematology, Hamilton Health Sciences (General Site), Hamilton, ON L8L 2X2, Canada
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, ON L8L 2X2, Canada
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Cosmi B, Legnani C, Cini M, Borgese L, Sartori M, Palareti G. Incidence and clinical outcomes of heparin-induced thrombocytopenia: 11 year experience in a tertiary care university hospital. Intern Emerg Med 2023; 18:1971-1980. [PMID: 37568069 DOI: 10.1007/s11739-023-03379-5] [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: 03/16/2023] [Accepted: 07/12/2023] [Indexed: 08/13/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a rare immuno-mediated adverse reaction with high thrombotic and mortality risk. To evaluate incidence and outcomes of HIT cases diagnosed at a tertiary care hospital from 2007 to 2018. A retrospective study was conducted. Patients with suspected HIT underwent 4Ts score assessment and anti-heparin PF4 IgG antibodies ELISA screening test. If the latter was positive, platelet aggregation test (PAT) was performed. If the latter was positive, any form of heparin was stopped, alternative anticoagulants were started and then overlapped with warfarin. HIT incidence was calculated by dividing HIT cases by the mean yearly number of admitted patients over 11 years. Follow-up was 90 days. Among 2125 screening tests, 96 (4.5%) were positive with confirmatory PAT in 82/90 (3.8% for missing data in 6). Median age was 75; 39 patients were surgical and 51 medical. The median 4Ts score was 5. Unfractionated heparin was employed in 34 (37%). HIT incidence was 0.16/1000/patient/years (95% CI: 0.12-0.23) in surgical and 0.15/1000/patient/years (95%: 0.12-0.20) in medical patients. HIT with thrombosis (HIT-T) was observed in 31 patients (0.05/1000/patient/years 95% CI: 0.04-0.1), with venous thromboses in 25 (80%). HIT without thrombosis was observed in 59 patients (0.1/1000 patient/years; 95% CI: 0.08-0.13, twofold vs HIT-T). All cause mortality was 25.5% (95% CI: 17.6-35.4), major bleeding 7.7% (95% CI:3.2-15.3), and thromboembolic complications 3.3% (95% CI:1.1-9.3). HIT is a rare event with high mortality, despite the use of non heparin anticoagulants.
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Affiliation(s)
- Benilde Cosmi
- Angiology and Blood Coagulation Unit , IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | | | | | - Laura Borgese
- Angiology and Blood Coagulation Unit , IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Michelangelo Sartori
- Angiology and Blood Coagulation Unit , IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Rostami M, Mansouritorghabeh H. Significance of heparin induced thrombocytopenia (HIT) in COVID-19: a systematic review and meta-analysis. J Thromb Thrombolysis 2023:10.1007/s11239-023-02827-5. [PMID: 37219826 DOI: 10.1007/s11239-023-02827-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 05/24/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) occurs in approximately 3% of patients receiving heparinoids. About 30-75% of patients with type 2 of HIT develop thrombosis as a result of platelet activation. The most important clinical symptom is thrombocytopenia. Patients with severe COVID-19 are among those receiving heparinoids. This meta-analysis performed to picture the current knowledge and results of published studies in this field. Three search engines were searched and 575 papers were found. After evaluation, 37 articles were finally selected of which 13 studies were quantitatively analyzed. The pooled frequency rate of suspected cases with HIT in 13 studies with 11,241 patients was 1.7%. The frequency of HIT was 8.2% in the extracorporeal membrane oxygenation subgroup with 268 patients and 0.8% in the hospitalization subgroup with 10,887 patients. The coincidence of these two conditions may increase the risk of thrombosis. Of the 37 patients with COVID-19 and confirmed HIT, 30 patients (81%) were treated in the intensive care unit or had severe COVID-19. The most commonly used anticoagulants were UFH in 22 cases (59.4%). The median platelet count before treatment was 237 (176-290) x 103/µl and the median nadir platelet count was 52 (31-90.5) x 103/µl.
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Affiliation(s)
- Mehrdad Rostami
- MSc of Hematology & Blood Banking, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hassan Mansouritorghabeh
- Central Diagnostic laboratories, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran., Ghaem Hospital, Mashhad University of Medical Sciences, P.O. Box: 91766-99199, Mashhad, Iran.
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Hogwood J, Mulloy B, Lever R, Gray E, Page CP. Pharmacology of Heparin and Related Drugs: An Update. Pharmacol Rev 2023; 75:328-379. [PMID: 36792365 DOI: 10.1124/pharmrev.122.000684] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 02/17/2023] Open
Abstract
Heparin has been used extensively as an antithrombotic and anticoagulant for close to 100 years. This anticoagulant activity is attributed mainly to the pentasaccharide sequence, which potentiates the inhibitory action of antithrombin, a major inhibitor of the coagulation cascade. More recently it has been elucidated that heparin exhibits anti-inflammatory effect via interference of the formation of neutrophil extracellular traps and this may also contribute to heparin's antithrombotic activity. This illustrates that heparin interacts with a broad range of biomolecules, exerting both anticoagulant and nonanticoagulant actions. Since our previous review, there has been an increased interest in these nonanticoagulant effects of heparin, with the beneficial role in patients infected with SARS2-coronavirus a highly topical example. This article provides an update on our previous review with more recent developments and observations made for these novel uses of heparin and an overview of the development status of heparin-based drugs. SIGNIFICANCE STATEMENT: This state-of-the-art review covers recent developments in the use of heparin and heparin-like materials as anticoagulant, now including immunothrombosis observations, and as nonanticoagulant including a role in the treatment of SARS-coronavirus and inflammatory conditions.
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Affiliation(s)
- John Hogwood
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Barbara Mulloy
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Rebeca Lever
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Elaine Gray
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
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Heparin-Induced Thrombocytopenia in a Patient With Coronavirus Disease-19: Diagnostic and Management Challenge. Am J Ther 2023; 30:e87-e89. [PMID: 33416245 DOI: 10.1097/mjt.0000000000001282] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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10
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Muacevic A, Adler JR, Ma MQ, Rojas Hernandez CM, Elsayem A. Heparin-Induced Thrombocytopenia at the Emergency Department Due to Intermittent Heparin Flush in a Patient Undergoing Stem Cell Transplant. Cureus 2022; 14:e31798. [PMID: 36569714 PMCID: PMC9780017 DOI: 10.7759/cureus.31798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 11/23/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an adverse reaction to heparin products, but not warfarin. HIT usually occurs 5‒10 days after exposure to heparin. Here, we report a case of HIT with multiple thrombotic events and severe thrombocytopenia resulting from intermittent intravenous heparin flushes for maintenance of a newly placed subclavian central venous catheter (CVC) for stem cell transplant. The patient is a woman in her forties with multiple myeloma who presented to the emergency department (ED) with dyspnea, pleuritic-type chest pain, hemoptysis, and worsening left-leg swelling. Heparin had been used to flush the CVC. Her platelet count began dropping approximately one week after insertion. The patient was receiving other medications known to cause thrombocytopenia. She had undergone multiple platelet transfusions. In the ED, her lab results showed thrombocytopenia), anemia; renal insufficiency; and elevated troponin, prothrombin time, and D-dimer levels. Because of the hemoptysis and thrombocytopenia, she initially received platelet transfusion and oxygen. She was found to have deep vein thrombosis of the lower extremity and started a referral to interventional radiology for inferior vena cava (IVC) filter placement. However, further review and consultation of the Benign Hematology service, discussion about the timing of decreased platelet count shortly after CVC placement and heparin administration, and the presence of thrombosis, suggested a high pre-test probability of HIT. Anticoagulation with argatroban was initiated, and IVC filter insertion was canceled. Further workup confirmed HIT diagnosis and saddle pulmonary embolism. During the patient's hospitalization, her platelets continued to improve and reached baseline upon discharge. She was transitioned to fondaparinux at the time of discharge. A few weeks later, she had successful stem cell transplantation. Emergency physicians treating patients with thrombocytopenia receiving heparin, even in small amounts, should consider the possibility of HIT and be familiar with its management.
