Purpose of reviewPrimary graft dysfunction (PGD) is one of the most common complications after lung transplant and is associated with significant early and late morbidity and mortality. The cause of primary graft dysfunction is often multifactorial involving patient, donor, and operational factors. Diastolic dysfunction is increasingly recognized as an important risk factor for development of PGD after lung transplant and here we examine recent evidence on the topic.Recent findingsPatients with end-stage lung disease are more likely to suffer from cardiovascular disease including diastolic dysfunction. PGD as result of ischemia–reperfusion injury after lung transplant is exacerbated by increased left atrial pressure and pulmonary venous congestion impacted by diastolic dysfunction. Recent studies on relationship between diastolic dysfunction and PGD after lung transplant show that patients with diastolic dysfunction are more likely to develop PGD with worse survival outcome and complicated hospital course.SummaryPatients with diastolic dysfunction is more likely to suffer from PGD after lung transplant. From the lung transplant candidate selection to perioperative and posttransplant care, thorough evaluation and documentation diastolic dysfunction to guide patient care are imperative.

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Patient: Male, 44Final Diagnosis: Heparin-induced thrombocytopenia Type IISymptoms: Congestive heart failure • short of breathMedication: —Clinical Procedure: LVAD explantation • TAH insertionSpecialty: AnesthesiologyObjective:Rare co-existance of disease or pathologyBackground:Heparin-induced thrombocytopenia (HIT) is a rare but life-threatening complication of heparin administration. It can present a major clinical dilemma for physicians caring for patients requiring life-saving urgent or emergent cardiac surgery. Studies have been published examining the use of alternative anticoagulants for patients undergoing cardiopulmonary bypass (CPB), however, evidence does not clearly support any particular approach. Presently, there are no large-scale, prospective randomized studies examining the impact of alternative anticoagulants on clinical outcomes for HIT-positive patients requiring cardiac surgery.Case Report:We present the case of a patient who underwent SynCardia Total Artificial Heart (TAH) implantation following a recent left ventricular assist device (LVAD) placement. The patient was receiving argatroban for type II HIT with anuric renal failure, and developed a thrombus which occluded the inflow cannula of the LVAD. Based on a published study and after establishing consensus with the surgical, anesthesiology, perfusion, and hematology teams, we decided to use tirofiban as an antiplatelet agent to inhibit the platelet aggregation induced by heparin, and ultimately used heparin as the anticoagulant for cardiopulmonary bypass.Conclusions:When selecting anticoagulation for a HIT-positive patient requiring CPB, so that benefits outweigh risks, it is of paramount importance that the decision be based on a multitude of factors. The team caring for the patient should have a shared mental model and be familiar with the pharmacology, devices used, and local practices. These three elements should be integrated with patient-specific comorbidities along with local monitoring capabilities to ensure safe, efficient patient care.

Anticoagulation in heparin-induced thrombocytopenia (HIT) requiring cardiopulmonary bypass presents a clinical challenge. Platelet activating immunoglobulin G antibodies target heparin-platelet factor-4 complexes, with subsequent platelet aggregation and thrombosis. We report successful use of cangrelor, a P2Y12 platelet receptor antagonist, with heparin during urgent pulmonary thromboendarterectomy (PTE) for chronic thromboembolic pulmonary hypertension (CTEPH). A 30 year-old male with morbid obesity presented with dyspnea and syncope. Chest computed tomography angiography demonstrated large-burden chronic pulmonary embolism with near complete occlusion of the left and right pulmonary arteries (Figure 1). Echocardiogram revealed severe right ventricular enlargement and dysfunction with right ventricular hypertrophy. Heparin infusion lead to a platelet drop from 260K to 66K. Given concern for HIT, he was switched to argatroban and transferred to our institution. Severe HIT was confirmed with an optimal density of 2.185 and a positive serotonin-release assay, mandating alternative anticoagulation. Bivalirudin has not been well-studied in PTE, surgically unique as it warrants cardiopulmonary bypass with deep hypothermia and circulatory arrest. Deep hypothermia delays bivalirudin metabolism by blood proteases, while circulatory arrest promotes stasis. Thus, bivalirudin in PTE significantly increases circuit thrombosis and patient bleeding risks. Cangrelor was used with heparin to minimize platelet aggregation and thrombosis. Cangrelor has advantages due to high-affinity causing almost complete inhibition of platelet aggregation, with a half-life of 2.6 to 3.3 minutes, allowing rapid removal and platelet function restoration. Intraoperatively, platelet reaction units (PRUs) were measured to assess cangrelor activity and ensure P2Y12 antiplatelet effect with the appropriate scale (baseline PRU 194 to 418, post anti-platelet administration 18 to 435). A cangrelor bolus and infusion were given before heparinization; PRU reduced from 293 to 156. Heparin was then safely administered (total 40,000 units) and cardiopulmonary bypass was started once activated clotting time was appropriate. The patient required a second cangrelor bolus to ensure appropriate PRU levels and anti-platelet effect. Total circulatory arrest was 33 minutes, and after discontinuation of cangrelor, protamine was given for heparin neutralization and hemostasis. Extensive clot material was removed with no perioperative complications (Figure 1). Hemodynamics preoperatively (pulmonary artery pressure 86/23 mm Hg, cardiac index 1.8 lpm 2) dramatically improved post-PTE (pulmonary artery pressure 33/10 mm Hg, cardiac index 3.4 lpm 2). This case represents a novel approach of using cangrelor with heparin intraoperatively for a patient with confirmed HIT requiring urgent PTE. Cangrelor use with heparin offers an effective and safe option in CTEPH while minimizing hematologic complications of thrombosis and bleeding.

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