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Arachchillage DJ, Thachil J, Anderson JAM, Baker P, Poles A, Kitchen S, Laffan M. Diagnosis and management of heparin-induced thrombocytopenia: Third edition. Br J Haematol 2024; 204:459-475. [PMID: 38153164 DOI: 10.1111/bjh.19180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Julia A M Anderson
- Department of Haematology, Edinburgh Royal Infirmary, Edinburgh, Scotland
| | - Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Anthony Poles
- Bristol NHS Blood and Transplant Centre, Bristol, UK
| | - Steve Kitchen
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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2
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Raadsen MP, Visser C, Lavell AHA, van de Munckhof AAGA, Coutinho JM, de Maat MPM, GeurtsvanKessel CH, Bomers MK, Haagmans BL, van Gorp ECM, Porcelijn L, Kruip MJHA. Transient Autoreactive PF4 and Antiphospholipid Antibodies in COVID-19 Vaccine Recipients. Vaccines (Basel) 2023; 11:1851. [PMID: 38140254 PMCID: PMC10747426 DOI: 10.3390/vaccines11121851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/05/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare autoimmune condition associated with recombinant adenovirus (rAV)-based COVID-19 vaccines. It is thought to arise from autoantibodies targeting platelet factor 4 (aPF4), triggered by vaccine-induced inflammation and the formation of neo-antigenic complexes between PF4 and the rAV vector. To investigate the specific induction of aPF4 by rAV-based vaccines, we examined sera from rAV vaccine recipients (AZD1222, AD26.COV2.S) and messenger RNA (mRNA) based (mRNA-1273, BNT162b2) COVID-19 vaccine recipients. We compared the antibody fold change (FC) for aPF4 and for antiphospholipid antibodies (aPL) of rAV to mRNA vaccine recipients. We combined two biobanks of Dutch healthcare workers and matched rAV-vaccinated individuals to mRNA-vaccinated controls, based on age, sex and prior history of COVID-19 (AZD1222: 37, Ad26.COV2.S: 35, mRNA-1273: 47, BNT162b2: 26). We found no significant differences in aPF4 FCs after the first (0.99 vs. 1.08, mean difference (MD) = -0.11 (95% CI -0.23 to 0.057)) and second doses of AZD1222 (0.99 vs. 1.10, MD = -0.11 (95% CI -0.31 to 0.10)) and after a single dose of Ad26.COV2.S compared to mRNA-based vaccines (1.01 vs. 0.99, MD = 0.026 (95% CI -0.13 to 0.18)). The mean FCs for the aPL in rAV-based vaccine recipients were similar to those in mRNA-based vaccines. No correlation was observed between post-vaccination aPF4 levels and vaccine type (mean aPF difference -0.070 (95% CI -0.14 to 0.002) mRNA vs. rAV). In summary, our study indicates that rAV and mRNA-based COVID-19 vaccines do not substantially elevate aPF4 levels in healthy individuals.
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Affiliation(s)
- Matthijs P. Raadsen
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (M.P.R.); (C.H.G.); (B.L.H.); (E.C.M.v.G.)
| | - Chantal Visser
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (C.V.); (M.P.M.d.M.)
| | - A. H. Ayesha Lavell
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (A.H.A.L.); (M.K.B.)
- Amsterdam Institute for Infection & Immunity, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Anita A. G. A. van de Munckhof
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.A.G.A.v.d.M.); (J.M.C.)
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (A.A.G.A.v.d.M.); (J.M.C.)
| | - Moniek P. M. de Maat
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (C.V.); (M.P.M.d.M.)
| | - Corine H. GeurtsvanKessel
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (M.P.R.); (C.H.G.); (B.L.H.); (E.C.M.v.G.)
| | | | - Marije K. Bomers
- Department of Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (A.H.A.L.); (M.K.B.)
- Amsterdam Institute for Infection & Immunity, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bart L. Haagmans
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (M.P.R.); (C.H.G.); (B.L.H.); (E.C.M.v.G.)
| | - Eric C. M. van Gorp
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (M.P.R.); (C.H.G.); (B.L.H.); (E.C.M.v.G.)
| | - Leendert Porcelijn
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands;
| | - Marieke J. H. A. Kruip
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (C.V.); (M.P.M.d.M.)
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Al-Azri K, Goldstone K, Phillips J, Bhana J, Patel N, Warkentin TE. Severe autoimmune heparin-induced thrombocytopenia postcardiac surgery: Implications for subsequent cardiac surgery. Am J Hematol 2023; 98:1953-1958. [PMID: 37823557 DOI: 10.1002/ajh.27123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Khalid Al-Azri
- Hematology Department, Waikato Hospital, Hamilton, New Zealand
| | - Kate Goldstone
- Cardiac Anaesthesia Department, Waikato Hospital, Hamilton, New Zealand
| | - Julia Phillips
- Hematology Department, Waikato Hospital, Hamilton, New Zealand
| | - Jack Bhana
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Nishith Patel
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Theodore E Warkentin
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Pathology & Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Service of Benign Hematology, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
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Pong T, Cyr K, Aparicio-Valenzuela J, Carlton C, Lee AM. A Modified 4Ts Score for Heparin-Induced Thrombocytopenia in the Mechanical Circulatory Support Population. J Cardiothorac Vasc Anesth 2023; 37:2499-2507. [PMID: 37407329 DOI: 10.1053/j.jvca.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE To identify risk factors and develop a pretest scoring system to differentiate patients with heparin-induced thrombocytopenia (HIT) in the mechanical circulatory support (MCS) population. The authors present a modified "4TMCS" scoring system, which considers the "type of mechanical circulatory support" that may help identify patients at risk for developing postoperative HIT. DESIGN A retrospective cohort study. Patients who underwent cardiac surgery were categorized into 3 groups: (1) normal platelet count, (2) thrombocytopenia with a negative HIT test, and (3) thrombocytopenia with a positive HIT test. A comparison of diagnostic accuracy between the 4Ts and 4TMCS probability scores was performed. SETTING At a single adult tertiary-care center. PARTICIPANTS A total of 5,314 patients who underwent cardiac surgery between May 1, 2008 and December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 125 out of 5,314 patients (2.4%) were diagnosed with HIT, of whom 75 out of 5,314 (1.4%) had clinical evidence of thrombosis. Overall, in-hospital mortality was 25.6%, 11.7%, and 1.5% in the HIT(+), HIT(-), and control groups, respectively (p < 0.001). Mechanical circulatory support was associated with a significantly increased risk for HIT, with an incidence of 5.9% in patients receiving MCS versus 1.9% in those without (p < 0.001). Area under the receiver operator curve (AUC) analysis demonstrated improved diagnostic accuracy of the 4TMCS score compared with the 4Ts (AUC = 0.83 v 0.77, p < 0.044). The 4TMCS score had higher sensitivity than the 4Ts, using the guideline-recommended score cutoff of ≥4 (95.2% v 85.7%). CONCLUSION Heparin-induced thrombocytopenia is associated with worse outcomes and increased morbidity and mortality in the MCS population. Awareness of patient risk factors and the application of a modified 4TMCS probability score may allow for more accurate screening and treatment of HIT in the MCS population.
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Affiliation(s)
- Terrence Pong
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Kevin Cyr
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Joy Aparicio-Valenzuela
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Cody Carlton
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Anson M Lee
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA.
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Hernandez J, Patel H, Biddlecome P, Kildea M, Dwivedi R, Sridhara S, Silvestry S, Cavarocchi N, Francis JL, Ventura D. Evaluation of Latex Immunoturbidimetric Assay Thresholds and HIT in Cardiothoracic Surgery. Clin Appl Thromb Hemost 2023; 29:10760296231166370. [PMID: 37069794 PMCID: PMC10123911 DOI: 10.1177/10760296231166370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/01/2023] [Accepted: 03/12/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a common differential diagnosis in cardiothoracic surgery. The latex immunoturbidimetric assay (LIA) is an enhanced immunoassay that has recently been introduced for the detection of total HIT immunoglobulin and retains a higher specificity of 95% compared to the enzyme-linked immunosorbent assay. OBJECTIVES To investigate if a semiquantitative relationship exists between increasing LIA levels beyond the current positivity threshold and its correlation to positive serotonin release assay results in cardiothoracic surgery. METHODS This was a multicenter, observational cohort of cardiothoracic surgery patients initiated on anticoagulation with heparin-based products. To conduct sensitivity and specificity analysis of LIA values, HIT positive was defined as a LIA value ≥1 unit/mL and HIT negative was defined as a LIA level <1 unit/mL. A receiver operating characteristic (ROC) analysis was utilized to evaluate the predictive performance of the LIA. RESULTS At manufactures' cutoffs of ≥1.0 unit/mL, LIA sensitivity and specificity was 93.8% and 22%, respectively, yielding a false positive rate of 78%. At a higher cutoff of 4.5 units/mL, LIA sensitivity and specificity was 75% and 71%, respectively, yielding a false positive rate of 29% and an area under the ROC curve of 0.75 (P = .01; 95% confidence interval: 0.621-0.889). Bivalirudin was initiated in 84.6% of false positive LIA results. CONCLUSION This study suggests that the diagnostic accuracy of the LIA can be optimized by increasing the LIA positivity threshold. Proposing a higher LIA cutoff, may mitigate unwarranted anticoagulation and bleeding outcomes.
