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

• Published in: Research and practice in thrombosis and haemostasis 2023-02, Vol.7 (2), p.100089, Article 100089
• Main Authors: Grazioli, Alison, Splinter, Noah P., Plazak, Michael E., Griffith, Bartley P., Dahi, Siamak, Bathula, Allison H., Cheung, Nora H., Padmanabhan, Anand
• Format: Article
• Language: English
• Subjects: Case Report; heparin; immunoglobulins; intravenous; plasma exchange; plasmapheresis; thrombocytopenia
• ISSN: 2475-0379; 2475-0379
• DOI: 10.1016/j.rpth.2023.100089

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. Can TPE coupled to IVIg allow for safe heparin exposure in patients with HIT? 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. 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. [Display omitted] •Platelet-activating anti-PF4 antibodies (Abs) mediate heparin-induced thrombocytopenia (HIT).•Some patients with HIT may need urgent surgical intervention using heparin-based anticoagulation.•HIT Abs are removed by therapeutic plasma exchange (TPE) and inhibited by intravenous IgG (IVIg).•Coupling TPE with IVIg appears to be effective in allowing safe exposure to heparin.