Implantation of left ventricular assist devices under extracorporeal life support in patients with heparin-induced thrombocytopenia

Hillebrand, Julia; Sindermann, Juergen R.; Schmidt, Christoph; Mesters, Rolf M.; Martens, Sven; Scherer, M.

doi:10.1007/s10047-015-0846-9

Cited by 23 publications

(23 citation statements)

References 21 publications

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“…Eight studies used aPTT [18][19][20][21][22][23][24][25] one study used ACT [26] and two studies used both parameters [27,28]. No information was available on the utilized monitoring parameter in two studies [29,30] Reports without control group [20][21][22][23][26][27][28][29][30] were not evaluated. Four retrospective observational studies [18,19,24,25] were assessed for risk of bias.…”

Section: Resultsmentioning

confidence: 99%

Argatroban Anticoagulation for Adult Extracorporeal Membrane Oxygenation: A Systematic Review

Geli

Capoccia

Maybauer

et al. 2021

J Intensive Care Med

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Background: Heparin is the widely used anti-coagulation strategy for patients on extracorporeal membrane oxygenation (ECMO). Nevertheless, heparin-induced thrombocytopenia (HIT) and acquired anti-thrombin (AT) deficiency preclude the use of heparin requiring utilization of an alternative anticoagulant agent. Direct thrombin inhibitors are being proposed as potential alternatives with argatroban as one of the main agents. We aimed to review the evidence with regard to safety and efficacy of argatroban as a potential definitive alternative to heparin in the adult patient population undergoing ECMO support. Methods: A web-based systematic literature search was performed in Medline (PubMed) and Embase from inception until June 18, 2020. Results: The search identified 13 publications relevant to the target (4 cohort studies and 9 case series). Case reports and case series with less than 3 cases were not included in the qualitative synthesis. The aggregate number of argatroban treated patients on ECMO was n = 307. In the majority of studies argatroban was used as a continuous infusion without loading dose. Starting doses on ECMO varied between 0.05 and 2 μg/kg/min and were titrated to achieve the chosen therapeutic target range. The activated partial thormboplastin time (aPTT) was the anticoagulation parameter used for monitoring purposes in most studies, whereas some utilized the activated clotting time (ACT). Optimal therapeutic targets varied between 43-70 and 60-100 seconds for aPTT and between 150-210 and 180-230 seconds for ACT. Bleeding and thromboembolic complication rates were comparable to patients treated with unfractionated heparin (UFH). Conclusions: Argatroban infusion rates and anticoagulation target ranges showed substantial variations. The rational for divergent dosing and monitoring approaches are discussed in this paper. Argatroban appears to be a potential alternative to UFH in patients requiring ECMO. To definitively establish its safety, efficacy and ideal dosing strategy, larger prospective studies on well-defined patient populations are warranted.

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Section: Resultsmentioning

confidence: 99%

Argatroban Anticoagulation for Adult Extracorporeal Membrane Oxygenation: A Systematic Review

Geli

Capoccia

Maybauer

et al. 2021

J Intensive Care Med

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“…Limited experience with alternative anticoagulants and various doses on ECLS include fondaparinux (10), danaparoid (40), lepirudin (10,25,41), argatroban (5,7,19,24,42), and bivalirudin (18) with variable success. The 2012 American College of Chest Physicians HIT guidelines did not provide guidance for patients on ECLS support.…”

Section: Ecmomentioning

confidence: 99%

Heparin-induced thrombocytopenia during extracorporeal life support: incidence, management and outcomes

Choi

Luc

Weber

et al. 2019

Ann. Cardiothorac. Surg.