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Affiliation(s)
- Jessica Hernandez
- Ascension Via Christi St. Francis, Wichita, KS, USA
- Department of Pharmacy, AdventHealth Orlando, Orlando, FL, USA
- College of Pharmacy, University of Kansas, Lawrence, KS, USA
| | - Hetal Patel
- Department of Pharmacy, AdventHealth Orlando, Orlando, FL, USA
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Phil Biddlecome
- Department of Pharmacy, AdventHealth Orlando, Orlando, FL, USA
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Megan Kildea
- Department of Pharmacy, AdventHealth Orlando, Orlando, FL, USA
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Ruti Dwivedi
- Department of Pharmacy, AdventHealth Orlando, Orlando, FL, USA
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Shashank Sridhara
- Department of Pharmacy, AdventHealth Orlando, Orlando, FL, USA
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | | | - Nicholas Cavarocchi
- Department of Critical Care Medicine, AdventHealth Medical Group, Orlando, FL, USA
| | - John L. Francis
- AdventHealth Hemostasis and Thrombosis Laboratory, Orlando, USA
| | - Davide Ventura
- College of Pharmacy, University of Kansas, Lawrence, KS, USA
- College of Pharmacy, University of Florida, Gainesville, FL, USA
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Pishko A, Cuker A. Early-onset heparin-induced thrombocytopenia after cardiac surgery: Should we lose sleep? J Thromb Haemost 2022; 20:2491-2493. [PMID: 36271465 DOI: 10.1111/jth.15840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Allyson Pishko
- Division of Hematology & Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam Cuker
- Division of Hematology & Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Warkentin TE, Sheppard JI, Whitlock RP. Temporal presentations of heparin-induced thrombocytopenia following cardiac surgery: A single-center, retrospective cohort study. J Thromb Haemost 2022; 20:2601-2616. [PMID: 35869817 PMCID: PMC9805231 DOI: 10.1111/jth.15826] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an important adverse drug reaction that can occur postcardiac surgery. Preoperative exposure to unfractionated heparin (UFH) is common, raising the issue of how frequently cardiac surgery-associated HIT occurs after immunizing preoperative exposure to heparin. OBJECTIVE To determine the frequency and clinical picture of HIT occurring within 4 days of cardiac surgery (early presentation) versus later presentations (typical, delayed). METHODS We identified patients with laboratory-confirmed HIT following cardiac surgery over 30 years in a single cardiac surgery center. Three different clinical presentations of HIT were identified: typical (HIT-related platelet count fall beginning between postoperative days [PODs] 5-10), delayed (patients with falls after POD10 or who presented following hospital discharge), and early (established before POD5, including during cardiac surgery [acute intraoperative HIT]). RESULTS Of 129 patients identified with HIT complicating cardiac surgery, 100 had typical and 16 had delayed presentation of HIT; only 13 patients (10.1%) presented with early HIT, all of whom had received exposure to UFH during the 10 days before cardiac surgery. No patient was identified in whom remote preoperative UFH exposure was implicated in explaining early HIT. Notably, five patients appeared to have had acute intraoperative HIT, without immediate adverse consequences. CONCLUSIONS Approximately 90% of patients with HIT after cardiac surgery appear to develop this complication due to immunization triggered by cardiac surgery; however, in approximately 10% of patients, early presentation during the first four PODs (or intraoperatively) can be explained by recent immunizing exposure to heparin.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
- Transfusion MedicineHamilton Regional Laboratory Medicine ProgramHamiltonOntarioCanada
- Service of Benign HematologyHamilton Health SciencesHamiltonOntarioCanada
| | - Jo‐Ann I. Sheppard
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Richard P. Whitlock
- Department of Surgery, Division of Cardiac SurgeryMcMaster UniversityHamiltonOntarioCanada
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Liu Y, Yuan Z, Han X, Song K, Xing J. A Comparison of Activated Partial Thromboplastin Time and Activated Coagulation Time for Anticoagulation Monitoring during Extracorporeal Membrane Oxygenation Therapy. Hamostaseologie 2022. [PMID: 35882351 DOI: 10.1055/a-1796-8652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
BACKGROUND Unfractionated heparin is used to prevent coagulation activation in patients undergoing extracorporeal membrane oxygenation (ECMO) support. We designed this study to determine the preferable indicator for anticoagulation monitoring. METHODS We conducted a retrospective study and divided the patients into an activated coagulation time (ACT)-target group and an activated partial thromboplastin time (aPTT)-target group. The correlations between ACT, aPTT, and the heparin dose were explored. RESULTS Thirty-six patients were included (19 aPTT-target and 17 ACT-target patients); a total of 555 matched pairs of ACT/aPTT results were obtained. The correlation between the ACT and aPTT measurements was Spearman's Rank Correlation Coefficient (rs) = 0.518 in all 555 pairs. The Bland-Altman plot showed data points outside the displayed range (51.2-127.7), suggesting that the agreement between ACT and aPTT was poor. The aPTT group had fewer heparin dose changes (2.12 ± 0.68 vs. 2.57 ± 0.64, p = 0.05) and a lower cumulative heparin dose (317.6 ± 108.5 vs. 396.3 ± 144.3, p = 0.00) per day than the ACT group. There was no difference in serious bleeding (9 vs. 5; p = 0.171) or embolism events (3 vs. 3; p = 1.0) or in the red blood cell and fresh frozen plasma transfusion volumes between the ACT- and aPTT-target groups. Similarly, there was no significant difference in the ECMO duration (9 [4-15] days vs. 4 [3-14] days; p = 0.124) or length of ICU hospitalization (17 [5-32] days vs. 13 [4-21] days; p = 0.451) between the groups. CONCLUSION The correlation between ACT and aPTT and the heparin dose was poor. The aPTT group had fewer daily heparin dose changes and a lower cumulative heparin dose per day than the ACT group, with no more bleeding and thrombotic events. Therefore, we recommend aPTT rather than ACT to adjust heparin dose in the absence of better monitoring indicators.
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Affiliation(s)
- Ying Liu
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People's Republic of China
| | - Zhiyong Yuan
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People's Republic of China
| | - Xiaoning Han
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People's Republic of China
| | - Kai Song
- School of Mathematics and Statistics, Qingdao University, Qingdao, Shandong, People's Republic of China
| | - Jinyan Xing
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, People's Republic of China
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Rinaldi I, Sudaryo MK, Mansjoer A. Pre-operative, Intraoperative, and Post-operative Determinants Associated with 30-day Mortality Post-Coronary Artery Bypass Graft: A Retrospective Cohort Study. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.9563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Abstract
Background: Various determinants of 30-day mortality risk in CABG patients have been formulated into certain scoring models such as the EuroSCORE and ACEF model. However, these models only consider preoperative parameters while excluding intraoperative, postoperative, and perioperative parameters. Currently, the prior research has increasingly emphasized the role of these excluded parameters as determinants of post-CABG mortality. Furthermore, there are differences in mortality rate of CABG procedures in Indonesia when compared with other countries. Hence, this study aimed to identify preoperative, intraoperative, and postoperative determinants of 30-day mortality after CABG surgery in Indonesian population.
Methods: In this retrospective cohort study, secondary data were obtained from the medical records of 263 patients aged ≥ 18 years who underwent CABG at a single center in Indonesia during the year 2012–2015. Selected preoperative, intraoperative, postoperative, and perioperative determinants were analyzed in both bivariate and multivariate Cox regression models to identify determinants associated with 30-day mortality.
Results: The 30-day mortality rate after CABG was 11.8%. Multivariate analysis identified neurological dysfunction (HR 6.16; 95% CI 2.42-15.66), renal impairment (HR 3.9; 95% CI 1.46-10.38), left ventricle dysfunction (HR 3.53;95% CI 1.55-8.03), aortic clamp duration (HR 3.7;95% CI 1.53-8.96), surgery duration (HR 3.85;95% CI 1.39-10.70), postoperative thrombocytopenia (HR 3.99;95% CI 1.72-9.23), and postoperative intra-aortic balloon pump (HR 10.98; 95% CI 4.77-25.28) as significant determinants associated with 30-day mortality after CABG
Conclusions: Neurological dysfunction, renal impairment, left ventricle dysfunction, aortic clamp duration, surgery duration, postoperative thrombocytopenia, and postoperative intra-aortic balloon pump were independent determinants for 30-day mortality after CABG.
