title: Perioperative use of iloprost in cardiac surgery patients diagnosed with heparin-induced thrombocytopenia-reactive antibodies or with true HIT (HIT-reactive antibodies plus thrombocytopenia): An 11-year experience.
abstract: Thrombocytopenia and thromboembolism(s) may develop in heparin immune-mediated thrombocytopenia (HIT) patients after reexposure to heparin. At the Onassis Cardiac Surgery Center, 530 out of 17,000 patients requiring heart surgery over an 11-year period underwent preoperative HIT assessment by ELISA and a three-point heparin-induced platelet aggregation assay (HIPAG). The screening identified 110 patients with HIT-reactive antibodies, out of which 46 were also thrombocytopenic (true HIT). Cardiac surgery was performed in HIT-positive patients under heparin anticoagulation and iloprost infusion. A control group of 118 HIT-negative patients received heparin but no iloprost during surgery. For the first 20 patients, the dose of iloprost diminishing the HIPAG test to ≤5% was determined prior to surgery by in vitro titration using the patients' own plasma and donor platelets. In parallel, the iloprost "target dose" was also established for each patient intraoperatively, but before heparin administration. Iloprost was infused initially at 3 ng/kg/mL and further adjusted intraoperatively, until ex vivo aggregation reached ≤5%. As a close correlation was observed between the "target dose" identified before surgery and that established intraoperatively, the remaining 90 patients were administered iloprost starting at the presurgery identified "target dose." This process significantly reduced the number of intraoperative HIPAG reassessments needed to determine the iloprost target dose, and reduced surgical time, while maintaining similar primary clinical outcomes to controls. Therefore, infusion of iloprost throughout surgery, under continuous titration, allows cardiac surgery to be undertaken safely using heparin, while avoiding life-threatening iloprost-induced hypotension in patients diagnosed with HIT-reactive antibodies or true HIT.
authors: 3rd Department of Cardiothoracic Surgery, Onassis Cardiac Surgery Center, Athens, Greece.
authors: George
authors: G
authors: Palatianos
authors: 2nd Department of Cardiothoracic Surgery, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Alkiviadis
authors: A
authors: Michalis
authors: 1st Department of Cardiothoracic Surgery, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Petros
authors: P
authors: Alivizatos
authors: Department of Anaesthesiology, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Stavroula
authors: S
authors: Lacoumenda
authors: Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Stefanos
authors: S
authors: Geroulanos
authors: Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Andreas
authors: A
authors: Karabinis
authors: Department of Haematology/Blood Transfusion, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Eugenia
authors: E
authors: Iliopoulou
authors: Department of Haematology/Blood Transfusion, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Giannoula
authors: G
authors: Soufla
authors: Department of Oncology, School of Medicine, University of Sheffield, Sheffield, United Kingdom.
authors: Chryso
authors: C
authors: Kanthou
authors: 2nd Department of Cardiothoracic Surgery, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Mazen
authors: M
authors: Khoury
authors: 1st Department of Cardiothoracic Surgery, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Petros
authors: P
authors: Sfyrakis
authors: 1st Department of Cardiothoracic Surgery, Onassis Cardiac Surgery Center, Athens, Greece.
authors: George
authors: G
authors: Stavridis
authors: 3rd Department of Cardiothoracic Surgery, Onassis Cardiac Surgery Center, Athens, Greece.
authors: George
authors: G
authors: Astras
authors: Department of Anaesthesiology, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Maria
authors: M
authors: Vassili
authors: Department of Anaesthesiology, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Christina
authors: C
authors: Antzaka
authors: Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Katerina
authors: K
authors: Marathias
authors: Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Ioannis
authors: I
authors: Kriaras
authors: Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Androniki
authors: A
authors: Tasouli
authors: Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Kyrillos
authors: K
authors: Papadopoulos
authors: Department of Haematology/Blood Transfusion, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Marina
authors: M
authors: Katafygioti
authors: Department of Haematology/Blood Transfusion, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Nikoletta
authors: N
authors: Matoula
authors: Department of Haematology/Blood Transfusion, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Antonios
authors: A
authors: Angelidis
authors: Department of Haematology/Blood Transfusion, Onassis Cardiac Surgery Center, Athens, Greece.
authors: Euthemia
authors: E
authors: Melissari
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000906:Antibodies / Q000097:blood*; D000925:Anticoagulants / Q000009:adverse effects; D001014:Aortic Aneurysm / Q000473:pathology / Q000601:surgery; D001792:Blood Platelets / Q000187:drug effects / Q000276:immunology / Q000473:pathology; D058385:Cardiac Valve Annuloplasty / Q000379:methods; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D001026:Coronary Artery Bypass / Q000379:methods; D004334:Drug Administration Schedule; D016903:Drug Monitoring; D005260:Female; D006493:Heparin / Q000009:adverse effects; D006801:Humans; D016285:Iloprost / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000379:methods; D010974:Platelet Aggregation / Q000187:drug effects; D010976:Platelet Count; D013921:Thrombocytopenia / Q000139:chemically induced / Q000276:immunology / Q000473:pathology*; D013923:Thromboembolism / Q000188:drug therapy* / Q000276:immunology / Q000473:pathology; D016896:Treatment Outcome
chemical_list: D000906:Antibodies; D000925:Anticoagulants; D002317:Cardiovascular Agents; D006493:Heparin; D016285:Iloprost