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Alamin MA, Al-Mashdali A, Al Kindi DI, Elshaikh EA, Othman F. Eptifibatide-induced acute profound thrombocytopenia: A case report. Medicine (Baltimore) 2022; 101:e28243. [PMID: 36281191 PMCID: PMC9592370 DOI: 10.1097/md.0000000000028243] [Citation(s) in RCA: 2] [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: 11/06/2022] Open
Abstract
RATIONALE Eptifibatide is an antiplatelet agent used in the medical management of acute coronary syndrome. Although multiple studies did not reveal a significant association between eptifibatide and the development of thrombocytopenia, recent case reports brought attention to this relatively rare side effect. PATIENT CONCERNS We report a 61 years old male with acute coronary syndrome who underwent primary coronary intervention. DIAGNOSIS AND INTERVENTION The patient developed acute profound thrombocytopenia following eptifibatide administration. Following prompt offending drug discontinuation, the platelet counts recovered, without clinical sequelae or the need for platelet transfusion. Dual antiplatelet therapy with aspirin and clopidogrel was resumed after platelet count normalization. OUTCOMES The patient had a normal platelet count and no bleeding events on follow-up after three months upon discharge. CONCLUSION Eptifibatide, a glycoprotein IIa/IIIb inhibitor used in the management of acute coronary syndrome, can induce acute, profound thrombocytopenia that can have significant morbidity in patients. This case highlights this relatively rare side effect and the importance of monitoring blood counts and observing for any signs of bleeding or thrombosis that might occur in such patients.
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Affiliation(s)
- Mohammed A. Alamin
- Hamad General Hospital, Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
- * Correspondence: Mohammed A. Alamin, Hamad General Hospital, Internal Medicine Department, Hamad Medical Corporation, P.O. Box 3050, Doha 00000, Qatar (e-mail: )
| | - Abdulrahman Al-Mashdali
- Hamad General Hospital, Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Dawoud I. Al Kindi
- Department of Adult Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Fahmi Othman
- Department of Adult Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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12
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Lasica R, Asanin M, Djukanovic L, Radovanovic N, Savic L, Polovina M, Stankovic S, Ristic A, Zdravkovic M, Lasica A, Kravic J, Perunicic J. Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application. Pharmaceuticals (Basel) 2022; 15:ph15091146. [PMID: 36145366 PMCID: PMC9501350 DOI: 10.3390/ph15091146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Correspondence:
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nebojsa Radovanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Polovina
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Arsen Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | | | | | - Jelena Kravic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jovan Perunicic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Cheema T, Kieu T, Balek M, Ahmad M, Singh P. Pulmonary Embolism (PE) in Transit in Heparin-Induced Thrombocytopenia (HIT) With Negative Serotonin-Release Assay (SRA). Cureus 2022; 14:e25868. [PMID: 35698467 PMCID: PMC9188760 DOI: 10.7759/cureus.25868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/12/2022] Open
Abstract
Pulmonary embolism (PE) is a potentially lethal condition, although frequently diagnosed, and is rarely associated with transit on initial presentation. Heparin-induced thrombocytopenia (HIT) can cause both arterial thrombus formation and venous thromboembolism. The two forms of HIT must be differentiated in order to guide management. We present a complex and unique case of PE in transit secondary to HIT diagnosed in a patient with a negative serotonin assay.
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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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15
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Gabarin N, Arnold DM, Nazy I, Warkentin TE. Treatment of vaccine-induced immune thrombotic thrombocytopenia (VITT). Semin Hematol 2022; 59:89-96. [PMID: 35512906 PMCID: PMC8898785 DOI: 10.1053/j.seminhematol.2022.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 03/01/2022] [Indexed: 11/30/2022]
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a novel prothrombotic disorder characterized by thrombosis, thrombocytopenia, and disseminated intravascular coagulation identified in hundreds of recipients of ChAdOx1 nCoV-19 (Oxford/AstraZeneca), an adenovirus vector coronavirus disease 2019 (COVID-19) vaccine. VITT resembles heparin-induced thrombocytopenia (HIT) in that patients have platelet-activating anti-platelet factor 4 antibodies; however, whereas heparin typically enhances platelet activation by HIT antibodies, VITT antibody-induced platelet activation is often inhibited in vitro by pharmacological concentrations of heparin. Further, the thrombotic complications in VITT feature much higher frequencies of atypical thrombosis, most notably cerebral vein thrombosis and splanchnic vein thrombosis, compared with HIT. In this review, we outline the treatments that have been used to manage this novel condition since its recognition in March 2021, including anticoagulation, high-dose intravenous immune globulin, therapeutic plasma exchange, corticosteroids, rituximab, and eculizumab. We discuss the controversial issue of whether heparin, which often inhibits VITT antibody-induced platelet activation, is harmful in the treatment of VITT. We also describe a case of “long VITT,” describing the treatment challenges resulting from platelet-activating anti-PF4 antibodies that persisted for more than 9 months.
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16
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A Multicenter Retrospective Evaluation of Direct Oral Anticoagulants for the Treatment of Heparin-Induced Thrombocytopenia. Am J Cardiovasc Drugs 2022; 22:417-424. [PMID: 35040095 DOI: 10.1007/s40256-021-00519-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) represent an off-label but potential alternative to traditional therapies for heparin-induced thrombocytopenia (HIT). OBJECTIVE The objective of this study was to evaluate the efficacy and safety of DOACs in patients with a diagnosis of laboratory-confirmed HIT. METHODS A multicenter retrospective cohort study of adult patients with HIT treated with apixaban, rivaroxaban, or dabigatran between 1 January 2013 and 1 January 2020 was performed. Patients with an intermediate or high pre-test probability for HIT and a positive antiplatelet factor 4/heparin complex assay, latex immunoturbidimetric assay, or serotonin release assay were included for analysis. The primary outcome was the composite of newly diagnosed venous or arterial thromboembolism, gangrene, or severe limb ischemia requiring amputation at 3 months following DOAC initiation. This study was approved by local institutional review boards, and the requirement for informed consent was waived. RESULTS A total of 77 patients from four health systems were included. The median 4Ts score was 5 (interquartile range 4.5-6), and 38 patients (49.4%) had a diagnosis of HIT with thrombosis. The most frequently used DOAC was apixaban (n = 51), followed by rivaroxaban (n = 24) and dabigatran (n = 2). In total, 63 (81.8%) patients received parenteral non-heparin anticoagulation prior to DOAC initiation. Nine patients (11.7%) experienced the primary outcome of HIT-related thrombotic events. Of the 14 patients who exclusively received DOAC therapy, none experienced the primary outcome. Major bleeding occurred in five (6.5%) patients. CONCLUSION In this retrospective cohort study, DOACs were associated with rates of thrombotic and hemorrhagic events similar to those with other therapies currently used in the treatment of HIT.