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Cutler NS, Marchant BE. Comparison of screening scores for heparin induced thrombocytopenia after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2022; 36:3570-3575. [DOI: 10.1053/j.jvca.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/21/2022] [Accepted: 04/06/2022] [Indexed: 11/11/2022]
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Zoller M, Atmowihardjo I, Huch J, Albrecht I, Habedank D. Near fatal stent thrombosis in an aneurysmatic RCX as first manifestation of heparin induced thrombocytopenia (HIT) without thrombocytopenia. BMC Cardiovasc Disord 2021; 21:624. [PMID: 34972517 PMCID: PMC8720211 DOI: 10.1186/s12872-021-02442-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/21/2021] [Indexed: 11/28/2022] Open
Abstract
Background Thrombosis resulting from heparin-induced thrombocytopenia (HIT) occurs in about 2% of patients without a significant decrease in platelet counts. We report on such a near fatal thrombotic event caused by coronary intervention. Case presentation A supposedly “completely healthy” 53-year-old patient was admitted to hospital with covered rupture of an aneurysm of the Aorta descendens. He was successfully operated on and underwent coronary angiography due to NSTEMI six days later. Immediately after intervention of a 90% RCX stenosis he developed ventricular flutter, was defibrillated, and re-angiography showed partial occlusion of the RCX stent. Lots of white thrombi could be retrieved by aspiration catheter and gave reason for a HIT without thrombocytopenia. The detection of platelet factor 4/heparin complex antibodies by immunoassay supported and the subsequent Heparin Induced Platelet Activation Assay proved this diagnosis. Conclusions The clinical event of an acute stent thrombosis should alarm the interventional team to the diagnosis of HIT even with a normal platelet count.
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Affiliation(s)
- Marc Zoller
- Intensive Care Unit, DRK Kliniken Berlin Köpenick, Berlin, Germany
| | - Iskandar Atmowihardjo
- Medizinische Klinik Kardiologie, DRK Kliniken Berlin Köpenick, S.-Allende-Str. 2-8, Berlin, 12559, Germany
| | - Jeanette Huch
- Medizinische Klinik Kardiologie, DRK Kliniken Berlin Köpenick, S.-Allende-Str. 2-8, Berlin, 12559, Germany
| | - Ines Albrecht
- Medizinische Klinik Kardiologie, DRK Kliniken Berlin Köpenick, S.-Allende-Str. 2-8, Berlin, 12559, Germany
| | - Dirk Habedank
- Medizinische Klinik Kardiologie, DRK Kliniken Berlin Köpenick, S.-Allende-Str. 2-8, Berlin, 12559, Germany. .,Medizinische Klinik und Poliklinik B, University Hospital Greifswald, Greifswald, Germany.
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12
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Abstract
Heparin-induced thrombocytopenia is a severe prothrombotic disease. Timely diagnosis and treatment are essential. Application of diagnostic algorithms based on validated clinical scoring tools and rapid, specific laboratory assays may improve outcomes.
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Pishko AM. Heparin-induced thrombocytopenia and cardiovascular surgery. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:536-544. [PMID: 34889428 PMCID: PMC8791147 DOI: 10.1182/hematology.2021000289] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Clinicians generally counsel patients with a history of heparin-induced thrombocytopenia (HIT) to avoid heparin products lifelong. Although there are now many alternative (nonheparin) anticoagulants available, heparin avoidance remains challenging for cardiac surgery. Heparin is often preferred in the cardiac surgery setting based on the vast experience with the agent, ease of monitoring, and reversibility. To "clear" a patient with a history of HIT for cardiac surgery, hematologists must first confirm the diagnosis of HIT, which can be challenging due to the ubiquity of heparin exposure and frequency of thrombocytopenia in patients in the cardiac intensive care unit. Next, the "phase of HIT" (acute HIT, subacute HIT A/B, or remote HIT) should be established based on platelet count, immunoassay for antibodies to platelet factor 4/heparin complexes, and a functional assay (eg, serotonin release assay). As long as the HIT functional assay remains positive (acute HIT or subacute HIT A), cardiac surgery should be delayed if possible. If surgery cannot be delayed, an alternative anticoagulant (preferably bivalirudin) may be used. Alternatively, heparin may be used with either preoperative/intraoperative plasma exchange or together with a potent antiplatelet agent. The optimal strategy among these options is not known, and the choice depends on institutional experience and availability of alternative anticoagulants. In the later phases of HIT (subacute HIT B or remote HIT), brief intraoperative exposure to heparin followed by an alternative anticoagulant as needed in the postoperative setting is recommended.
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Affiliation(s)
- Allyson M. Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Correspondence Allyson M. Pishko, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 3rd Floor Dulles, Philadelphia, PA 19104; e-mail:
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Ahmadinejad M, Shahbazi M, Chegini A. Heparin-Induced Thrombocytopenia in Iranian Cardiac Surgery Patients Using the 4Ts Clinical Scoring System and Laboratory Methods. Int J Hematol Oncol Stem Cell Res 2021; 15:230-238. [PMID: 35291665 PMCID: PMC8888360 DOI: 10.18502/ijhoscr.v15i4.7478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 09/11/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction. HIT diagnosis needs an algorithmic approach including clinical evaluation and laboratory tests (screening and confirmatory). Few studies have been conducted on HIT in Iran, and most existing research has been general and based on clinical evaluations alone. The present study was conducted to determine the prevalence of HIT among cardiac surgery patients using an algorithmic approach. Materials and Methods: A cross-sectional study was carried out over a period of 10 months, at Modares Hospital (Tehran, Iran) on 92 patients who were candidates for cardiac surgery. For the clinical evaluation, the 4Ts scoring system was used; in cases with 4Ts scores ≥4, a laboratory evaluation of anti-PF4/heparin antibody (Ab) was performed by enzyme-linked immunosorbent assay (ELISA) and a HIPA test too as a functional confirmatory method. The patients with 4Ts scores ≥4 who were ELISA positive (OD ≥0.2) and HIPA positive were taken as a definite case of HIT. Results: Of the 92 patients who had undergone cardiac surgery, 14 (15%) had 4Ts scores ≥4. Anti- PF4/heparin Ab was detected in eight patients using the ELISA and in six patients using the HIPA. Ultimately, definite HIT was confirmed in five of the patients. Conclusion: The prevalence of HIT was 5.4% among the cardiac surgery patients assessed in the present study. To the researchers’ knowledge, this is the first time that HIT has been evaluated in Iran using a comprehensive algorithmic approach including clinical history-taking and both immunological and functional laboratory tests, and the findings showed a slightly higher HIT frequency in this single-center study in comparison with the other studies carried out in other countries.
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Affiliation(s)
- Minoo Ahmadinejad
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Massoumeh Shahbazi
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Azita Chegini
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
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Cheng Y, Chen C, Yang J, Yang H, Fu M, Zhong X, Wang B, He M, Hu Z, Zhang Z, Jin X, Kang Y, Wu Q. Using Machine Learning Algorithms to Predict Hospital Acquired Thrombocytopenia after Operation in the Intensive Care Unit: A Retrospective Cohort Study. Diagnostics (Basel) 2021; 11:diagnostics11091614. [PMID: 34573956 PMCID: PMC8466367 DOI: 10.3390/diagnostics11091614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 02/05/2023] Open
Abstract
Hospital acquired thrombocytopenia (HAT) is a common hematological complication after surgery. This research aimed to develop and compare the performance of seven machine learning (ML) algorithms for predicting patients that are at risk of HAT after surgery. We conducted a retrospective cohort study which enrolled adult patients transferred to the intensive care unit (ICU) after surgery in West China Hospital of Sichuan University from January 2016 to December 2018. All subjects were randomly divided into a derivation set (70%) and test set (30%). ten-fold cross-validation was used to estimate the hyperparameters of ML algorithms during the training process in the derivation set. After ML models were developed, the sensitivity, specificity, area under the curve (AUC), and net benefit (decision analysis curve, DCA) were calculated to evaluate the performances of ML models in the test set. A total of 10,369 patients were included and in 1354 (13.1%) HAT occurred. The AUC of all seven ML models exceeded 0.7, the two highest were Gradient Boosting (GB) (0.834, 0.814-0.853, p < 0.001) and Random Forest (RF) (0.828, 0.807-0.848, p < 0.001). There was no difference between GB and RF (0.834 vs. 0.828, p = 0.293); however, these two were better than the remaining five models (p < 0.001). The DCA revealed that all ML models had high net benefits with a threshold probability approximately less than 0.6. In conclusion, we found that ML models constructed by multiple preoperative variables can predict HAT in patients transferred to ICU after surgery, which can improve risk stratification and guide management in clinical practice.