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Background: Heparin-induced thrombocytopenia (HIT) is a severe antibody-mediated reaction leading to transient prothrombosis. However, its incidence in patients on extracorporeal life support (ECLS) is not well described. The aim of this systematic review was to report the incidence of HIT in patients on ECLS, as well as compare the characteristics and outcomes of HIT in patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and veno-venous ECMO (VV-ECMO). Methods: An electronic search was performed to identify all studies in the English literature examining outcomes of patients with HIT on ECLS. All identified articles were systematically assessed using specific inclusion and exclusion criteria. Random effects meta-analysis as well as univariate analysis was performed. Results: Of 309 patients from six retrospective studies undergoing ECLS, 83% were suspected, and 17% were confirmed to have HIT. Due to the sparsity of relevant retrospective data regarding patients with confirmed HIT on ECLS, patient-based data was subsequently collected on 28 patients from case reports and case series. Out of these 28 patients, 53.6% and 46.4% of them underwent VA-ECMO and VV-ECMO, respectively. Patients on VA-ECMO had a lower median platelet count nadir (VA-ECMO: 26.0 vs. VV-ECMO: 45.0 per µL, P=0.012) and were more likely to experience arterial thromboembolism (VA-ECMO: 53.3% vs. VV-ECMO: 0.0%, P=0.007), though there was a trend towards decreased likelihood of experiencing ECLS circuit oxygenator thromboembolism (VA-ECMO: 0.0% vs. VV-ECMO: 30.8%, P=0.075) and thromboembolism necessitating ECLS device or circuit exchange (VA-ECMO: 13.3% vs. VV-ECMO 53.8%, P=0.060). Kaplan-Meier survival plots including time from ECLS initiation reveal no significant differences in survival in patients supported on VA-ECMO as compared to VV-ECMO (P=0.300). Conclusions: Patients who develop HIT on VA-ECMO are more likely to experience more severe thrombocytopenia and arterial thromboembolism than those on VV-ECMO. Further research in this area and development of standardized protocols for the monitoring, diagnosis and management of HIT in patients on ECLS support are warranted.

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“…With a frequency of about 20 % each, bleeding as well as thromboembolic events were common (54, 55), but not more frequent compared to UFH in non-HIT patients (55). Experience with argatroban during VAD implantation derives from a case series of seven patients in whom preoperative argatroban anticoagulation was continued for CPB (56). The first patient was treated with a target aPTT of 50-60 s during surgery and suffered from severe intraoperative cardiac and device thrombosis.…”

Section: Non-heparin Anticoagulationmentioning

confidence: 99%

Heparin-induced thrombocytopenia in cardiac surgery and critically ill patients

Selleng

Selleng²

2016

Thromb Haemost

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SummaryThrombocytopenia as well as anti-platelet factor 4/heparin (PF4/H) antibodies are common in cardiac surgery patients and those treated in the intensive care unit. In contrast, heparin-induced thrombocytopenia (HIT) is uncommon in these populations (~1 % and ~0.5 %, respectively). A stepwise approach where testing for anti-PF4/H antibodies is performed only in patients with typical clinical symptoms of HIT improves diagnostic specificity of the laboratory assays without losing sensitivity, thereby helping to avoid overdiagnosis and resulting HIT overtreatment. Short-term re-exposure to heparin, especially given intraoperatively for cardiovascular surgery, is a reasonable therapeutic option in patients with a history of HIT who subsequently test negative for HIT antibodies. Organ failure(s), enhanced bleeding risks, and other characteristics require special considerations regarding non-heparin anticoagulation: Argatroban is the alternative anticoagulant with pharmacokinetics independent of renal function, but it has a prolonged half-life in case of impaired liver function. For bivalirudin, protocols during cardiopulmonary bypass surgery are established, and it is suitable for patients with liver insufficiency. A major issue of direct thrombin inhibitors are false high activated partial thromboplastin time values in patients with comorbidities affecting prothrombin, which can result in systematic underdosing of the drugs. This is not the case for danaparoid and fondaparinux, which can be monitored by anti-factor Xa assays, but have long half-lives and no suitable antidote. This review includes also information on management of on-and off-pump cardiac surgery, ventricular assist devices, percutaneous interventions, continuous renal replacement therapy, and extracorporeal membrane oxygenation in patients with HIT.

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Implantation of left ventricular assist devices under extracorporeal life support in patients with heparin-induced thrombocytopenia

Cited by 23 publications

References 21 publications

Argatroban Anticoagulation for Adult Extracorporeal Membrane Oxygenation: A Systematic Review

Argatroban Anticoagulation for Adult Extracorporeal Membrane Oxygenation: A Systematic Review

Heparin-induced thrombocytopenia during extracorporeal life support: incidence, management and outcomes

Heparin-induced thrombocytopenia in cardiac surgery and critically ill patients

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