Cardiac transplantation and/or mechanical circulatory support device placement using heparin anti-coagulation in the presence of acute heparin-induced thrombocytopenia.
BACKGROUND
Patients with congestive heart failure, decreased left ventricular function, and debilitation are frequently maintained on anti-coagulants, including heparin. As such, these patients are at high risk for developing heparin-induced thrombocytopenia (HIT). Some of these HIT-positive individuals will ultimately undergo urgent heart transplantation or placement of a mechanical circulatory support device (MCSD). Such procedures require cardiopulmonary bypass (CPB) and full anti-coagulation. The safety of re-exposure to heparin during CPB despite the presence of recent-onset thrombocytopenia and Hep/PF4 antibodies has not been studied in the transplant or MCSD populations.


METHODS
Over a 24-month period, 75 heart transplants and 55 MCSD implants were performed. Fourteen patients with acute HIT (thrombocytopenia and positive Hep/PF4 antibody by enzyme-linked immunosorbent assay [ELISA]) and 3 patients with a history of remote HIT underwent cardiac transplantation (n = 9) and/or MCSD placement (n = 8) using heparin as the anti-coagulant during CPB. The median time from diagnosis to CPB was 4.5 days in patients with acute HIT.


RESULTS
Thirty-day survival was 100% in transplant patients and 75% in MCSD patients. Post-transplant ELISA testing was found to be negative in 4 patients with acute HIT and 3 with remote HIT.


CONCLUSIONS
This series demonstrates that short-term re-exposure to heparin during urgent CPB for heart transplantation or MCSD placement is safe despite the presence of thrombocytopenia and Hep/PF4 antibodies. Moreover, the rapid clearance of Hep/PF4 antibodies in our transplant patients suggests a potential therapeutic role for immunosuppressive therapy in the management of HIT in the acute setting.
Zucker
Mark J
MJ
Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey 07112, USA. mzucker@sbhcs.com
Sabnani
Indu
I
Baran
David A
DA
Balasubramanian
Sangeetha
S
Camacho
Margarita
M
D000293:Adolescent; D000328:Adult; D000368:Aged; D000906:Antibodies / Q000097:blood; D000925:Anticoagulants / Q000009:adverse effects* / Q000276:immunology / Q000627:therapeutic use*; D002315:Cardiopulmonary Bypass / Q000379:methods; D005260:Female; D006333:Heart Failure / Q000188:drug therapy / Q000601:surgery; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006493:Heparin / Q000009:adverse effects* / Q000276:immunology / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013921:Thrombocytopenia / Q000139:chemically induced* / Q000453:epidemiology; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000188:drug therapy / Q000601:surgery
D000906:Antibodies; D000925:Anticoagulants; D006493:Heparin