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Affiliation(s)
- Yisong Cheng
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Chaoyue Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, China;
| | - Jie Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Hao Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Min Fu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Xi Zhong
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Min He
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Zhi Hu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Xiaodong Jin
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Qin Wu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
- Correspondence: ; Tel.: +86-028-8542-2506
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Tardy-Poncet B, de Maistre E, Pouplard C, Presles E, Alhenc-Gelas M, Lasne D, Horellou MH, Mouton C, Serre-Sapin A, Bauters A, Nguyen P, Mullier F, Perrin J, Le Gal G, Morange PE, Grunebaum L, Lillo-Le Louet A, Elalamy I, Gruel Y, Greinacher A, Lecompte T, Tardy B. Heparin-induced thrombocytopenia: Construction of a pretest diagnostic score derived from the analysis of a prospective multinational database, with internal validation. J Thromb Haemost 2021; 19:1959-1972. [PMID: 33872452 DOI: 10.1111/jth.15344] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 04/09/2021] [Accepted: 04/09/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Diagnosis of heparin-induced thrombocytopenia (HIT) requires pretest probability assessment and dedicated laboratory assays. OBJECTIVE To develop a pretest score for HIT. DESIGN Observational; analysis of prospectively collected data of hospitalized patients suspected with HIT (ClinicalTrials.gov NCT00748839). SETTING Thirty-one tertiary hospitals in France, Switzerland, and Belgium. PATIENTS Patients tested for HIT antibodies (2280 evaluable), randomly allocated to derivation and validation cohorts. MEASUREMENTS Independent adjudicators diagnosed HIT based on the prospectively collected data and serotonin release assay results. RESULTS Heparin-induced thrombocytopenia was diagnosed in 234 (14.7%) and 99 (14.5%) patients in the two cohorts. Eight features were associated with HIT (in brackets, points assigned for score calculation of the score): unfractionated heparin (1); therapeutic-dose heparin (1); cardiopulmonary bypass (cardiac surgery) (2); major trauma (3); 5- to 21-day interval from anticoagulation initiation to suspicion of HIT (4); ≥40% decrease in platelet count over ≤6 days (3); thrombotic event, arterial (3) or venous (3). The C-statistic was 0.79 (95% CI, 0.76-0.82). In the validation cohort, the area under the receiver operating characteristic curve was 0.77 (95% CI, 0.74-0.80). Three groups of scores were defined; HIT prevalence reached almost 30% in the high-probability group. LIMITATION The performance of the score may depend on settings and practices. CONCLUSION The objective, easy-to-collect, clinical features of HIT we evidenced were incorporated into a pretest score, which may guide clinical decisions regarding diagnostic testing and anticoagulation.
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Affiliation(s)
- Brigitte Tardy-Poncet
- CIC 1408, Inserm U1059 SAINBIOSE, F-Crin INNOVTE, Université de Lyon, Saint-Etienne, France
| | | | - Claire Pouplard
- Division of Hematology - Hemostasis, University Hospital of Tours, Tours, France
| | - Emilie Presles
- CIC 1408, Inserm U1059 SAINBIOSE, F-Crin INNOVTE, Université de Lyon, Saint-Etienne, France
| | | | - Dominique Lasne
- Hemostasis Unit, Hôpital Necker, AP-HP, Paris, France
- Université Paris Sud Paris Saclay, Inserm U1176, Le Kremlin-Bicêtre, France
| | | | | | | | | | | | - François Mullier
- Namur Thrombosis and Hemostasis Center, Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | | | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, ON, Canada
| | - Pierre-Emmanuel Morange
- C2VN, Aix Marseille University, INSERM, INRA; Laboratory of Hematology, La Timone Hospital, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Lélia Grunebaum
- Laboratory of Hematology, CHU Strasbourg, Strasbourg, France
| | - Agnès Lillo-Le Louet
- Pharmacovigilance Center, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Ismail Elalamy
- Hematology and Thrombosis Center, Tenon University Hospital, INSERM UMRS 938, Sorbonne University, Paris, France
| | - Yves Gruel
- Division of Hematology - Hemostasis, University Hospital of Tours, Tours, France
| | - Andreas Greinacher
- Institut fuer Immunologie und Transfusionsmedizin, Universitaetsmedizin Greifswald, Greifswald, Germany
| | - Thomas Lecompte
- Department of Medicine, Geneva University Hospitals, and Geneva Platelet Group (GpG), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernard Tardy
- CIC 1408, Inserm U1059 SAINBIOSE, F-Crin INNOVTE, Université de Lyon, Saint-Etienne, France
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Lorusso R, Jiritano F, Roselli E, Shrestha M, Folliguet T, Meuris B, Pollari F, Fischlein T. Perioperative platelet reduction after sutureless or stented valve implantation: results from the PERSIST-AVR controlled randomized trial. Eur J Cardiothorac Surg 2021; 60:1359-1365. [PMID: 34118150 DOI: 10.1093/ejcts/ezab175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/19/2021] [Accepted: 02/28/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Platelet count reduction is a common but not fully understood phenomenon after aortic valve replacement (AVR) with bioprosthesis implantation. The aim of the present study was to investigate the occurrence and the clinical impact of platelet count reduction in patients receiving the Perceval bioprosthesis compared to those receiving standard sutured stented bioprosthetic aortic valve in a randomized, controlled AVR study. METHODS PERceval Sutureless Implant versus STandard Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016-September 2018) to AVR with a sutureless or stented valve. Ad hoc analyses have been performed to evaluate the occurrence of platelet count reduction and the clinical impact of the platelet variations in the 2 groups. RESULTS The Perceval group showed a higher platelet reduction than the control group (46% vs 32%). The phenomenon was transient in both groups, with a slow recovery of the platelet count by hospital discharge. No differences were observed between groups regarding need of transfusions, blood loss, major bleeding and stroke events. CONCLUSIONS The Perceval sutureless aortic bioprosthesis implantation is associated with higher rate of transient platelet reduction as compared to stented bioprostheses for AVR. However, the platelet count reduction is transient and the decline does not affect the patient's clinical outcomes. Current explanations for this phenomenon are speculative, and further investigations are required to elucidate it. CLINICAL TRIAL REGISTRATION NUMBER NCT02673697-ClinicalTrials.gov-4 February 2016.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Federica Jiritano
- Cardio-Thoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, Netherlands.,Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Eric Roselli
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Thierry Folliguet
- Department of Cardiac Surgery, Hôpital Henri Mondor, Université Paris 12, Créteil, Paris, France
| | - Bart Meuris
- Cardiac Surgery Department, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Francesco Pollari
- Klinikum Nürnberg, Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
| | - Theodor Fischlein
- Klinikum Nürnberg, Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany
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Hage A, Dolan DP, Nasr VG, Castelo-Branco L, Motta-Calderon D, Ghandour H, Hage F, Papatheodorou S, Chu MWA. Safety of Direct Oral Anticoagulants Compared to Warfarin for Atrial Fibrillation after Cardiac Surgery: A Systematic Review and Meta-Analysis. Semin Thorac Cardiovasc Surg 2021; 34:947-957. [PMID: 34111554 DOI: 10.1053/j.semtcvs.2021.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 11/11/2022]
Abstract
The evidence for use of direct oral anticoagulants (DOACs) in the management of post-operative cardiac surgery atrial fibrillation is limited and mostly founded on clinical trials that excluded this patient population. We performed a systematic review and meta-analysis of clinical trials and observational studies to evaluate the hypothesis that DOACs are safe compared to warfarin for the anticoagulation of patients with post-operative cardiac surgery atrial fibrillation. We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and the Cochrane Library for clinical trials and observational studies comparing DOAC with warfarin in patients ≥18 years old who had post-cardiac surgery atrial fibrillation. Primary outcomes included stroke, systemic embolization, bleeding, and mortality. We performed a random-effects meta-analysis of all outcomes. The meta-analysis for the primary outcomes showed significantly lower risk of stroke with DOAC use (6 studies, 7143 patients, RR 0.64; 95% CI 0.50-0.81, I2: 0.0%) compared to warfarin, a trend towards lower risk of systemic embolization (4 studies, 7289 patients, RR 0.64, 95% CI 0.41-1.01, I2: 31.99%) and similar risks of bleeding (14 studies, 10182 patients, RR 0.91; 95% CI 0.74-1.10, I2: 26.6%) and mortality (12 studies, 9843 patients, relative risk [RR] 1.01; 95% CI 0.74-1.37, I2: 26.5%). Current evidence suggests that DOACs, compared to warfarin, in the management of atrial fibrillation after cardiac surgery is associated with lower risk of stroke and a strong trend for lower risk of systemic embolization, and no evidence of increased risk for hospital readmission, bleeding and mortality.
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Affiliation(s)
- Ali Hage
- Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | - Daniel P Dolan
- Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Viviane G Nasr
- Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Luis Castelo-Branco
- Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Neuroscience, Neuromodulation Center, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Daniel Motta-Calderon
- Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hiba Ghandour
- Global Surgery, Harvard Medical School, Boston, Massachusetts
| | - Fadi Hage
- Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; Division of Cardiac Surgery, Western University, London, Ontario, Canada
| | | | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London, Ontario, Canada.
