A retrospective evaluation of fondaparinux for confirmed or suspected heparin-induced thrombocytopenia in left-ventricular-assist device patients

Abstract

BackgroundThrombotic events are a common complication of left ventricular assist device placement and warrant prophylactic anticoagulation. Heparin is the most common anticoagulant used for prophylaxis of thrombotic events in left ventricular assist device patients as a transition to oral anticoagulants but carries the risk of heparin-induced thrombocytopenia. Limited data is available for the treatment of heparin-induced thrombocytopenia in this patient population. We report an evaluation of 8 left ventricular assist device patients with suspected or confirmed HIT started on fondaparinux at the time of heparin-induced platelet-factor-4 antibody positivity.MethodsAdult patients were reported if they were heparin-induced platelet antibody positive, tested via enzyme-linked immunusorbent assay, post-operative after left-ventricular assist device, and were initiated on fondaparinux at the time of heparin-induced platelet antibody positivity. Waiver of informed consent was granted from the institutional review board. Baseline demographics, clinical course of HIT, safety and efficacy variables were collected.ResultsEight patients receiving fondaparinux were identified and included in this report. The patient group was on average 49 years old, weighing 95 kg, with calculated BMI 28.8 and consisted primarily of Caucasian males. Three patients developed new thromboses after initiation of fondaparinux for heparin-induced thrombocytopenia. Only one patient had a major bleeding event of an overt bleed after initiation of fondaparinux therapy.ConclusionsGiven the lack of major bleeding in this evaluation, fondaparinux could be a potentially safe treatment option for left ventricular assist device patients that are heparin-induced platelet antibody positive pending confirmatory testing results. Given the development of new thromboses in 3 of 8 patients, concern exists about the efficacy of fondaparinux in this patient population. Significant limitations exist regarding these conclusions in this evaluation. Controlled, systematic evaluations are necessary to delineate safety and efficacy of fondaparinux for heparin-induced thrombocytopenia in this population.

Hemostatic complications associated with ventricular assist devices

“…The first step in treatment of HIT is to avoid heparin. Alternatives for anticoagulation include argatroban, bivalirudin, or fondaparinux . For patients with renal insufficiency, argatroban is the preferred choice.…”

“…Alternatives for anticoagulation include argatroban, bivalirudin, or fondaparinux. 63,64 For patients with renal insufficiency, argatroban is the preferred choice. Clearance of argatroban is decreased in hepatic disease, and the dose is typically decreased as well.…”

Heparin-induced thrombocytopenia: research and clinical updates

“…In this small study, 7 patients treated with fondaparinux showed similar rates of platelet recovery without new thrombosis as compared with historical controls treated with DTI. 48 Because increased bleeding rates (~10% to 22%) have been noted in small series, 49,50 caution must be exercised for use in critically-ill patients due to the drug's long half-life and renal clearance. British guidelines recommend the use of therapeutic dose fondaparinux for the management of HIT based on level 2C evidence.…”