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Review
. 2019 Jan;8(1):19-31.
doi: 10.21037/acs.2018.12.02.

Heparin-induced thrombocytopenia during extracorporeal life support: incidence, management and outcomes

Jae Hwan Choi  1 , Jessica G Y Luc  2 , Matthew P Weber  1 , Haritha G Reddy  1 , Elizabeth J Maynes  1 , Avijit K Deb  3 , Louis E Samuels  1 , Rohinton J Morris  1 , H Todd Massey  1 , Antonio Loforte  4 , Vakhtang Tchantchaleishvili  1
Affiliations
Review

Heparin-induced thrombocytopenia during extracorporeal life support: incidence, management and outcomes

Jae Hwan Choi et al. Ann Cardiothorac Surg. 2019 Jan.

Abstract

Background: Heparin-induced thrombocytopenia (HIT) is a severe antibody-mediated reaction leading to transient prothrombosis. However, its incidence in patients on extracorporeal life support (ECLS) is not well described. The aim of this systematic review was to report the incidence of HIT in patients on ECLS, as well as compare the characteristics and outcomes of HIT in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and veno-venous ECMO (VV-ECMO).

Methods: An electronic search was performed to identify all studies in the English literature examining outcomes of patients with HIT on ECLS. All identified articles were systematically assessed using specific inclusion and exclusion criteria. Random effects meta-analysis as well as univariate analysis was performed.

Results: Of 309 patients from six retrospective studies undergoing ECLS, 83% were suspected, and 17% were confirmed to have HIT. Due to the sparsity of relevant retrospective data regarding patients with confirmed HIT on ECLS, patient-based data was subsequently collected on 28 patients from case reports and case series. Out of these 28 patients, 53.6% and 46.4% of them underwent VA-ECMO and VV-ECMO, respectively. Patients on VA-ECMO had a lower median platelet count nadir (VA-ECMO: 26.0 vs. VV-ECMO: 45.0 per µL, P=0.012) and were more likely to experience arterial thromboembolism (VA-ECMO: 53.3% vs. VV-ECMO: 0.0%, P=0.007), though there was a trend towards decreased likelihood of experiencing ECLS circuit oxygenator thromboembolism (VA-ECMO: 0.0% vs. VV-ECMO: 30.8%, P=0.075) and thromboembolism necessitating ECLS device or circuit exchange (VA-ECMO: 13.3% vs. VV-ECMO 53.8%, P=0.060). Kaplan-Meier survival plots including time from ECLS initiation reveal no significant differences in survival in patients supported on VA-ECMO as compared to VV-ECMO (P=0.300).

Conclusions: Patients who develop HIT on VA-ECMO are more likely to experience more severe thrombocytopenia and arterial thromboembolism than those on VV-ECMO. Further research in this area and development of standardized protocols for the monitoring, diagnosis and management of HIT in patients on ECLS support are warranted.

Keywords: Extracorporeal life support (ECLS); extracorporeal membrane oxygenation (ECMO); heparin-induced thrombocytopenia (HIT); thrombosis.

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Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
PRISMA schematic diagram of the search strategy. PRISMA, preferred reporting items for systematic reviews and meta-analysis. ECLS, extracorporeal life support; HIT, heparin-induced thrombocytopenia.
Figure 2
Figure 2
Estimated survival of patients with confirmed HIT post-ECLS during follow-up after time of admission, (A) in all patients and (B) stratified by VA-ECMO and VV-ECMO groups. HIT, heparin-induced thrombocytopenia; ECLS, extracorporeal life support; VA, veno-arterial; VV, veno-venous; ECMO, extracorporeal membrane oxygenation.
See this image and copyright information in PMC

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