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Frequency of Thrombocytopenia and Heparin-Induced Thrombocytopenia in Patients Receiving Extracorporeal Membrane Oxygenation Compared With Cardiopulmonary Bypass and the Limited Sensitivity of Pretest Probability Score. Crit Care Med 2021; 48:e371-e379. [PMID: 32058356 DOI: 10.1097/ccm.0000000000004261] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To ascertain: 1) the frequency of thrombocytopenia and heparin-induced thrombocytopenia; 2) positive predictive value of the Pretest Probability Score in identifying heparin-induced thrombocytopenia; and 3) clinical outcome of heparin-induced thrombocytopenia in adult patients receiving venovenous- or venoarterial-extracorporeal membrane oxygenation, compared with cardiopulmonary bypass. DESIGN A single-center, retrospective, observational cohort study from January 2016 to April 2018. SETTING Tertiary referral center for cardiac and respiratory failure. PATIENTS Patients who received extracorporeal membrane oxygenation for more than 48 hours or had cardiopulmonary bypass during specified period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical and laboratory data were collected retrospectively. Pretest Probability Score and heparin-induced thrombocytopenia testing results were collected prospectively. Mean age (± SD) of the extracorporeal membrane oxygenation and cardiopulmonary bypass cohorts was 45.4 (± 15.6) and 64.9 (± 13), respectively (p < 0.00001). Median duration of cardiopulmonary bypass was 4.6 hours (2-16.5 hr) compared with 170.4 hours (70-1,008 hr) on extracorporeal membrane oxygenation. Moderate and severe thrombocytopenia were more common in extracorporeal membrane oxygenation compared with cardiopulmonary bypass throughout (p < 0.0001). Thrombocytopenia increased in cardiopulmonary bypass patients on day 2 but was normal in 83% compared with 42.3% of extracorporeal membrane oxygenation patients at day 10. Patients on extracorporeal membrane oxygenation also followed a similar pattern of platelet recovery following cessation of extracorporeal membrane oxygenation. The frequency of heparin-induced thrombocytopenia in extracorporeal membrane oxygenation and cardiopulmonary bypass were 6.4% (19/298) and 0.6% (18/2,998), respectively (p < 0.0001). There was no difference in prevalence of heparin-induced thrombocytopenia in patients on venovenous-extracorporeal membrane oxygenation (8/156, 5.1%) versus venoarterial-extracorporeal membrane oxygenation (11/142, 7.7%) (p = 0.47). The positive predictive value of the Pretest Probability Score in identifying heparin-induced thrombocytopenia in patients post cardiopulmonary bypass and on extracorporeal membrane oxygenation was 56.25% (18/32) and 25% (15/60), respectively. Mortality was not different with (6/19, 31.6%) or without (89/279, 32.2%) heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation (p = 0.79). CONCLUSIONS Thrombocytopenia is already common at extracorporeal membrane oxygenation initiation. Heparin-induced thrombocytopenia is more frequent in both venovenous- and venoarterial-extracorporeal membrane oxygenation compared with cardiopulmonary bypass. Positive predictive value of Pretest Probability Score in identifying heparin-induced thrombocytopenia was lower in extracorporeal membrane oxygenation patients. Heparin-induced thrombocytopenia had no effect on mortality.
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A practical approach to evaluating postoperative thrombocytopenia. Blood Adv 2021; 4:776-783. [PMID: 32097460 DOI: 10.1182/bloodadvances.2019001414] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/21/2020] [Indexed: 12/19/2022] Open
Abstract
Identifying the cause(s) of postoperative thrombocytopenia is challenging. The postoperative period includes numerous interventions, including fluid administration and transfusion of blood products, medication use (including heparin), and increased risk of organ dysfunction and infection. Understanding normal thrombopoietin physiology and the associated expected postoperative platelet count changes is the crucial first step in evaluation. Timing of thrombocytopenia is the most important feature when differentiating causes of postoperative thrombocytopenia. Thrombocytopenia within 4 days of surgery is commonly caused by hemodilution and increased perioperative platelet consumption prior to thrombopoietin-induced platelet count recovery and transient platelet count overshoot. A much broader list of possible conditions that can cause late-onset thrombocytopenia (postoperative day 5 [POD5] or later) is generally divided into consumptive and destructive causes. The former includes common (eg, infection-associated disseminated intravascular coagulation) and rare (eg, postoperative thrombotic thrombocytopenic purpura) conditions, whereas the latter includes such entities as drug-induced immune thrombocytopenia or posttransfusion purpura. Heparin-induced thrombocytopenia is a unique entity associated with thrombosis that is typically related to intraoperative/perioperative heparin exposure, although it can develop following knee replacement surgery even in the absence of heparin exposure. Very late onset (POD10 or later) of thrombocytopenia can indicate bacterial or fungal infection. Lastly, thrombocytopenia after mechanical device implantation requires unique considerations. Understanding the timing and severity of postoperative thrombocytopenia provides a practical approach to a common and challenging consultation.
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21
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The molecular basis of immune-based platelet disorders. Clin Sci (Lond) 2021; 134:2807-2822. [PMID: 33140828 DOI: 10.1042/cs20191101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/12/2020] [Accepted: 10/23/2020] [Indexed: 12/17/2022]
Abstract
Platelets have a predominant role in haemostasis, the maintenance of blood volume and emerging roles as innate immune cells, in wound healing and in inflammatory responses. Platelets express receptors that are important for platelet adhesion, aggregation, participation in inflammatory responses, and for triggering degranulation and enhancing thrombin generation. They carry a cargo of granules bearing enzymes, adhesion molecules, growth factors and cytokines, and have the ability to generate reactive oxygen species. The platelet is at the frontline of a host of cellular responses to invading pathogens, injury, and infection. Perhaps because of this intrinsic responsibility of a platelet to rapidly respond to thrombotic, pathological and immunological factors as part of their infantry role; platelets are susceptible to targeted attack by the adaptive immune system. Such attacks are often transitory but result in aberrant platelet activation as well as significant loss of platelet numbers and platelet function, paradoxically leading to elevated risks of both thrombosis and bleeding. Here, we discuss the main molecular events underlying immune-based platelet disorders with specific focus on events occurring at the platelet surface leading to activation and clearance.
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Ezelsoy M, Saracoglu KT, Oral K, Saracoglu A, Akpinar B. Positive Heparin/PF4 Antibodies and High Mortality Rate: a Retrospective Case-Series Analysis. Braz J Cardiovasc Surg 2020; 35:950-957. [PMID: 33306320 PMCID: PMC7731847 DOI: 10.21470/1678-9741-2019-0360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Heparin-induced thrombocytopenia (HIT) is a potentially lethal complication of unfractionated or low-molecular weight heparin therapy. We aimed to determine the incidence and mortality rate of patients with positive heparin/platelet factor 4 (PF4) antibodies, which is a rapid detection test of HIT. Methods Coronary artery bypass grafting and mitral and aortic valve surgeries were evaluated. Cardiopulmonary bypass was employed in all patients. The diagnosis of HIT was based on immunological assays. Postoperative complications, mortality rates, and the causes of death were specified in patients with positive heparin/PF4 antibodies. Results Postoperative thrombocytopenia was detected in 257 patients. Twenty of these patients undergoing open heart surgery were included in the final analysis. Antibodies against heparin/PF4 complex were positive in 20 patients. The mean body mass index was 28.8±2.3 kg/m2, mean value of left ventricular ejection fraction was 48.3±6.7%, cardiopulmonary bypass time was 113.0±35.0 min, aortic cross-clamping time was 88.0±32.7 min, mean intensive care unit length of stay was 10.9±4.9 days, mean preoperative platelet count was 307.250±88528 platelets/microliter, and mean postoperative platelet count was 243.050±89.354 platelets/microliter. The mean duration of heparin exposure was 6.9±2.9 days. The mortality rate was 45% (nine patients) and 1.2% (three patients) in heparin/PF4 complex positive and negative patients, respectively. Conclusion Although the incidence of HIT was low in patients undergoing open heart surgery, an increased rate of early mortality was observed in patients with positive heparin/PF4 antibodies.
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Affiliation(s)
- Mehmet Ezelsoy
- Department of Cardiovascular Surgery, Istanbul Demiroglu Bilim University Medical School, Istanbul, Turkey
| | - Kemal Tolga Saracoglu
- Department of Anesthesiology and Intensive Care, Health Sciences University Medical School, Istanbul, Turkey
| | - Kerem Oral
- Department of Cardiovascular Surgery, Istanbul Demiroglu Bilim University Medical School, Istanbul, Turkey
| | - Ayten Saracoglu
- Department of Anesthesiology and Intensive Care, Istanbul Marmara University Medical School, Istanbul, Turkey
| | - Belhan Akpinar
- Department of Cardiovascular Surgery, Istanbul Demiroglu Bilim University Medical School, Istanbul, Turkey
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Abstract
Purpose of Review This review will illustrate the importance of heparin-induced thrombocytopenia in the intraoperative and critical care settings. Recent Findings Heparin-induced thrombocytopenia (HIT) occurs more frequently in surgical patients compared with medical patients due to the inflammatory release of platelet factor 4 and perioperative heparin exposure. Recognition of this disease requires a high index of suspicion. Diagnostic tools and therapeutic strategies have been expanded and refined in recent years. Summary HIT is a condition where antibodies against the heparin/platelet factor 4 complex interact with platelet receptors to promote platelet activation, aggregation, and thrombus formation. Our review will focus on intraoperative and postoperative considerations related to HIT to help the clinician better manage this rare but often devastating hypercoagulable disease process.
