Thromb Haemost 2020; 120(02): 300-305
DOI: 10.1055/s-0039-3401825
New Technologies, Diagnostic Tools and Drugs
Georg Thieme Verlag KG Stuttgart · New York

Outcomes of Cardiovascular Surgery Utilizing Heparin versus Direct Thrombin Inhibitors in Cardiopulmonary Bypass in Patients with Previously Diagnosed HIT

Daniel S. Carlson
1   Medicine Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
,
John R. Bartholomew
2   Department of Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, United States
,
Marcelo P. Gomes
2   Department of Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, United States
,
Keith R. McCrae
3   Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, United States
,
4   Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
› Author Affiliations
Further Information

Publication History

18 June 2019

05 November 2019

Publication Date:
30 December 2019 (online)

Abstract

Heparin-induced thrombocytopenia (HIT) is a life-threatening complication of heparin therapy. Heparin is generally avoided in patients with a history of HIT; however, it remains the anticoagulant of choice for cardiac surgery requiring cardiopulmonary bypass (CPB) because of limited experience with alternative anticoagulants such as direct thrombin inhibitors (DTIs) during CPB. We report outcomes of surgery requiring CPB (30-day mortality, rate of thrombosis, and hemorrhage) in patients with prior HIT who received either heparin or a DTI intraoperatively. Seventy-two patients with a prior diagnosis of HIT confirmed by a positive serotonin release assay underwent CBP with a positive HIT antibody at the time of surgery. Thirty-day mortality was 0 and 8.5% in the DTI and heparin cohorts (p = 0.277). Thrombotic events occurred in 1 (7.7%) of the patients treated with DTI and 15 (25.4%) receiving heparin (p = 0.164). In the DTI cohort, 7 (53.8%) had minimal bleeding, 5 (38.5%) had mild bleeding, 1 (7.8%) had moderate bleeding, and none had severe bleeding. In the heparin group, 16 (27.1%) had minimal bleeding, 14 (23.7%) had mild bleeding, 25 (42.4%) had moderate bleeding, and 4 (6.8%) had severe bleeding (p = 0.053). DTI was associated with a lower rate of moderate to severe hemorrhage than heparin (odds ratio 0.097 [95% confidence interval 0.011–0.824], p = 0.033) in a logistic regression model adjusted for thrombocytopenia and length on bypass. DTI appears to be safe in selected patients undergoing CPB after a diagnosis of HIT, and was not associated with higher rates of 30-day mortality, thrombosis, or hemorrhage.

