Argatroban as Purge Solution in Patients With Heparin-Induced Thrombocytopenia on an Impella Device

Mir, Tanveer; Changal, Khalid; Smith, Antonio; Ambreen, Sabah

doi:10.1097/mjt.0000000000001114

Cited by 4 publications

(5 citation statements)

References 15 publications

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“…Concerning anticoagulation in HIT, anti-thrombin inhibitors, e.g., argatroban [3,6,7] or bivalirudin [2,4,5], are preferably administrated for systemic anticoagulation. Hence, antithrombin inhibitors are occasionally used as an additive agent in purge solutions.…”

Section: Anticoagulation In Hit With Impella As a Part Of Mcsmentioning

confidence: 99%

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Heparin-Induced Thrombocytopenia under Mechanical Circulatory Support by Large Impella for Acute Cardiogenic Shock

Sugimura

Bauer

Immohr

et al. 2021

JCDD

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Despite the critical feature of heparin-induced thrombocytopenia (HIT) for patients on mechanical circulatory support, reports on its incidence and outcome are still scarce. Thus, we report on clinical features of HIT in patients under Impella 5.0 or 5.5 (Abiomed Inc., Danvers, MA, USA) (Impella 5+) support for acute cardiogenic shock (CS) by focusing on observed thrombotic events. Between November 2018 and December 2020, a total of 56 consecutive patients were enrolled in a single-center retrospective study. A total of 21 patients (37.5%) were tested for HIT, and 6 (10.7%) proved positive for HIT at 10.5 ± 2.89 days after the first heparin administration during current admission. Interestingly, thrombocyte counts dropped under Impella support in all groups (all cases, no HIT test, and HIT negative group: p < 0.001, HIT-positive group: p = 0.001). All HIT-positive patients were switched from heparin to argatroban. HIT-associated thrombotic events were observed in two cases resulting in Impella dysfunction due to pump thrombosis (n = 1) and left ventricular (LV) thrombus formation (n = 1). Under large Impella support, the prevalence of HIT was relatively high. Further, thrombocytopenia does not deliver a high specificity in the setting of Impella 5+ support. Considering HIT manifestation, a routine HIT test may be considered to avoid critical thrombotic adverse events.

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Section: Anticoagulation In Hit With Impella As a Part Of Mcsmentioning

confidence: 99%

“…Even though HIT is a crucial issue in utilizing the Impella system, only a few cases are reported in the literature [2][3][4][5][6][7]. Further, reports are even more limited in the setting of large surgical Impella systems, i.e., Impella 5 or 5.5 (Impella 5+).…”

Section: Introductionmentioning

confidence: 99%

Heparin-Induced Thrombocytopenia under Mechanical Circulatory Support by Large Impella for Acute Cardiogenic Shock

Sugimura

Bauer

Immohr

et al. 2021

JCDD

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“…[6][7][8]10,[21][22][23] Despite this, real-world utilization of DTI-based purge solution has been described through case reports and case series, largely in cases of suspected HIT. [29][30][31][32][33][34] However, case reports of low purge flows with rising purge pressure, pump failure, and/or thrombosis with DTIbased purge solutions also have been described and the ongoing use of Impella support in confirmed HIT should be re-evaluated. 15,30 Another treatment strategy in situations where heparin, or any other aforementioned alternative is not desirable, is running D5Wonly purge.…”

Section: Non-standard Non-heparin Purge Solutionsmentioning

confidence: 99%

Optimizing anticoagulation for patients receiving Impella support

Beavers

DiDomenico²,

Dunn

et al. 2021

Pharmacotherapy

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Cardiogenic shock is a complication experienced by 1-10% of patients hospitalized for either acute myocardial infarction or acute heart failure that leads to hypoperfusion of vital organs and contributes to an in-hospital mortality rate of up to 51%. [1][2][3][4] Temporary mechanical circulatory support (MCS) is often utilized in patients with cardiogenic shock to provide hemodynamic support. Although several temporary MCS options are available, the proportion of critically ill patientsincluding those with cardiogenic shock-receiving temporary MCS

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“…A variety of strategies have been documented to prevent tMCS pump failure while avoiding UFH exposure, with mixed success. [7][8][9][10][11][12] The use of systemic bivalirudin-a direct thrombin inhibitor-with a bivalirudin-dextrose based purge has been reported with limited success, with failures attributed to the bivalirudin purge solution lacking the appropriate ionic charge. 10,13 Recent publications with the Impella RP®, CP®, 5.0® and 5.5® devices have suggested that using sodium bicarbonate-dextrose purge solution (SBPS), compounded as 25 mEq of sodium bicarbonate in 1 L of 5% dextrose in water, may provide a sustainable option to avoid a UFH-based purge solution.…”

Section: Introductionmentioning

confidence: 99%

“…A variety of strategies have been documented to prevent tMCS pump failure while avoiding UFH exposure, with mixed success 7‐12 . The use of systemic bivalirudin—a direct thrombin inhibitor—with a bivalirudin‐dextrose based purge has been reported with limited success, with failures attributed to the bivalirudin purge solution lacking the appropriate ionic charge 10,13 .…”

Section: Introductionmentioning

confidence: 99%

Outcomes of systemic bivalirudin and sodium bicarbonate purge solution for Impella 5.5

et al. 2022

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Background: Impella 5.5 (Abiomed; Danvers, MA) (IMP5) is a commonly used, surgically implanted, tMCS device that requires systemic anticoagulation and purge solution to avoid pump failure. To avoid heparin-induced thrombocytopenia (HIT) from unfractionated heparin (UFH) use, our program has explored the utility of bivalirudin (BIV) for systemic anticoagulation and sodium bicarbonatedextrose purge solution (SBPS) in IMP5.5. Methods: This single center, retrospective study included 34 patients supported on IMP5.5 with BIV based AC and SBPS between December 1st 2020 to December 1st 2021.The efficacy and safety end points were incidence of development of HIT, Tissue Plasminogen Activator (tPA) use for suspected pump thrombosis, stroke, and device failure as well as clinically significant bleeding. Results:The median duration of IMP5.5 support was 9.8 days (IQR: 6-15). Most patients were bridged to HTX (58%) followed by recovery (27%) and LVAD implantation (15%). Patients were therapeutic on bivalirudin for 64% of their IMP5.5 support. One patient (2.9%) suffered from ischemic stroke and 26.5% (9) patients developed clinically significant bleeding. tPA was administered to 7(21%) patients. One patient in the entire cohort developed HIT. Conclusions:Our experience supports the use of systemic BIV and SBPS as a method to avoid heparin exposure in a patient population predisposed to the development of HIT.

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Argatroban as Purge Solution in Patients With Heparin-Induced Thrombocytopenia on an Impella Device

Cited by 4 publications

References 15 publications

Heparin-Induced Thrombocytopenia under Mechanical Circulatory Support by Large Impella for Acute Cardiogenic Shock

Heparin-Induced Thrombocytopenia under Mechanical Circulatory Support by Large Impella for Acute Cardiogenic Shock

Optimizing anticoagulation for patients receiving Impella support

Outcomes of systemic bivalirudin and sodium bicarbonate purge solution for Impella 5.5

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