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Adverse outcomes associated with managing suspected heparin induced thrombocytopenia in the critically ill. Thromb Res 2020; 193:218-220. [PMID: 32798962 DOI: 10.1016/j.thromres.2020.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 06/23/2020] [Accepted: 08/05/2020] [Indexed: 11/23/2022]
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Song JC, Liu SY, Zhu F, Wen AQ, Ma LH, Li WQ, Wu J. Expert consensus on the diagnosis and treatment of thrombocytopenia in adult critical care patients in China. Mil Med Res 2020; 7:15. [PMID: 32241296 PMCID: PMC7118900 DOI: 10.1186/s40779-020-00244-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/20/2020] [Indexed: 01/14/2023] Open
Abstract
Thrombocytopenia is a common complication of critical care patients. The rates of bleeding events and mortality are also significantly increased in critical care patients with thrombocytopenia. Therefore, the Critical Care Medicine Committee of Chinese People's Liberation Army (PLA) worked with Chinese Society of Laboratory Medicine, Chinese Medical Association to develop this consensus to provide guidance for clinical practice. The consensus includes five sections and 27 items: the definition of thrombocytopenia, etiology and pathophysiology, diagnosis and differential diagnosis, treatment and prevention.
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Affiliation(s)
- Jing-Chun Song
- Department of Critical Care Medicine, the 908th Hospital of Joint Logistics Support Forces of Chinese PLA, Nanchang, 360104, China.
| | - Shu-Yuan Liu
- Emergency Department, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Feng Zhu
- Burns and Trauma ICU, Changhai Hospital, Naval Medical University, Shanghai, 200003, China
| | - Ai-Qing Wen
- Department of Blood Transfusion, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Lin-Hao Ma
- Department of Emergency and Critical Care Medicine, Changzheng Hospital, Naval Medical University, Shanghai, 200003, China
| | - Wei-Qin Li
- Surgery Intensive Care Unit, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China.
| | - Jun Wu
- Department of Clinical Laboratory, Peking University Fourth School of Clinical Medicine, Beijing Jishuitan Hospital, Beijing, 100035, China.
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Hogan M, Berger JS. Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management. Vasc Med 2020; 25:160-173. [PMID: 32195628 DOI: 10.1177/1358863x19898253] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. Here, we review the pathogenesis, incidence, diagnosis, and management of HIT. The first step in thwarting devastating complications from this entity is to maintain a high index of clinical suspicion, followed by an accurate clinical scoring assessment using the 4Ts. Next, appropriate stepwise laboratory testing must be undertaken in order to rule out HIT or establish the diagnosis. In the interim, all heparin must be stopped immediately, and the patient administered alternative anticoagulation. Here we review alternative anticoagulation choice, therapy alternatives in the difficult-to-manage patient with HIT, and the problem of overdiagnosis.
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Affiliation(s)
- Marie Hogan
- Department of Pediatrics, Division of Hematology Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology and Hematology, New York University School of Medicine, New York, NY, USA
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Heparininduzierte Thrombopenie in der Kardiochirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-019-00345-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bloom MB, Johnson J, Volod O, Lee EY, White T, Margulies DR. Improved prediction of HIT in the SICU using an improved model of the Warkentin 4-T system: 3-T. Am J Surg 2019; 219:54-57. [PMID: 31400811 DOI: 10.1016/j.amjsurg.2019.07.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/18/2019] [Accepted: 07/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Warkentin 4-T scoring system for determining the pretest probability of heparin-induced thrombocytopenia (HIT) has been shown to be inaccurate in the ICU and does not take into account body mass index (BMI). METHODS Prospectively collected data on patients in the surgical and cardiac ICU between January 2007 and February 2016 who were presumed to have HIT by clinical suspicion were reviewed. Patients were categorized into 3 BMI groups and assigned scores: Normal weight, overweight, and obese. Multivariate analyses were used to identify independent predictors of HIT. RESULTS A total of 523 patients met inclusion criteria. Multivariate analysis showed that only BMI, Timing, and oTher variables were independently associated with HIT. This new 3-T model was better than a five-component model consisting of the entire 4-T scoring system plus BMI (AUC = 0.791). CONCLUSIONS Incorporating patient 'T'hickness into a pretest probability model along with platelet 'T'iming and the exclusion of o'T'her causes of thrombocytopenia yields a simplified "3-T" scoring system that has increased predictive accuracy in the ICU.
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Affiliation(s)
- Matthew B Bloom
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Jeffrey Johnson
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Oksana Volod
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Ernest Y Lee
- UCLA-Caltech Medical Scientist Training Program, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
| | - Terris White
- United Regional Health Care System, Wichita Falls, TX, USA.
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
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Stanger O, Grabherr M, Gahl B, Longnus S, Meinitzer A, Fiedler M, Tevaearai H, Carrel T. Thrombocytopaenia after aortic valve replacement with stented, stentless and sutureless bioprostheses. Eur J Cardiothorac Surg 2019; 51:340-346. [PMID: 28186236 DOI: 10.1093/ejcts/ezw295] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/27/2016] [Accepted: 07/29/2016] [Indexed: 11/12/2022] Open
Affiliation(s)
- Olaf Stanger
- Clinic for Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Michael Grabherr
- Clinic for Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Brigitta Gahl
- Clinic for Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Sarah Longnus
- Clinic for Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Andreas Meinitzer
- Department of Laboratory Medicine, University Hospital, Auenbrugger University, Graz, Austria
| | - Martin Fiedler
- Center for Laboratory Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Hendrik Tevaearai
- Clinic for Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Thierry Carrel
- Clinic for Cardiovascular Surgery, Inselspital, University Hospital Bern, Bern, Switzerland
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Ivascu NS, Fitzgerald M, Ghadimi K, Patel P, Evans AS, Goeddel LA, Shaefi S, Klick J, Johnson A, Raiten J, Horak J, Gutsche J. Heparin-Induced Thrombocytopenia: A Review for Cardiac Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2019; 33:511-520. [DOI: 10.1053/j.jvca.2018.10.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Indexed: 01/02/2023]
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Heparin-Induced Thrombocytopenia. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00041-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Nagrebetsky A, Al-Samkari H, Davis N, Kuter D, Wiener-Kronish J. Perioperative thrombocytopenia: evidence, evaluation, and emerging therapies. Br J Anaesth 2019; 122:19-31. [DOI: 10.1016/j.bja.2018.09.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 08/28/2018] [Accepted: 09/02/2018] [Indexed: 01/19/2023] Open
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Ostadi Z, Shadvar K, Sanaie S, Mahmoodpoor A, Saghaleini SH. Thrombocytopenia in the intensive care unit. Pak J Med Sci 2018; 35:282-287. [PMID: 30881439 PMCID: PMC6408643 DOI: 10.12669/pjms.35.1.19] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Thrombocytopenia is a frequent finding in intensive care unit especially among adults and medical ICU patients. Thrombocytopenia is defined as a platelet count less than 100×109/l in ICU setting. Platelets are made in the bone marrow from megakaryocytes. Although not fully understood, proplatelets transform into platelets in the lung. The body tries to maintain platelet count relatively constant throughout life. Pathophysiology of thrombocytopenia can be defined by hemodilution, elevated levels of platelet consumption, compromise of platelet production, increased platelet sequestration and increased platelet destruction. Unlike in other situations, absolute platelet count alone does not provide sufficient data in characterizing thrombocytopenia in ICU patients. In such cases, the time course of changes in platelet count is also pivotal. The dynamics of platelet count decrease vary considerably between different ICU patient populations including trauma, major surgery and minor surgery/medical conditions. There are strong evidences available that delay in platelet count restoration in ICU patients is an indicator of a bad outcome.