 
  • References

  • 1 Ahmed I, Majeed A, Powell R. Heparin induced thrombocytopenia: diagnosis and management update. Postgrad Med J 2007; 83 (983) 575-582
  • 2 Salter BS, Weiner MM, Trinh MA. , et al. Heparin-induced thrombocytopenia: a comprehensive clinical review. J Am Coll Cardiol 2016; 67 (21) 2519-2532
  • 3 Linkins LA, Dans AL, Moores LK. , et al. Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed.: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2, Suppl): e495S-e530S
  • 4 Bloemen A, Testroote MJG, Janssen-Heijnen ML, Janzing HM. Incidence and diagnosis of heparin-induced thrombocytopenia (HIT) in patients with traumatic injuries treated with unfractioned or low-molecular-weight heparin: a literature review. Injury 2012; 43 (05) 548-552
  • 5 Bauer TL, Arepally G, Konkle BA. , et al. Prevalence of heparin-associated antibodies without thrombosis in patients undergoing cardiopulmonary bypass surgery. Circulation 1997; 95 (05) 1242-1246
  • 6 Visentin GP, Malik M, Cyganiak KA, Aster RH. Patients treated with unfractionated heparin during open heart surgery are at high risk to form antibodies reactive with heparin:platelet factor 4 complexes. J Lab Clin Med 1996; 128 (04) 376-383
  • 7 Cuker A, Cines DB. How I treat heparin-induced thrombocytopenia. Blood 2012; 119 (10) 2209-2218
  • 8 Warkentin TE, Sheppard JA, Horsewood P, Simpson PJ, Moore JC, Kelton JG. Impact of the patient population on the risk for heparin-induced thrombocytopenia. Blood 2000; 96 (05) 1703-1708
  • 9 Koster A, Faraoni D, Levy JH. Argatroban and bivalirudin for perioperative anticoagulation in cardiac surgery. Anesthesiology 2018; 128 (02) 390-400
  • 10 Yusuf AM, Warkentin TE, Arsenault KA, Whitlock R, Eikelboom JW. Prognostic importance of preoperative anti-PF4/heparin antibodies in patients undergoing cardiac surgery. A systematic review. Thromb Haemost 2012; 107 (01) 8-14
  • 11 Warkentin TE, Sheppard JA, Chu FV, Kapoor A, Crowther MA, Gangji A. Plasma exchange to remove HIT antibodies: dissociation between enzyme-immunoassay and platelet activation test reactivities. Blood 2015; 125 (01) 195-198
  • 12 Welsby IJ, Um J, Milano CA, Ortel TL, Arepally G. Plasmapheresis and heparin reexposure as a management strategy for cardiac surgical patients with heparin-induced thrombocytopenia. Anesth Analg 2010; 110 (01) 30-35
  • 13 Pishko AM, Cuker A. Heparin-induced thrombocytopenia in cardiac surgery patients. Semin Thromb Hemost 2017; 43 (07) 691-698
  • 14 Dyke CM, Smedira NG, Koster A. , et al. A comparison of bivalirudin to heparin with protamine reversal in patients undergoing cardiac surgery with cardiopulmonary bypass: the EVOLUTION-ON study. J Thorac Cardiovasc Surg 2006; 131 (03) 533-539
  • 15 Koster A, Spiess B, Jurmann M. , et al. Bivalirudin provides rapid, effective, and reliable anticoagulation during off-pump coronary revascularization: results of the “EVOLUTION OFF” trial. Anesth Analg 2006; 103 (03) 540-544
  • 16 Koster A, Dyke CM, Aldea G. , et al. Bivalirudin during cardiopulmonary bypass in patients with previous or acute heparin-induced thrombocytopenia and heparin antibodies: results of the CHOOSE-ON trial. Ann Thorac Surg 2007; 83 (02) 572-577
  • 17 Dyke CM, Aldea G, Koster A. , et al. Off-pump coronary artery bypass with bivalirudin for patients with heparin-induced thrombocytopenia or antiplatelet factor four/heparin antibodies. Ann Thorac Surg 2007; 84 (03) 836-839
  • 18 Nashef SA, Roques F, Sharples LD. , et al. EuroSCORE II. Eur J Cardiothorac Surg 2012; 41 (04) 734-744
  • 19 Austin SR, Wong YN, Uzzo RG, Beck JR, Egleston BL. Why summary comorbidity measures such as the Charlson Comorbidity Index and Elixhauser Score work. Med Care 2015; 53 (09) e65-e72
  • 20 Mutschler M, Paffrath T, Wölfl C. , et al. The ATLS(®) classification of hypovolaemic shock: a well established teaching tool on the edge?. Injury 2014; 45 (Suppl. 03) S35-S38
  • 21 Warkentin TE, Anderson JA. How I treat patients with a history of heparin-induced thrombocytopenia. Blood 2016; 128 (03) 348-359
  • 22 Siregar S, de Heer F, Groenwold RH. , et al. Trends and outcomes of valve surgery: 16-year results of Netherlands Cardiac Surgery National Database. Eur J Cardiothorac Surg 2014; 46 (03) 386-397
  • 23 Woodman RC, Harker LA. Bleeding complications associated with cardiopulmonary bypass. Blood 1990; 76 (09) 1680-1697
  • 24 Shultz B, Timek T, Davis AT. , et al. Outcomes in patients undergoing complex cardiac repairs with cross clamp times over 300 minutes. J Cardiothorac Surg 2016; 11 (01) 105
  • 25 Dhakal P, Giri S, Pathak R, Bhatt VR. Heparin reexposure in patients with a history of heparin-induced thrombocytopenia. Clin Appl Thromb Hemost 2015; 21 (07) 626-631