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Jimenez DC, Warner ED, Ahmad D, Rosen JL, Al-Rawas N, Morris RJ, Alvarez R, Rame JE, Entwistle JW, Massey HT, Tchantchaleishvili V. Cardiac transplantation after heparin induced thrombocytopenia: A systematic review. Clin Transplant 2021; 36:e14567. [PMID: 34927287 DOI: 10.1111/ctr.14567] [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: 09/14/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Heparin induced thrombocytopenia (HIT) presents a unique challenge in patients requiring orthotopic heart transplantation (OHT). We sought to pool the existing evidence in a systematic review. METHODS Electronic search was performed to identify all relevant studies on OHT in patients with HIT. Patient-level data for 33 patients from 21 studies were extracted for statistical analysis. RESULTS Median patient age was 51 [41, 55] years, with 75.8% (25/33) males. All patients had a clinical diagnosis of HIT, and anti PF4/Heparin antibodies were positive in 87.9% (29/33). Median lowest reported platelet count was 46 × 109 /L [27.2, 73.5]. Intraoperatively, 61% (20/33) of patients were given unfractionated heparin (UFH), while 39% (13/33) were given alternative anticoagulants. The alternative agent subgroup required more antifibrinolytics [54% (7/13) vs. 10% (2/20), p = 0.02] and clotting factors [69.2% (9/13) vs. 15.0% (3/20) p<0.01]. Peri-operative thrombosis occurred more in [53.8% (7/13) vs 0% (0/20, p<0.01) alternate agent subgroup. More patients in the alternate agent subgroup required post-operative transfusions [54% (7/13) vs. 0% (0/20), p<0.01]. Thirty-day mortality of 15.2% (5/33) was comparable between the subgroups. CONCLUSION Heparin use during OHT may be associated with less adverse effects compared to use of other anticoagulants with no difference in 30-day mortality. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Diana C Jimenez
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Eric D Warner
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Danial Ahmad
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jake L Rosen
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nawar Al-Rawas
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rohinton J Morris
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rene Alvarez
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - J Eduardo Rame
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John W Entwistle
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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18
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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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19
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Abstract
Background: Heparin-induced thrombocytopenia (HIT) is a rare autoimmune reaction that involves a decrease in platelet count following heparin exposure and can be associated with life-threatening thrombosis. Because of their prolonged heparin exposure, patients undergoing cardiac surgery are at risk of HIT, with an incidence of 0.1% to 3%. Case Report: A 65-year-old male with severe mitral regurgitation and preoperative ejection fraction of 20% to 25% underwent mitral valve bioprosthetic replacement with coronary artery bypass graft surgery. Heparin anticoagulation was started on postoperative day (POD) 1. Respiratory failure resulted in prolonged mechanical ventilation and heparinization without the ability to initiate warfarin. While the patient was on heparin, his platelet count declined on POD 2 and then steadily increased to above the preoperative level on POD 7. On POD 10, the patient's platelet count dramatically decreased, and on POD 13 he developed acute common femoral artery occlusion necessitating embolectomy. Intraoperative transesophageal echocardiography revealed heavy thrombus burden across the mitral bioprosthesis. HIT was confirmed with a positive heparin-induced platelet antibody and serotonin release assay. Heparin was stopped and argatroban initiated. The patient underwent reoperative bioprosthetic mitral valve replacement on POD 18 using bivalirudin intraoperatively. Despite resolution of HIT, the patient developed sepsis and died on POD 59. Conclusion: The diagnosis of HIT is challenging in patients who undergo cardiopulmonary bypass. Platelet counts often decrease 40% to 60% during the first 72 hours postoperatively, and the frequency of nonspecific anti-platelet factor 4/heparin antibody formation is high. These findings can mask early signs of HIT and delay diagnosis.
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Furuto Y, Kawamura M, Yamashita J, Yoshikawa T, Namikawa A, Isshiki R, Takahashi H, Shibuya Y. Anti-neutrophil cytoplasmic antibody-associated vasculitis accompanied by type II heparin-induced thrombocytopenia resulting in asymptomatic cerebral infarction: a case report. BMC Nephrol 2021; 22:220. [PMID: 34126959 PMCID: PMC8204417 DOI: 10.1186/s12882-021-02433-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 06/08/2021] [Indexed: 11/11/2022] Open
Abstract
Background Heparin-induced thrombocytopenia (HIT) involves platelet activation and aggregation caused by heparin or HIT antibodies associated with poor survival outcomes. We report a case of HIT that occurred after hemodialysis was started for rapidly progressive glomerulonephritis (RPGN), which was caused by anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV), and ultimately resulted in asymptomatic cerebral infarction. Case presentation A 76-year-old Japanese man was urgently admitted to our hospital for weight loss and acute kidney injury (serum creatinine: 12 mg/dL). Hemodialysis therapy was started using heparin for anticoagulation. Blood testing revealed elevated titers of myeloperoxidase anti-neutrophil cytoplasmic antibodies, and renal biopsy revealed crescentic glomerulonephritis with broad hyalinization of most of the glomeruli and a pauci-immune staining pattern. These findings fulfilled the diagnostic criteria for microscopic polyangiitis, and the patient was diagnosed with RPGN caused by AAV. Steroid pulse therapy, intermittent pulse intravenous cyclophosphamide, and oral steroid therapy failed to improve the patient’s renal function, and maintenance dialysis was started. However, on day 15, his platelet count had decreased to 47,000/µL, with clotting observed in the hemodialysis catheter. Magnetic resonance imaging of the head identified acute asymptomatic brain infarction in the left occipital lobe, and a positive HIT antibody test result supported a diagnosis of type II HIT. During hemodialysis, the anticoagulant treatment was changed from heparin to argatroban. Platelet counts subsequently normalized, and the patient was discharged. A negative HIT antibody test result was observed on day 622. Conclusions There have been several similar reports of AAV and HIT co-existence. However, this is a rare case report on cerebral infarction with AAV and HIT co-existence. Autoimmune diseases are considered risk factors for HIT, and AAV may overlap with other systemic autoimmune diseases. To confirm the relationship between these two diseases, it is necessary to accumulate more information from future cases with AAV and HIT co-existence. If acute thrombocytopenia and clotting events are observed when heparin is used as an anticoagulant, type II HIT should always be considered in any patient due to its potentially fatal thrombotic complications.
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Affiliation(s)
- Yoshitaka Furuto
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan.
| | - Mariko Kawamura
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Jumpei Yamashita
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Takahiro Yoshikawa
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Akio Namikawa
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Rei Isshiki
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Hiroko Takahashi
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
| | - Yuko Shibuya
- Department of Hypertension and Nephrology, NTT Medical Centre, 5-9-22, Higasi- Gotanda, Shinagawa-ku, 141-8625, Tokyo, Japan
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21
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Current Management of Acute Pulmonary Embolism. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00293-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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22
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Hvas AM, Favaloro EJ, Hellfritzsch M. Heparin-induced thrombocytopenia: pathophysiology, diagnosis and treatment. Expert Rev Hematol 2021; 14:335-346. [PMID: 33736552 DOI: 10.1080/17474086.2021.1905512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Immune-mediated heparin-induced thrombocytopenia (HIT) is an infrequent complication following heparin exposure but with potentially fatal outcome due to thrombotic complications. Prompt suspension of heparin is necessary if HIT is suspected, followed by initiation of non-heparin anticoagulant therapy.Areas covered: In this review, the pathophysiology and challenges in diagnosing HIT are elucidated. Current and emerging treatment options are discussed with special focus on parenteral thrombin inhibitors (argatroban, bivalirudin), parenteral factor Xa inhibitors (danaparoid, fondaparinux) and direct oral anticoagulants (DOACs [rivaroxaban, apixaban, dabigatran]) including dosing strategies for DOACs. The database PubMed was employed without time boundaries.Expert opinion: Only argatroban holds regulatory approval for HIT treatment in both U.S. and Europe. This treatment is, however, challenged by the need for close monitoring and high costs. Fondaparinux has been increasingly used for off-label treatment and during recent years, evidence for the use of DOACs has emerged. Preliminary results from observational studies hold promise for future use of DOACs in the acute and subacute phase of HIT. However, so far, the use of DOACs in acute HIT should be reserved for clinically stable patients without severe thrombotic complications. Importantly, both fondaparinux and DOAC use is contraindicated in severe renal insufficiency.
