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Urgent Cardiac Surgery in a Patient with Heparin Induced Thrombocytopenia

1School of Medicine, University of Zagreb, Zagreb, Croatia, 2Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia, 3Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Zagreb, Croatia, 4Department of Cardiac Surgery, University Hospital Center Zagreb, Zagreb, Croatia, 5Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia

Abstract Number: PB0862

Meeting: ISTH 2021 Congress

Theme: Platelet Disorders, von Willebrand Disease and Thrombotic Microangiopathies » HIT

Background: Heparin induced thrombocytopenia (HIT) requires immediate replacement of heparin with non-heparin anticoagulants. Nevertheless, anticoagulation during cardiac surgery necessitates administration of unfractionated heparin, and the management of patients with positive HIT antibodies may be challenging if urgent surgery is needed.

Aims: We present a case of a 57-year-old male patient with heart failure treated with veno-arterial extracorporeal membrane oxygenation and the need for an urgent upgrade to a paracorporeal, surgically placed left ventricular assist device (LVAD) shortly after detection of high-titer HIT antibodies.

Methods: The patient had ischemic cardiomyopathy, arterial hypertension and diabetes. The acutization of heart failure was provoked by refractory ventricular arrhythmias following the amputation of the left toe due to gangrene. Following re-amputation of the left foot, thrombocytopenia was observed and HIT was verified by ELISA. Heparin was then replaced by fondaparinux, followed by the normalization of the platelet count. 
The planned cardiac surgery included anticoagulation with unfractionated heparin. As preparation for the surgery, five procedures of plasma exchange were performed to remove HIT antibodies from the circulation. The surgery was done after two consecutive negative HIT antibodies tests, with additional infusion of intravenous gamma globulins (IvIg) given immediately before the procedure.

Results: The cardiac surgery procedure went uneventful regarding thrombotic events and hemostasis, while a right ventricular assist device was needed in addition to the planned LVAD. Postoperative anticoagulant treatment was continued with fondaparinux. No rise in HIT antibodies or platelet drop was described after the procedure, not later during follow up. Cardiac transplantation was done a month later with intraoperative administration of unfractionated heparin. No thrombocytopenia nor the anamnestic response of HIT was described after transplant, either.

Conclusions: The combination of plasma exchange and IvIg resulted in negative HIT antibodies and enabled safe, life-saving cardiac surgery procedures with unfractionated heparin in a patient with a recent history of high-titer HIT.

To cite this abstract in AMA style:

Romić M, Mišura D, Tomac G, Čikeš M, Gašparović H, Boban A. Urgent Cardiac Surgery in a Patient with Heparin Induced Thrombocytopenia [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/urgent-cardiac-surgery-in-a-patient-with-heparin-induced-thrombocytopenia/. Accessed October 1, 2023.

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