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Heparin-induced Thrombocytopenia (HIT) during Extracorporeal Membrane Oxygenation (ECMO) in COVID-19: A Case Report

1National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico, 2Department of Medicine, Division of Hospital Medicine, Northcentral Baptist Medical Center, San Antonio, Texas; USA and Department of Medicine, Division of Hospital Medicine, Sierra Providence Healthcare Network and Hospitals, El Paso, United States, 3Department of Medicine, Division of Cardiovascular Diseases; Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, United States

Abstract Number: PB0259

Meeting: ISTH 2021 Congress

Theme: COVID and Coagulation » COVID and Coagulation, Clinical

Background: Heparin-induced thrombocytopenia (HIT) is an antibody-mediated reaction against the heparin-platelet factor 4 complex (H-PF4). Incidence in patients with extracorporeal circulation membrane (ECMO) is unknown.

Aims: We describe a case of HIT confirmed during ECMO support in a COVID-19 patient.

Methods: N/A

Results:
Platelet count in relation to time and response to the treatment. Blue bars: platelet count. Yellow bar: Enoxaparine 80 mg BID, Green bar: infusion time with UFH (unfrationated heparine) 700 UI/h. Light blue bar: treatment time with fondaparinux 7.5 mg SC. QD. Green arrows: anti-Xa levels for UFH expressed in IU/mL. Red arrows: serum levels of fondaparinux (micrograms /mL).
 A 48 year-old man with severe COVID-19 confirmed by RT-PCR for SARS-CoV2, was admitted to intensive care unit (ICU). After 21 days of the diagnosis he required mechanical ventilation support and V-V ECMO. Since his admission he received anticoagulation with enoxaparin 80mg SC every 12 hours, when ECMO started, he continued anticoagulation with intravenous infusion of 700 U/hour of unfractionated heparin (UFH). On the third day of infusion, there was a decrease in platelets > 50% (nadir 25,000 / mm3), it was documented 6 points in a 4T HIT score having a probability 64% for HIT. It was confirmed by functional test with platelet aggregometry induced by UFH using the Born method. UFH was suspended and fondaparinux 7.5mg SC every 24 hours. We made serial measurements of anti-Xa (Stago®).  Therapeutic response to HIT was documented at day 9 from the start of fondaparinux, without requiring an ECMO membrane change.

Conclusions: The diagnosis of HIT was made by clinical suspicion, using the 4T HIT score and later confirmation platelet aggregometryUFH induced. The usual pharmacological treatment is based on argatroban, bivalirudin, and lepirudin. To our knowledge, there is only one case reported with fondaparinux as treatment in ECMO. Determination of plasma levels by antiXa activity was used to guide dosing because previous studies have reported bleeding rates between 10 to 22% with fondaparinux. This is a success case of fondaparinux as treatment for HIT in an ICU patient with ECMO support, and the first one in the clinical context of severe COVID -19 infection.

To cite this abstract in AMA style:

Altamirano-Solorzano GA, Cortina-de la Rosa E, Grimaldo-Gomez FA, Anguiano-Alvarez VM, Cortes-Cortes KG, Porres-Aguilar M, Rojas-Velasco G, Izaguirre-Avila R. Heparin-induced Thrombocytopenia (HIT) during Extracorporeal Membrane Oxygenation (ECMO) in COVID-19: A Case Report [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/heparin-induced-thrombocytopenia-hit-during-extracorporeal-membrane-oxygenation-ecmo-in-covid-19-a-case-report/. Accessed November 30, 2023.

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