Acute intraoperative heparin-induced thrombocytopenia (HIT) and thrombosis during coronary artery bypass grafting: Two case reports providing evidence for the role of preoperative LMWH in triggering sensitization. Issue 146 (October 2016)

• Record Type: Journal Article
• Authors: Khoury, M.; Pitsis, A.; Poumpouridou-Kioura, H.; Soufla, G.; Kanthou, C.; Matoula, N.; Angelidis, A.; Melissari, E.
• Is Part Of: Thrombosis research. Issue 146(2016)
• Page Start: 126
• Page End: 130
• Publication Date: 2016-10
• Subjects: HIT heparin-induced thrombocytopenia -- UFH unfractionated heparin -- LMWH low molecular weight heparin -- ONCAB on-pump coronary artery bypass -- OPCAB off-pump coronary artery bypass -- CPB cardiopulmonary bypass -- AT antithrombin -- ACT activated clotting time -- RαPTT ratio activated partial thromboplastin time -- AMI acute myocardial infraction -- ACCP American College of Chest Physicians -- HIPAG heparin induced platelet aggregation test -- O.D. optical density -- IABP intra-aortic balloon pump -- CORO cardiac catheterization; CPB -- Fondaparinux -- HIT -- Thrombocytopenia -- Thromboembolism; Thrombosis -- Periodicals; 616.135
• DOI: 10.1016/j.thromres.2016.08.020
• Languages: English
• ISSNs: 0049-3848

Abstract

Abstract: Introduction: Systemic anticoagulation is necessary during cardiac surgery. To date, the only well established anticoagulation protocol involves the use of heparin. However, heparin can cause heparin-induced thrombocytopenia (HIT) a potentially life threatening immune-mediated thromboembolic syndrome. Until now, devastating consequences of HIT syndrome in patients undergoing heart surgery have been described, but only postoperatively. Here we report the development of HIT syndrome during cardiac revascularization by intra-operative heparin administration in two patients previously exposed to LMWH. Patients/methods: We report on two patients who developed rapid and profound intravascular coagulation with severe thrombocytopenia (platelet count decreased from ≥ 250 × 10 9 /L to 50 × 10 9 /L) due to HIT development caused by heparin administration during coronary artery bypass graft surgery. In addition we report that fondaparinux, given intra-operatively in association with antithrombin, may be a suitable alternative anticoagulant for successfully preventing the devastating consequences of intra-operative HIT development. Conclusion: To our knowledge, this is the first report describing the development of acute intra-operative HIT, secondary to high-dose UFH administered for coronary revascularization, in which the unexpected presence of platelet-activating anti-PF4/heparin antibodies at surgery was explained by preoperative administration of a one-week course of LMWH but without any preoperative evidence for HIT. Highlights: HIT syndrome development during cardiac revascularization by surgical heparin Both patients with HIT during surgery were previously exposed to LMWH. Intraoperative fondaparinux (in association with AT) anticipated the consequences of HIT. Fondaparinux may be effective in anticipating possible HIT syndrome development intraoperatively.