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Affiliation(s)
- Zohreh Ostadi
- Zohreh Ostadi, Anesthesiologist, Fellowship of Critical Care Medicine, Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamran Shadvar
- Kamran Shadvar, Associate Professor of Anesthesiology, Fellowship of Critical Care Medicine, Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sarvin Sanaie
- Sarvin Sanaie, Assistant Professor of Nutrition, MD, PhD, Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Ata Mahmoodpoor, Professor of Anesthesiology, Fellowship of Critical Care Medicine, Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seied Hadi Saghaleini
- Seied Hadi Saghaleini, Assistant Professor of Anesthesiology, Fellowship of Critical Care Medicine, Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
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Patel R, Varga C. Heparin-induced thrombocytopenia in a cardiac surgery patient with early and persistent thrombocytopenia and initial negative immunological and functional assays. Thromb Res 2018; 169:93-95. [DOI: 10.1016/j.thromres.2018.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 06/28/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022]
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Stoll F, Gödde M, Leo A, Katus HA, Müller OJ. Characterization of hospitalized cardiovascular patients with suspected heparin-induced thrombocytopenia. Clin Cardiol 2018; 41:1521-1526. [PMID: 30144122 DOI: 10.1002/clc.23061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/21/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Little is known about heparin-induced thrombocytopenia (HIT), a pro-thrombotic, potentially life-threatening immune-mediated reaction to heparin exposure, in conservative and interventional cardiovascular medicine. HYPOTHESIS The 4T score, validated for prediction of HIT in surgical patients before, is also suitable for assessing HIT probability in cardiovascular patients with unclear thrombocytopenia. METHODS A total of 403 consecutive patients from our Department of Cardiology, Angiology and Pneumology in whom a HIT screening test was performed between 2009 and 2016 were identified. All 72 patients with a positive screening test were subjected to a functional confirmation test (heparin-induced platelet activation test, HIPA), resulting in 23 patients with serologically confirmed HIT (positive screening test, positive HIPA) and 49 patients with nonconfirmed HIT (positive screening test, negative HIPA). RESULTS The 4TScore had a sensitivity of 82.6% and a specificity of 28.6% in our patients, suggesting that it might not sufficiently predict the clinical probability of HIT in cardiovascular patients. In both confirmed and nonconfirmed HIT, intrahospital mortality was high without a significant difference (30% in confirmed HIT vs 43% in nonconfirmed HIT). Bacteremia was more often found in patients with nonconfirmed HIT, suggesting infection as a frequent differential diagnosis of thrombocytopenia in these patients (49% vs 17%, P = 0.0185). CONCLUSION HIT screening should be initiated in cardiovascular patients with unclear thrombocytopenia despite a low 4Tscore in order to distinguish patients requiring alternative anticoagulants from those with other causes such as infections. Further research is needed to specify the risk profile for HIT in cardiovascular patients.
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Affiliation(s)
- Felicitas Stoll
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Miriel Gödde
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Albrecht Leo
- Institute for Clinical Transfusion Medicine and Cell Therapy Heidelberg gGmbH, Heidelberg, Germany
| | - Hugo A Katus
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Oliver J Müller
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany.,Department of Internal Medicine III, University of Kiel, Germany
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Kimmoun A, Oulehri W, Sonneville R, Grisot PH, Zogheib E, Amour J, Aissaoui N, Megarbane B, Mongardon N, Renou A, Schmidt M, Besnier E, Delmas C, Dessertaine G, Guidon C, Nesseler N, Labro G, Rozec B, Pierrot M, Helms J, Bougon D, Chardonnal L, Medard A, Ouattara A, Girerd N, Lamiral Z, Borie M, Ajzenberg N, Levy B. Prevalence and outcome of heparin-induced thrombocytopenia diagnosed under veno-arterial extracorporeal membrane oxygenation: a retrospective nationwide study. Intensive Care Med 2018; 44:1460-1469. [PMID: 30136139 DOI: 10.1007/s00134-018-5346-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 08/10/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Thrombocytopenia is a frequent and serious adverse event in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. Similarly to postcardiac surgery patients, heparin-induced thrombocytopenia (HIT) could represent the causative underlying mechanism. However, the epidemiology as well as related mortality regarding HIT and VA-ECMO remains largely unknown. We aimed to define the prevalence and associated 90-day mortality of HIT diagnosed under VA-ECMO. METHODS This retrospective study included patients under VA-ECMO from 20 French centers between 2012 and 2016. Selected patients were hospitalized for more than 3 days with high clinical suspicion of HIT and positive anti-PF4/heparin antibodies. Patients were classified according to results of functional tests as having either Confirmed or Excluded HIT. RESULTS A total of 5797 patients under VA-ECMO were screened; 39/5797 met the inclusion criteria, with HIT confirmed in 21/5797 patients (0.36% [95% CI] [0.21-0.52]). Fourteen of 39 patients (35.9% [20.8-50.9]) with suspected HIT were ultimately excluded because of negative functional assays. Drug-induced thrombocytopenia tended to be more frequent in Excluded HIT at the time of HIT suspicion (p = 0.073). The platelet course was similar between Confirmed and Excluded HIT (p = 0.65). Mortality rate was 33.3% [13.2-53.5] in Confirmed and 50% [23.8-76.2] in Excluded HIT (p = 0.48). CONCLUSIONS Prevalence of HIT among patients under VA-ECMO is extremely low at 0.36% with an associated mortality rate of 33.3%, which appears to be in the same range as that observed in patients treated with VA-ECMO without HIT. In addition, HIT was ultimately ruled out in one-third of patients with clinical suspicion of HIT and positive anti-PF4/heparin antibodies.
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Affiliation(s)
- Antoine Kimmoun
- Medical Intensive Care Unit Brabois, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, INSERM U1116, Université de Lorraine, Vandoeuvre-les-Nancy, 54511, Nancy, France
| | - Walid Oulehri
- Department of Anesthesiology and Surgical Critical Care, Nouvel Hôpital Civil, CHU Strasbourg, Strasbourg, France
| | - Romain Sonneville
- Department of Intensive Care Medicine and Infectious Diseases, Hôpital Bichat Claude Bernard, Assistance Publique, Hôpitaux de Paris, INSERM, UMR 1148, Université Paris Diderot, Paris, France
| | - Paul-Henri Grisot
- Medical Intensive Care Unit Brabois, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, INSERM U1116, Université de Lorraine, Vandoeuvre-les-Nancy, 54511, Nancy, France
| | - Elie Zogheib
- Cardiothoracic and Vascular Intensive Care Unit, Amiens University Hospital, INSERM U1088, Jules Verne University of Picardy, Amiens, France
| | - Julien Amour
- Department of Anesthesiology and Surgical Critical Care, Institut Hospitalo-Universitaire de Cardiométabolisme et Nutrition, Hôpital Pitié-Salpêtrière, Assistance Publique, Hôpitaux de Paris, UMR INSERM 1166, Université Sorbonne, Paris, France
| | - Nadia Aissaoui
- Critical Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, INSERM U970, Université Paris-Descartes, Paris, France
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, INSERM UMRS-1144, Université Paris Diderot, Paris, France
| | - Nicolas Mongardon
- Department of Anesthesiology and Surgical Critical Care, CHU Henri Mondor, Assistance Publique-Hôpitaux de Paris, INSERM U955 Team 3, Université Paris Est, Paris, France
| | - Amelie Renou
- Department of Anesthesiology and Surgical Critical Care, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France
| | - Matthieu Schmidt
- Medical Intensive Care Unit, Institut Hospitalo-Universitaire de Cardiométabolisme et Nutrition, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, UMR INSERM 1166, Université Sorbonne, Paris, France
| | - Emmanuel Besnier
- Department of Anesthesiology and Surgical Critical Care, Hôpital de Rouen, Université de Rouen, Rouen, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Hôpital de Rangueil, Université de Toulouse 3 Paul Sabatier, Toulouse, France
| | - Geraldine Dessertaine
- Intensive Cardiac Care Unit, Hôpital de Grenoble, Université de Grenoble Alpes, Grenoble, France
| | - Catherine Guidon
- Department of Cardiac Surgery, Hôpital La Timone, Marseille, France
| | - Nicolas Nesseler
- Department of Anesthesiology and Surgical Critical Care, Hôpital de Pontchaillou, INSERM, UMR 1214 and INSERM 1414, Université de Rennes 1, Rennes, France
| | - Guylaine Labro
- Medical Intensive Care Unit, Hôpital Jean Minjoz, Université de Franche-Comté, Besançon, France
| | - Bertrand Rozec
- Department of Anesthesiology and Surgical Critical Care, Hôpital Guillaume et René Laennec, CHRU Nantes, Institut du Thorax, Université de Nantes, Nantes, France
| | - Marc Pierrot
- Department of Medical Intensive Care and Hyperbaric Medicine, Hôpital d'Angers, Université d' Angers, Angers, France
| | - Julie Helms
- Medical Intensive Care Unit, Nouvel Hôpital Civil, CHU de Strasbourg, INSERM, UMR_S1109, Université de Strasbourg, Strasbourg, France
| | - David Bougon
- Intensive Care Unit, Hôpital Annecy Genevois, Annecy, France
| | - Laurent Chardonnal
- Department of Anesthesiology and Surgical Critical Care, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Anne Medard
- Department of Anesthesiology and Surgical Critical Care, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Alexandre Ouattara
- Department of Anesthesiology and Surgical Critical Care, Centre Médico-Chirurgical Magellan, CHU de Bordeaux, INSERM, UMR 1034, Université de Bordeaux, Bordeaux, France
| | - Nicolas Girerd
- INSERM CIC1433, CHRU de Nancy, Université de Lorraine, Nancy, France
| | - Zohra Lamiral
- INSERM CIC1433, CHRU de Nancy, Université de Lorraine, Nancy, France
| | | | - Nadine Ajzenberg
- Department of Hematology, Hôpital Bichat Claude Bernard, Assistance Publique, Hôpitaux de Paris, INSERM, UMR 1148, Université Paris Diderot, Paris, France
| | - Bruno Levy
- Medical Intensive Care Unit Brabois, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, INSERM U1116, Université de Lorraine, Vandoeuvre-les-Nancy, 54511, Nancy, France.