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Affiliation(s)
- Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University. Address: Palle Juul-Jensens Boulevard 99, Aarhus N, Denmark
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, Australia
| | - Maja Hellfritzsch
- Department of Cardiology, Herning Regional Hospital, Herning, Denmark
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Colarossi G, Maffulli N, Trivellas A, Schnöring H, Hatam N, Tingart M, Migliorini F. Superior outcomes with Argatroban for heparin-induced thrombocytopenia: a Bayesian network meta-analysis. Int J Clin Pharm 2021; 43:825-838. [PMID: 33774764 PMCID: PMC8352815 DOI: 10.1007/s11096-021-01260-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 03/15/2021] [Indexed: 12/20/2022]
Abstract
Background Argatroban, lepirudin, desirudin, bivalirudin, and danaparoid are commonly used to manage heparin-induced thrombocytopenia related complications. However, the most suitable drug for this condition still remains controversial. Aim of the review This Bayesian network meta-analysis study compared the most common anticoagulant drugs used in the management of heparin-induced thrombocytopenia. Method All clinical trials comparing two or more anticoagulant therapies for suspected or confirmed heparin-induced thrombocytopenia were considered for inclusion. Studies concerning the use of heparins or oral anticoagulants were not considered. Data concerning hospitalisation length, thromboembolic, major, and minor haemorrhagic events, and mortality rate were collected. The network analyses were made through the STATA routine for Bayesian hierarchical random-effects model analysis with standardised mean difference (SMD) and log odd ratio (LOR) effect measures. Results Data from a total of 4338 patients were analysed. The overall mean age was 62.31 ± 6.6 years old. Hospitalization length was considerably shorter in favour of the argatroban group (SMD: − 1.70). Argatroban evidenced the lowest rate of major (LOR: − 1.51) and minor (LOR: − 0.57) haemorrhagic events. Argatroban demonstrated the lowest rate of thromboembolic events (LOR: 0.62), and mortality rate (LOR: − 1.16). Conclusion Argatroban performed better overall for selected patients with HIT. Argatroban demonstrated the shortest hospitalization, and lowest rate of haemorrhages, thromboembolisms, and mortality compared to bivalirudin, lepirudin, desirudin, and danaparoid.
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Affiliation(s)
- Giorgia Colarossi
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
| | - Heike Schnöring
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Nima Hatam
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Markus Tingart
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
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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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25
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Nadtochiy SM, Baldzizhar A, Stefanos T, Feng C, O'Leary KE, Jones-Smith KL, Angona RE, Eaton MP. High-Dose Dabigatran Is an Effective Anticoagulant for Simulated Cardiopulmonary Bypass Using Human Blood. Anesth Analg 2021; 132:566-574. [PMID: 32833714 DOI: 10.1213/ane.0000000000005089] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Currently no ideal alternative exists for heparin for cardiopulmonary bypass (CPB). Dabigatran is a direct thrombin inhibitor for which a reversal agent exists. The primary end point of the study was to explore whether Dabigatran was an effective anticoagulant for 120 minutes of simulated CPB. METHODS The study was designed in 2 sequential steps. Throughout, human blood from healthy donors was used for each experimental step. Initially, increasing concentrations of Dabigatran were added to aliquots of fresh whole blood, and the anticoagulant effect measured using kaolin/tissue factor-activated thromboelastography (rapidTEG). The dynamics of all thromboelastography (TEG) measurements were studied with repeated measures analysis of variance (ANOVA). Based on these data, aliquots of blood were treated with high-concentration Dabigatran and placed in a Chandler loop as a simple ex vivo bypass model to assess whether Dabigatran had sufficient anticoagulant effects to maintain blood fluidity for 2 hours of continuous contact with the artificial surface of the PVC tubing. Idarucizumab, humanized monoclonal antibody fragment, was used to verify the reversibility of Dabigatran effects. Finally, 3 doses of Dabigatran were tested in a simulated CPB setup using a heart-lung machine and a commercially available bypass circuit with an arteriovenous (A-V) loop. The primary outcome was the successful completion of 120 minutes of simulated CPB with dabigatran anticoagulation, defined as lack of visible thrombus. Thromboelastographic reaction (R) time was measured repeatedly in each bypass simulation, and the circuits were continuously observed for clot. Scanning Electron Microscopy (SEM) was used to visualize fibrin formation in the filters meshes during CPB. RESULTS In in vitro blood samples, Dabigatran prolonged R time and reduced the dynamics of clot propagation (as measured by speed of clot formation [Angle], maximum rate of thrombus generation [MRTG], and time to maximum rate of thrombus generation [TMRTG]) in a dose-dependent manner. In the Chandler Loop, high doses of Dabigatran prevented clot formation for 120 minutes, but only at doses higher than expected. Idarucizumab decreased R time and reversed anticoagulation in both in vitro and Chandler Loops settings. In the A-V loop bypass simulation, Dabigatran prevented gross thrombus generation for 120 minutes of simulated CPB. CONCLUSIONS Using sequential experimental approaches, we showed that direct thrombin inhibitor Dabigatran in high doses maintained anticoagulation of blood for simulated CPB. Idarucizumab reduced time for clot formation reversing the anticoagulation action of Dabigatran.
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Affiliation(s)
- Sergiy M Nadtochiy
- From the Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Sandoval E, Lozano M, Pereda D, Quintana E, Cid J, García-Álvarez A, Fernández-Cisneros A, Castellá M. A combined approach to treat heparin-induced thrombocytopaenia before heart transplant. Interact Cardiovasc Thorac Surg 2020; 31:881-883. [DOI: 10.1093/icvts/ivaa196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 08/09/2020] [Accepted: 08/16/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
Heparin-induced thrombocytopaenia (HIT) complicates the management of patients in need for mechanical circulatory support awaiting heart transplantation. The limited available treatment options are fraught with complications and limitations in their applicability. We report on the combined use of therapeutic plasma exchange therapy and intravenous immunoglobulin, used in 3 consecutive heparin-induced thrombocytopaenia-positive patients on temporary mechanical circulatory support awaiting urgent heart transplant. This combined approach allowed us to use heparin safely.
