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Case Reports
. 2023 Feb 23;7(2):100089.
doi: 10.1016/j.rpth.2023.100089. eCollection 2023 Feb.

Cardiac surgery in acute heparin-induced thrombocytopenia managed with therapeutic plasma exchange and intravenous immunoglobulin

Alison Grazioli  1 , Noah P Splinter  2 , Michael E Plazak  3 , Bartley P Griffith  4 , Siamak Dahi  4 , Allison H Bathula  3 , Nora H Cheung  5 , Anand Padmanabhan  2
Affiliations
Case Reports

Cardiac surgery in acute heparin-induced thrombocytopenia managed with therapeutic plasma exchange and intravenous immunoglobulin

Alison Grazioli et al. Res Pract Thromb Haemost. .

Abstract

Background: Urgent surgery requiring heparin exposure during cardiopulmonary bypass can be challenging in patients with acute heparin-induced thrombocytopenia (HIT). The use of treatments such as therapeutic plasma exchange (TPE) to remove HIT antibodies and intravenous immunoglobulin (IVIg) to antagonize HIT antibody-mediated platelet activation are increasingly reported in patients who undergo cardiac surgery. The optimal treatment approach to mitigate the risks of heparin administration in this situation is not known.

Key clinical question: Can TPE coupled to IVIg allow for safe heparin exposure in patients with HIT?

Clinical approach: TPE and IVIg were used to enable heparin exposure for surgical placement of a left ventricular assist device in a patient with HIT. Serial patient samples were tested in antigen-based and functional HIT assays.

Conclusion: Dissociation between antigen-based (enzyme-linked immunosorbent assay) and functional (serotonin release assay) testing was noted, and TPE coupled to IVIg was associated with an excellent clinical response.

Keywords: heparin; immunoglobulins; intravenous; plasma exchange; plasmapheresis; thrombocytopenia.

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Figures

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Graphical abstract
Figure 1
Figure 1
Platelet trend during hospital admission and clinical interventions (argatroban use, TPE, IVIg, CPB, heparin administration). The dotted line indicates the lower limit of the normal platelet count reference range (150,000/μL). CPB, cardiopulmonary bypass; ECMO, extracorporeal membrane oxygenation; IVIg, intravenous immunoglobulin; TPE, therapeutic plasma exchange; UFH, unfractionated heparin.
Figure 2
Figure 2
HIT testing trends prior to, during, and following TPE coupled with IVIg. The left ordinate depicts functional testing results from the SRA (dashed blue line with solid squares) and PEA (dashed red line with solid circles), whereas the right ordinate depicts HIT ELISA (dashed gray line with solid circles) testing results. The patient was persistently ELISA positive (OD, >0.5), had positive serotonin release until the third TPE session, and remained PEA positive until after the second IVIg dose. The ELISA, SRA, and PEA test cutoffs are OD 0.5, 20%, and 19%, respectively. CPB, cardiopulmonary bypass; ELISA, enzyme-linked immunosorbent assay; HIT, heparin-induced thrombocytopenia; IVIg, intravenous immunoglobulin; OD, optical density; PEA, PF4-dependent P-selectin expression assay; PF4, platelet factor 4; SRA, serotonin release assay; TPE, therapeutic plasma exchange.
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