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Affiliation(s)
- Elena Sandoval
- Department of Cardiovascular Surgery, ICCV, Hospital Clínic, Barcelona, Spain
| | - Miquel Lozano
- Hemostasis and Hemotherapy Department, ICMHO, Hospital Clínic, Barcelona, Spain
| | - Daniel Pereda
- Department of Cardiovascular Surgery, ICCV, Hospital Clínic, Barcelona, Spain
| | - Eduard Quintana
- Department of Cardiovascular Surgery, ICCV, Hospital Clínic, Barcelona, Spain
| | - Joan Cid
- Hemostasis and Hemotherapy Department, ICMHO, Hospital Clínic, Barcelona, Spain
| | | | | | - Manuel Castellá
- Department of Cardiovascular Surgery, ICCV, Hospital Clínic, Barcelona, Spain
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27
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Colarossi G, Schnöring H, Trivellas A, Betsch M, Hatam N, Eschweiler J, Tingart M, Migliorini F. Prognostic factors for patients with heparin-induced thrombocytopenia: a systematic review. Int J Clin Pharm 2020; 43:449-460. [PMID: 33044680 DOI: 10.1007/s11096-020-01166-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/23/2020] [Indexed: 10/23/2022]
Abstract
Background Little is known with regards to the prognostic factors for patients with suspected or diagnosed Heparin-Induced Thromobocytopenia (HIT). The role of patient and therapy characteristics may play a role in predicting the outcome. Aim of the review To investigate the role of patient and therapy characteristics as potential prognostic factors for HIT-related complications (haemorrhagic and thromboembolic events), and mortality. Method The present systematic review was conducted according to the PRISMA statement. In September 2020, the main online databases were accessed: Pubmed, EMBASE, Scopus, Google Scholar. All the clinical trials concerning the management of patients with suspected or confirmed HIT were eligible. Studies evaluating the use of oral anticoagulants (e.g. vitamin K antagonists, Apixaban) were not considered, along with those comparing the use of heparin. For pairwise correlation, the Pearson Product-Moment Correlation Coefficient (r) was used. The final effect was evaluated according to the Cauchy-Schwarz inequality.Results Data from 33 clinical studies (4338 patients) were retrieved. The overall mean age was 62.3 ± 6.6 years old. Patients with HIT-related thromboembolism at the moment of diagnosis were associated with greater rate of haemorrhages (P > 0.0001), thromboembolism (P > 0.0001) and mortality (P = 0.001). Patients with more comorbidities at diagnosis were associated with a greater risk of haemorrhages (P = 0.07), thromboembolism (P = 0.002) and mortality (P = 0.002). Patients with longer duration of the therapy were associated with lower rate of mortality (P = 0.04). ConclusionsPatient comorbidities, presence of HIT-related thromboembolism on admission and shorter anticoagulant therapy were found to be negative prognostic factors. Thrombocythemia on admission, patients age and gender did not influence the overall outcome.
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Affiliation(s)
- Giorgia Colarossi
- Department of Cardiac and Thoracic Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Heike Schnöring
- Department of Cardiac and Thoracic Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Marcel Betsch
- Women´s College Hospital, University of Toronto Orthopaedic Sports Medicine Program (UTOSM), Toronto, ON, Canada
| | - Nima Hatam
- Department of Cardiac and Thoracic Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Jörg Eschweiler
- Department of Orthopaedics Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Markus Tingart
- Department of Orthopaedics Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Filippo Migliorini
- Department of Orthopaedics Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany.
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Comparison of a predefined dose increment nomogram with a percentage adjustment nomogram in patients receiving argatroban therapy. J Am Pharm Assoc (2003) 2020; 60:702-707. [DOI: 10.1016/j.japh.2020.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/21/2020] [Accepted: 01/26/2020] [Indexed: 11/23/2022]
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Erdoes G, Ortmann E, Martinez Lopez De Arroyabe B, Reid C, Koster A. Role of Bivalirudin for Anticoagulation in Adult Perioperative Cardiothoracic Practice. J Cardiothorac Vasc Anesth 2020; 34:2207-2214. [DOI: 10.1053/j.jvca.2019.08.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/25/2019] [Accepted: 08/14/2019] [Indexed: 12/11/2022]
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Movileanu I, Pepa M, Cândea M, Ureche C. Heart valve mechanical prosthesis: The perfect match until it is not - A case report. Exp Ther Med 2020; 20:2481-2483. [PMID: 32765738 DOI: 10.3892/etm.2020.8959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/01/2020] [Indexed: 12/12/2022] Open
Abstract
Primary immune thrombocytopenia (ITP), formerly known as idiopathic thrombocytopenia, is defined by a reduced platelet count <50x109 and is clinically manifested through signs and symptoms such as bleeding, ecchymosis and petechiae. Its coexistence with the implantation of the mechanical valves and the necessity of anticoagulation creates an additional risk of bleeding. Although mechanical valves are indispensable in prolonging and improving the quality of life in patients with valvular heart disease, in the context of an additional bleeding risk factor, their presence could represent a threat to life exposing the patient to major complications and leading to death. The purpose of this case report is to discuss the disadvantages and possible fatal complications of the association between mechanical valves and severe thrombocytopenia. A possible solution to these downsides could be found in the future search in regenerative medicine and tissue engineering of heart valves resulting in products that do not require anticoagulation and do not pose a threat to patients with thrombocytopenia.
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Affiliation(s)
- Ionela Movileanu
- First Cardiology Department, Emergency Institute of Cardiovascular Diseases and Transplant, 540136 Târgu Mure?, Romania
| | - Miruna Pepa
- First Cardiology Department, Emergency Institute of Cardiovascular Diseases and Transplant, 540136 Târgu Mure?, Romania
| | - Marcela Cândea
- First Internal Medical Department, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Târgu Mure?, Romania
| | - Corina Ureche
- First Internal Medical Department, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Târgu Mure?, Romania
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31
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Guzman AK, Balagula Y. Drug-induced cutaneous vasculitis and anticoagulant-related cutaneous adverse reactions: insights in pathogenesis, clinical presentation, and treatment. Clin Dermatol 2020; 38:613-628. [PMID: 33341196 DOI: 10.1016/j.clindermatol.2020.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Drug-induced vasculitis and anticoagulant-related skin reactions are commonly encountered in the inpatient and outpatient settings. The spectrum of clinical presentation is broad and ranges from focal, skin-limited disease, to more extensive cutaneous and soft tissue necrosis, to potentially fatal systemic involvement. The prompt recognition of these adverse events can have a significant impact on patient morbidity and mortality. We highlight the key features of the clinical presentation with an emphasis on primary lesion morphology, distribution, and epidemiology of purpuric drug reactions. The proposed pathophysiology, histologic findings, and therapeutic interventions of these potentially life-threatening diseases are discussed.
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Affiliation(s)
- Anthony K Guzman
- Division of Dermatology, Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Yevgeniy Balagula
- Division of Dermatology, Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
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Acute Stent Thrombosis Associated with Eptifibatide-Induced Profound Thrombocytopenia. Case Rep Cardiol 2020; 2020:8386709. [PMID: 32566320 PMCID: PMC7303759 DOI: 10.1155/2020/8386709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/23/2020] [Accepted: 06/02/2020] [Indexed: 11/18/2022] Open
Abstract
Background Eptifibatide is an inhibitor of the platelet glycoprotein (GP) IIb/IIIa receptor that is commonly used in patients undergoing percutaneous coronary intervention (PCI). Case We describe a case of a 62-year-old female patient admitted with acute ST-elevation myocardial infarction (STEMI) treated by primary coronary intervention (primary PCI) with a drug-eluting stent placement. She developed profound thrombocytopenia within 8 hours of first administration of eptifibatide and subsequent acute stent thrombosis next day. Other causes of thrombocytopenia were excluded and intravascular ultrasound (IVUS) showed good stent expansion and opposition to the coronary wall. Platelet count gradually returned to normal after discontinuation of eptifibatide. Conclusion Although Eptifibatide has been associated with the development of thrombocytopenia, to the best of our knowledge, this is the first case report in the medical literature that associates acute stent thrombosis and eptifibatide-induced thrombocytopenia.
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Zhang W, Shen J, Sun JL. Risk scores, prevention, and treatment of maternal venous thromboembolism. World J Clin Cases 2020; 8:2210-2218. [PMID: 32548151 PMCID: PMC7281061 DOI: 10.12998/wjcc.v8.i11.2210] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/01/2020] [Accepted: 04/30/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND At present, the preventive treatment for pregnancy-related venous thromboembolism (VTE) in China is in its infancy, and there is no uniform or standardized industry guide. Drug prevention and treatment of pregnancy-related VTE rely highly on foreign guidelines; however, due to the differences in ethnicity and national conditions, there are many controversies over the indications for drug treatment, drug selection, and dose selection for anticoagulant therapy.
AIM To investigate the risk scores, prevention, and treatment of maternal VTE to promote the prevention and standardized treatment of maternal thrombosis.
METHODS A retrospective analysis was performed on 7759 patients who gave birth at our hospital from June 2018 to June 2019. Risk factors for pregnancy-related VTE, prenatal and postpartum VTE risk scores, prophylactic anticoagulant therapy, side effects after medication, and morbidity were analysed.
RESULTS The risk factors for VTE were mainly caesarean delivery, obesity, and advanced maternal age. Regarding pregnancy-related VTE risk scores, there were 7520 patients in the low-risk group with a prenatal score < 3 points and 239 in the high-risk group with a score ≥ 3, and 44 patients received drug prevention and treatment during pregnancy. There were 4223 patients in the low-risk group with a postpartum score < 2 points and 3536 in the high-risk group with a score ≥ 2 points, and 824 patients received drug prevention and treatment for 10 d. Among the patients who did not present with VTE before delivery, we found one case each of pulmonary embolism secondary to lower extremity venous thrombosis, intracranial venous sinus thrombosis, and asymptomatic lower extremity venous thrombosis during the postpartum follow-up.
CONCLUSION VTE poses a serious threat to maternal safety, and the society should increase its vigilance against pregnancy-related VTE.
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Affiliation(s)
- Wei Zhang
- Department of Obstetrics and Gynecology, General Hospital of Northern Theater Command (Heping Campus), Shenyang 110000, Liaoning Province, China
| | - Jian Shen
- Department of Obstetrics and Gynecology, General Hospital of Northern Theater Command (Heping Campus), Shenyang 110000, Liaoning Province, China
| | - Jing-Li Sun
- Department of Obstetrics and Gynecology, General Hospital of Northern Theater Command (Heping Campus), Shenyang 110000, Liaoning Province, China
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Samarakoon LB, Chua F, Yap HY, Choke E. Heparin-induced thrombocytopaenia following abdominal aortic aneurysm repair complicated by treatment failure of rivaroxaban. PROCEEDINGS OF SINGAPORE HEALTHCARE 2020. [DOI: 10.1177/2010105820921206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Heparin-induced thrombocytopaenia (HIT) is a rare life-threatening complication following exposure to heparin. It is mediated by immune-mediated thrombocytopaenia due to antibody against heparin platelet factor 4 complex. Early identification of the condition and the prompt administration of appropriate treatment are important to prevent morbidity and mortality from HIT. We report a case of HIT associated with open abdominal aortic aneurysm repair causing anterior tibial artery and peroneal artery thrombosis following prophylactic use of unfractionated heparin for prophylaxis of venous thromboembolism. Even though enoxaparin was switched to rivaroxaban after HIT was suspected, our patient unfortunately developed a minor cerebrovascular accident during the hospital stay as a consequence of HIT.
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Affiliation(s)
| | - Felicia Chua
- Depatment of General Surgery, Singapore General Hospital, Singapore
| | - Hao Yun Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Edward Choke
- Department of Vascular surgery, Sengkang General Hospital, Singapore
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den Exter PL, Beeres SLMA, Eikenboom J, Klok FA, Huisman MV. Anticoagulant treatment and bleeding complications in patients with left ventricular assist devices. Expert Rev Cardiovasc Ther 2020; 18:363-372. [PMID: 32449431 DOI: 10.1080/14779072.2020.1773803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The treatment options for advanced heart failure patients drastically changed with the introduction of left ventricular assist devices (LVADs), either as bridge to transplant or as destination therapy for patients ineligible for transplant. Despite major benefits in terms of survival, functional status and quality of life, managing patients with LVADs comes with several challenges. The most significant challenge is balancing between the risks of thrombotic and bleeding complications. AREAS COVERED The present review describes the pathophysiological mechanisms explaining the alterations in the hemostatic profile of LVAD patients, and summarizes current evidence to guide clinical decision making with regard to anticoagulant treatment and management of bleeding complications. EXPERT OPINION LVAD patients require life-long anticoagulant therapy to reduce the risk of pump thrombosis. However, exposing LVAD patients to anticoagulant therapy, in combination with common acquired coagulopathies after LVAD implantation such as acquired von Willebrand syndrome, comes with high risks of bleeding. There is a need for randomized controlled trials in LVAD patients to determine the optimal antithrombotic regimen and find the most effective balance between thrombotic and bleeding complications. In addition, strategies to specifically target the acquired von Willebrand syndrome and its associated angiodysplasias need to be evaluated in the LVAD population.
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Affiliation(s)
- Paul L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
| | - Saskia L M A Beeres
- Department of Cardiology, Leiden University Medical Center , Leiden, The Netherlands
| | - Jeroen Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center , Leiden, The Netherlands
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Zhou P, Yin JX, Tao HL, Zhang HW. Pathogenesis and management of heparin-induced thrombocytopenia and thrombosis. Clin Chim Acta 2020; 504:73-80. [DOI: 10.1016/j.cca.2020.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 01/19/2023]
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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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Evolution of Acute Pulmonary Embolism Management: Review Article. Curr Probl Cardiol 2020; 46:100551. [PMID: 32204946 DOI: 10.1016/j.cpcardiol.2020.100551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/05/2020] [Indexed: 01/27/2023]
Abstract
Acute pulmonary emboli are a major cause of morbidity and mortality and require prompt evaluation, diagnosis, and treatment. To date, anticoagulation using low molecular weight heparin or non-Vitamin K oral anticoagulants has been the mainstay of treatment in the subset of patients in whom pulmonary embolism does not compromise hemodynamics. On the other hand however, patients with massive pulmonary embolism and shock, thrombolytic therapy is necessary. This raises the question whether ultrasound-assisted catheter directed thrombolytic delivery might be superior to systemic administration. This review article aims to consolidate recent literature to help achieve a better understanding toward the utility of catheter directed therapy.
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Rizk J, Mehra MR. Anticoagulation management strategies in heart transplantation. Prog Cardiovasc Dis 2020; 63:210-218. [PMID: 32035125 DOI: 10.1016/j.pcad.2020.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/03/2020] [Indexed: 12/19/2022]
Abstract
Anticoagulation before, during, and after heart transplantation (HT) presents unique challenges to clinicians. Bleeding and thrombotic morbidity continues to affect this patient population throughout all phases of the HT journey. Reversal is commonly required since patients are commonly bridged to HT with left ventricular assist devices, which require chronic anti platelet and anticoagulation. Caution must be exercised in patients requiring cardiopulmonary bypass during surgery who are at risk of complications from heparin induced thrombocytopenia. The reported incidence of venous thromboembolism following HT is high, particularly during the first post-HT year, most likely due to surgery, biopsies, specific immunosuppression (mTOR inhibitors) and immobilization. It is crucial to maintain long-term oral anticoagulation after the first venous thromboembolism event, especially when risk factors exist. A major issue, and one for which there remains considerable debate, is the optimal treatment of such complications, particularly upper extremity venous thrombosis. For both warfarin and the thrombin inhibitors or Factor Xa inhibitors, the clinician must determine potential drug interactions based on the HT drug regimen, and then develop a patient-specific management strategy.
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Affiliation(s)
- John Rizk
- Arizona State University, Edson College, Phoenix, AZ, United States of America
| | - Mandeep R Mehra
- Brigham and Women's Heart & Vascular Center and Harvard Medical School, Boston, MA, United States of America.
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Rizk J, Mehra MR. WITHDRAWN: Anticoagulation management strategies in heart transplantation. Prog Cardiovasc Dis 2020:S0033-0620(20)30026-8. [PMID: 32014513 DOI: 10.1016/j.pcad.2020.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/29/2020] [Indexed: 11/22/2022]
Affiliation(s)
- John Rizk
- Arizona State University, Edson College, Phoenix, AZ, United States of America
| | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States of America.
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Althaus K, Straub A, Häberle H, Rosenberger P, Hidiatov O, Hammer S, Nowak-Harnau S, Enkel S, Riessen R, Bakchoul T. Heparin-induced thrombocytopenia: Diagnostic challenges in intensive care patients especially with extracorporeal circulation. Thromb Res 2020; 188:52-60. [PMID: 32059134 DOI: 10.1016/j.thromres.2020.01.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/09/2020] [Accepted: 01/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious drug induced reaction that may be associated with life threatening complications. Platelet-activating antibodies directed against platelet factor 4 (PF4)/heparin complexes cause the disease. The diagnosis of HIT is challenging, as thrombocytopenia is a frequent finding in intensive care (ICU) patient population, especially during extracorporeal membrane oxygenation. OBJECTIVE To investigate the performance of a diagnostic algorithm for HIT in ICU patients. METHODS ICU patients who developed thrombocytopenia or thrombosis under heparin treatment were included in this study. The pretest probability for HIT was estimated using the 4Ts-score and patient's sera were tested using two rapid immunoassays (RA) LFI-HIT and PaGIA (from Milenia Biotec and DiaMed), and within 72 h using the IgG enzyme immunoassay (EIA) from Hyphen and the heparin induced platelet activation assay (HIPA). RESULTS 392 consecutive ICU patients with suspected HIT were enrolled in this study, of whom 83/392 (21.2%) patients had extracorporeal circulation. Sera from 120/392 (30.6%) and 98/392 (25.0%) patients revealed positive results in RA and IgG EIA, respectively. The HIPA test revealed heparin-dependent platelet activation in a total of 15/392 (3.8%) ICU patients (3 medical and 12 surgical patients). In addition, sera from 7 patients revealed indeterminate HIPA results, of whom 2 patients had a clinical course compatible with HIT. CONCLUSIONS Data from our study confirm the high frequency of IgG PF4/heparin antibodies in ICU patients under unfractionated heparin and shows that the combination of 4Ts-score and RA does not reduce the laboratory overinvestigation for HIT in these patients.
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Affiliation(s)
- Karina Althaus
- Center for Clinical Transfusion Medicine, University of Tübingen, Tübingen, Germany; Transfusion Medicine, Medical Faculty of Tübingen, Tübingen, Germany
| | - Andreas Straub
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Helene Häberle
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Oleg Hidiatov
- Transfusion Medicine, Medical Faculty of Tübingen, Tübingen, Germany
| | - Stefanie Hammer
- Center for Clinical Transfusion Medicine, University of Tübingen, Tübingen, Germany
| | | | - Sigrid Enkel
- Center for Clinical Transfusion Medicine, University of Tübingen, Tübingen, Germany
| | - Reimer Riessen
- Medical Intensive Care Unit, Department of Medicine, University of Tübingen, Tübingen, Germany
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, University of Tübingen, Tübingen, Germany; Transfusion Medicine, Medical Faculty of Tübingen, Tübingen, Germany.
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Prospective Evaluation of a Rapid Functional Assay for Heparin-Induced Thrombocytopenia Diagnosis in Critically Ill Patients. Crit Care Med 2020; 47:353-359. [PMID: 30507843 DOI: 10.1097/ccm.0000000000003574] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Overdiagnosis of heparin-induced thrombocytopenia remains an unresolved issue in the ICU leading to the unjustified switch from heparin to alternative anticoagulants or delays in anticoagulation. Platelet function assays significantly improve the specificity of heparin-induced thrombocytopenia diagnosis, but they are not readily available, involve technical difficulties and have a long turnaround time. We evaluated the performance of a rapid and easy to perform functional assay for heparin-induced thrombocytopenia diagnosis in ICU patients, known as "heparin-induced multiple electrode aggregometry." DESIGN In this observational prospective study patients were tested with the immunoglobulin G enzyme-linked immunosorbent assay, the serotonin release assay and heparin-induced multiple electrode aggregometry. Heparin-induced multiple electrode aggregometry was assessed against heparin-induced thrombocytopenia diagnosis (clinical picture in favor, serotonin release assay, and immunoglobulin G enzyme-linked immunosorbent assay positive) and serotonin release assay. SETTING Medical or surgical ICU of 35 medical centers. PATIENTS Patients suspected for heparin-induced thrombocytopenia hospitalized in medical or surgical ICU from January 2013 to May 2013. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Heparin-induced thrombocytopenia diagnosis was retained in 12 patients (14%). Using heparin-induced thrombocytopenia diagnosis as reference, heparin-induced multiple electrode aggregometry showed an excellent negative predictive value and sensitivity, at 98% and 92% respectively. Its positive predictive value and specificity were 100%. Receiver operating characteristic analysis with the serotonin release assay as reference showed an optimal heparin-induced multiple electrode aggregometry cut-off at 1,300 AU × minutes (specificity, 100%; sensitivity, 90%; area under the curve, 0.98; 95% CI, 0.95-1.0). The Kappa coefficient between heparin-induced multiple electrode aggregometry and the serotonin release assay was at 0.90%. CONCLUSIONS Heparin-induced multiple electrode aggregometry performed very well in heparin-induced thrombocytopenia diagnosis in ICU patients and agreed with the gold standard test for heparin-induced thrombocytopenia diagnosis, the serotonin release assay. Heparin-induced multiple electrode aggregometry is a reliable and rapid platelet functional assay that could decrease heparin-induced thrombocytopenia overdiagnosis in the ICU setting.
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Taguchi K, Ishiyama K, Ide K, Ohira M, Tahara H, Ohdan H. Simultaneous Liver-Kidney Transplantation in Patient with a History of Heparin-Induced Thrombocytopenia: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:980-987. [PMID: 31285416 PMCID: PMC6640169 DOI: 10.12659/ajcr.916717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patient: Male, 58 Final Diagnosis: Heparin-induced thrombocytopenia Symptoms: Liver and kidney failure Medication: — Clinical Procedure: Simultaneous liver-kidney transplantation Specialty: Transplantology
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Affiliation(s)
- Kazuhiro Taguchi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan.,Institute for Clinical Research, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Hiroshima, Japan
| | - Kohei Ishiyama
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan.,Department of Surgery, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Hiroshima, Japan
| | - Kentaro Ide
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
| | - Hiroyuki Tahara
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
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Zhu X, Chen M, Ma C. Sensitive Detection of Coralyne and Heparin Using a Singly Labeled Fluorescent Oligonucleotide Probe. ChemistrySelect 2019. [DOI: 10.1002/slct.201900942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Xingxing Zhu
- School of Life SciencesCentral South University Changsha 410013 China
| | - Miangjian Chen
- School of Life SciencesCentral South University Changsha 410013 China
| | - Changbei Ma
- School of Life SciencesCentral South University Changsha 410013 China
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Schaefer AK, Donhauser B, Kroeckel I, Füreder L, Holaubek C, Braunschmid T, Mouhieddine M, Panzer S, Dworschak M, Steinlechner B. Heparin-induced thrombocytopaenia diagnostic testing after adult cardiac surgery: a single-centre experience and development. Eur J Cardiothorac Surg 2019; 55:722-728. [PMID: 30395203 DOI: 10.1093/ejcts/ezy350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/06/2018] [Accepted: 09/11/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To assess the incidence and outcome of heparin-induced thrombocytopaenia (HIT) in patients after cardiac surgery on cardiopulmonary bypass (CPB) and to review the time course of platelet counts and the use of different immunological diagnostic tests. METHODS All patients ≥18 years of age who underwent CPB from 2006 to 2015 and who were postoperatively admitted to our cardiac intensive care unit (ICU) were included in this retrospective study. Screening for heparin/platelet factor-4 antibodies was performed using an antibody test, which was later replaced with a screening test specific for IgG antibodies without IgA/IgM cross-reactivity. The enzyme immunoassay (EIA) for the detection of antibodies of all immunoglobulin classes against heparin/PF4 complexes was replaced with an IgG-specific EIA. HIT was confirmed by a heparin-induced platelet aggregation test until 2014. RESULTS Among 4978 patients admitted between 2006 and 2015, 539 (11%) patients were evaluated for HIT. Patients were excluded because of age <18 years (n = 9), non-cardiac surgery without CPB (n = 10) or incomplete data (n = 3). Of the remaining 517 patients, 43 (8.3%) patients were HIT-positive. HIT incidence was 0.86%. The proportion of HIT-positive patients was similar in men and women (8.4% and 8.2%, respectively). Men and women with suspected HIT also had similar in-hospital mortality (odds ratio ≈ 1; P = 0.926). CONCLUSIONS The incidence of HIT was lower in our study than previously reported. Novel immunological tests have improved to specifically detect IgG antibodies. Furthermore, they are able to detect anti-protamine antibodies, which may be present in patients with high clinical probability of testing negative for HIT. Incidence and clinical relevance of heparin/protamine antibodies will be subjects of future investigation.
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Affiliation(s)
- Anne-Kristin Schaefer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Beatrice Donhauser
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Ivonne Kroeckel
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Lisa Füreder
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Caroline Holaubek
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Tamara Braunschmid
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Mohamed Mouhieddine
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Martin Dworschak
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Barbara Steinlechner
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
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Cleavage of anti-PF4/heparin IgG by a bacterial protease and potential benefit in heparin-induced thrombocytopenia. Blood 2019; 133:2427-2435. [PMID: 30917957 DOI: 10.1182/blood.2019000437] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 03/25/2019] [Indexed: 12/22/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is due to immunoglobulin G (IgG) antibodies, which bind platelet factor 4 (PF4) modified by polyanions, such as heparin (H). IgG/PF4/polyanion complexes directly activate platelets via Fc gamma type 2 receptor A (FcγRIIA) receptors. A bacterial protease, IgG-degrading enzyme of Streptococcus pyogenes (IdeS), cleaves the hinge region of heavy-chain IgG, abolishing its ability to bind FcγR, including FcγRIIA. We evaluated whether cleavage of anti-PF4/H IgG by IdeS could suppress the pathogenicity of HIT antibodies. IdeS quickly cleaved purified 5B9, a monoclonal chimeric anti-PF4/H IgG1, which led to the formation of single cleaved 5B9 (sc5B9), without any reduction in binding ability to the PF4/H complex. However, as compared with uncleaved 5B9, the affinity of sc5B9 for platelet FcγRIIA was greatly reduced, and sc5B9 was also unable to induce heparin-dependent platelet activation. In addition, incubating IdeS in whole blood containing 5B9 or HIT plasma samples led to cleavage of anti-PF4/H antibodies, which fully abolished the ability to induce heparin-dependent platelet aggregation and tissue factor messenger RNA synthesis by monocytes. Also, when whole blood was perfused in von Willebrand factor-coated microfluidic channels, platelet aggregation and fibrin formation induced by 5B9 with heparin was strongly reduced after IdeS treatment. Finally, IdeS prevented thrombocytopenia and hypercoagulability induced by 5B9 with heparin in transgenic mice expressing human PF4 and FcγRIIA receptors. In conclusion, cleavage of anti-PF4/H IgG by IdeS abolishes heparin-dependent cellular activation induced by HIT antibodies. IdeS injection could be a potential treatment of patients with severe HIT.
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Ivascu NS, Fitzgerald M, Ghadimi K, Patel P, Evans AS, Goeddel LA, Shaefi S, Klick J, Johnson A, Raiten J, Horak J, Gutsche J. Heparin-Induced Thrombocytopenia: A Review for Cardiac Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2019; 33:511-520. [DOI: 10.1053/j.jvca.2018.10.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Indexed: 01/02/2023]
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48
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Heparin-Induced Thrombocytopenia. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00041-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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49
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Bergen TA, Mesropyan NA. DIFFERENTIAL DIAGNOSIS OF NON-TRAUMATIC BRAIN HEMORRHAGE WITH ETIOPATHOGENETIS ASSOSIATION. ACTA ACUST UNITED AC 2018. [DOI: 10.22328/2079-5343-2018-9-3-23-27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Differential diagnostics of non-traumatic intracerebral hemorrhages is a critical area of scientific research and development in neuroradiology. In modern clinical practice, diagnostics are often limited to anatomical description of pathology without taking into account its etiology and pathogenesis. This paper analyzes the ethiopathogenetic factors underlying non-traumatic intracranial hemorrhages, as well as the potential of tomography in differential diagnosis of intracerebral non-traumatic hemorrhages with regard to localization and prevalence. Additionally, the paper analyzes the most common misinterpretations in the diagnostics of non-traumatic intracerebral hemorrhages, providing examples of pathologies with different etiologic but similar hallmarks in magnetic resonance imaging (MRI) and computed tomography (CT).
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Warkentin TE. Heparin-induced thrombocytopenia-associated thrombosis: from arterial to venous to venous limb gangrene. J Thromb Haemost 2018; 16:2128-2132. [PMID: 30099843 DOI: 10.1111/jth.14264] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Indexed: 12/17/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is an acquired immune-mediated hypercoagulability state that is strongly associated with thrombosis. During the 1970s and 1980s, the prevailing concept was that HIT was associated only with arterial thrombosis, through its unique pathogenesis via heparin-dependent, platelet-activating IgG antibodies. However, in 1990, when I began to encounter HIT in my clinical practice, I found that most such patients developed symptomatic venous thrombosis. This historical sketch summarizes some of the research that challenged the dogma of HIT being a mainly arterial prothrombotic disorder. Two studies - one a substudy of a randomized trial of post-orthopedic surgery thromboprophylaxis, and the second a retrospective five-hospital analysis of consecutive patients with positive test results for HIT antibodies - showed a marked predominance of venous over arterial thrombosis complicating HIT (~ 4 : 1). By the end of the 1990s, an even more dramatic manifestation of HIT-associated venous thrombosis was recognized: venous limb gangrene. Here, ischemic limb necrosis occurs despite palpable arterial pulses, as a result of both macrovascular and microvascular venous thrombosis. The surprising explanation was natural anticoagulant impairment (severe depletion of protein C, a vitamin K-dependent anticoagulant) resulting from treatment of HIT-associated deep vein thrombosis with warfarin (vitamin K antagonist). These insights from HIT research helped to elucidate the pathogenesis of ischemic limb losses in other intense non-HIT hypercoagulability states, including warfarin-associated venous limb gangrene complicating cancer-associated hypercoagulability, and symmetrical peripheral gangrene complicating disseminated intravascular coagulation of critical illness, in which proximate 'shock liver' helps to explain the profound failure of natural anticoagulant systems (protein C; antithrombin) in predisposing to peripheral limb microthrombosis in circulatory shock.
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Affiliation(s)
- T E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
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