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Nazy I, Clare R, Staibano P, Warkentin TE, Larché M, Moore JC, Smith JW, Whitlock RP, Kelton JG, Arnold DM. Cellular immune responses to platelet factor 4 and heparin complexes in patients with heparin-induced thrombocytopenia. J Thromb Haemost 2018; 16:1402-1412. [PMID: 29723924 DOI: 10.1111/jth.14132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Indexed: 01/31/2023]
Abstract
Essentials The immunogenesis of Heparin-induced thrombocytopenia (HIT) is not well understood. Immunization to platelet factor 4 (PF4)-heparin occurs early in life, before any heparin exposure. PF4 and PF4-heparin complexes induce the proliferation of CD14+ cells. Reduced levels of regulatory cytokines contribute to immune dysregulation in HIT. SUMMARY Background Heparin-induced thrombocytopenia (HIT) is an adverse reaction to heparin characterized by thrombocytopenia and thrombotic complications. HIT is caused by pathogenic antibodies that bind to complexes of platelet factor 4 (PF4) and heparin, leading to platelet activation and inducing a hypercoagulable state. Previous studies have shown immunity to PF4-heparin complexes occurs early in life, even before heparin exposure; however, the immunogenesis of HIT is not well characterized. Objectives To investigate cellular proliferation in response to PF4-heparin complexes in patients with HIT. Patients/Methods Peripheral blood mononuclear cells (PBMCs) from healthy controls (n = 30), postoperative cardiac surgery patients who had undergone cardiopulmonary bypass (CPB) (n = 17) and patients with confirmed HIT (n = 41) were cultured with PF4 and PF4-heparin complexes. Cellular proliferation was assessed by [3 H]thymidine uptake and 5-ethynyl-2'-deoxyuridine detection. Results and Conclusions PBMCs proliferated in the presence of PF4, and this was enhanced by the addition of heparin in all study groups. CPB and HIT patients showed significantly greater proliferative responses than healthy controls. PBMC proliferation was antigen-specific, depended on the presence of platelets, and only CD14+ cells were identified as proliferating cells. Culture supernatants were tested for the levels of regulatory cytokines, and both CPB and HIT patients produced significantly lower levels of interleukin-10 and transforming growth factor-β1 than healthy controls. These findings further demonstrate cellular immune sensitization to PF4-heparin complexes occurs before heparin exposure, and suggests immune dysregulation can contribute to HIT.
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Affiliation(s)
- I Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - R Clare
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - P Staibano
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - T E Warkentin
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - M Larché
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J C Moore
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J W Smith
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - R P Whitlock
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - J G Kelton
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - D M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
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Platelet-Activating Antibodies Are Detectable at the Earliest Onset of Heparin-Induced Thrombocytopenia, With Implications for the Operating Characteristics of the Serotonin-Release Assay. Chest 2018; 153:1396-1404. [DOI: 10.1016/j.chest.2018.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/01/2017] [Accepted: 01/02/2018] [Indexed: 11/21/2022] Open
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Dewitte A, Lepreux S, Villeneuve J, Rigothier C, Combe C, Ouattara A, Ripoche J. Blood platelets and sepsis pathophysiology: A new therapeutic prospect in critically [corrected] ill patients? Ann Intensive Care 2017; 7:115. [PMID: 29192366 PMCID: PMC5709271 DOI: 10.1186/s13613-017-0337-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/12/2017] [Indexed: 02/06/2023] Open
Abstract
Beyond haemostasis, platelets have emerged as versatile effectors of the immune response. The contribution of platelets in inflammation, tissue integrity and defence against infections has considerably widened the spectrum of their role in health and disease. Here, we propose a narrative review that first describes these new platelet attributes. We then examine their relevance to microcirculatory alterations in multi-organ dysfunction, a major sepsis complication. Rapid progresses that are made on the knowledge of novel platelet functions should improve the understanding of thrombocytopenia, a common condition and a predictor of adverse outcome in sepsis, and may provide potential avenues for management and therapy.
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Affiliation(s)
- Antoine Dewitte
- INSERM U1026, BioTis, Univ. Bordeaux, 33000, Bordeaux, France. .,Department of Anaesthesia and Critical Care II, Magellan Medico-Surgical Center, CHU Bordeaux, 33000, Bordeaux, France.
| | - Sébastien Lepreux
- INSERM U1026, BioTis, Univ. Bordeaux, 33000, Bordeaux, France.,Department of Pathology, CHU Bordeaux, 33000, Bordeaux, France
| | - Julien Villeneuve
- Cell and Developmental Biology Department, Centre for Genomic Regulation, The Barcelona Institute for Science and Technology, 08003, Barcelona, Spain
| | - Claire Rigothier
- INSERM U1026, BioTis, Univ. Bordeaux, 33000, Bordeaux, France.,Department of Nephrology, Transplantation and Haemodialysis, CHU Bordeaux, 33000, Bordeaux, France
| | - Christian Combe
- INSERM U1026, BioTis, Univ. Bordeaux, 33000, Bordeaux, France.,Department of Nephrology, Transplantation and Haemodialysis, CHU Bordeaux, 33000, Bordeaux, France
| | - Alexandre Ouattara
- Department of Anaesthesia and Critical Care II, Magellan Medico-Surgical Center, CHU Bordeaux, 33000, Bordeaux, France.,INSERM U1034, Biology of Cardiovascular Diseases, Univ. Bordeaux, 33600, Pessac, France
| | - Jean Ripoche
- INSERM U1026, BioTis, Univ. Bordeaux, 33000, Bordeaux, France
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Selleng S, Selleng K. Heparin-induced thrombocytopenia in cardiac surgery and critically ill patients. Thromb Haemost 2017; 116:843-851. [DOI: 10.1160/th16-03-0230] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/16/2016] [Indexed: 11/05/2022]
Abstract
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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Pollak U, Mishaly D, Kenet G, Vardi A. Heparin-induced thrombocytopenia complicating children after the Fontan procedure: Single-center experience and review of the literature. CONGENIT HEART DIS 2017; 13:16-25. [DOI: 10.1111/chd.12557] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/27/2017] [Accepted: 11/06/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Uri Pollak
- Department of Pediatric Cardiac Intensive Care; The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center; Tel Aviv Israel
- Department of Pediatric Cardiology; The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center; Tel Hashomer Israel
- The Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - David Mishaly
- The Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- Department of Pediatric and Congenital Cardiac Surgery; The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center; Tel Hashomer Israel
| | - Gili Kenet
- The Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
- National Hemophilia Center and Institute of Thrombosis and Hemostasis, The Chaim Sheba Medical Center; Tel Hashomer Israel
| | - Amir Vardi
- Department of Pediatric Cardiac Intensive Care; The Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center; Tel Aviv Israel
- The Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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44
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Moore JC, Vogel S, Sheppard JAI, Warkentin NI, Eikelboom JW, Warkentin TE. The serological profile of early-onset and persisting post-cardiac surgery thrombocytopenia complicated by “true” heparin-induced thrombocytopenia. Thromb Haemost 2017; 107:998-1000. [DOI: 10.1160/th11-12-0839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 02/03/2012] [Indexed: 11/05/2022]
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Motohashi S, Matsuo T, Inoue H, Kaneko M, Shindo S. Clinical Significance of the Serotonin Release Assay and Platelet Count Monitoring After Cardiac Surgery. Clin Appl Thromb Hemost 2017; 24:944-949. [PMID: 29046071 PMCID: PMC6714719 DOI: 10.1177/1076029617734308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is one of the serious complications in patients who undergo cardiac surgery. However, there remains a major problem in diagnosing HIT because the current immunological assays for detection of HIT antibody have limitations. Furthermore, the clinical course of thrombocytopenia in this surgery makes it increasingly difficult to diagnose HIT. We investigated the relationship between platelet count and HIT antibody in 59 patients who underwent cardiac surgery using cardiopulmonary bypass (CPB). The number of postoperative HIT antibody-positive patients evaluated using enzyme-linked immunosorbent assay kit (polyanion IgG/IgA/IgM complex antibodies/antiplatelet factor 4 enhanced) was 37 (62.7%). In contrast, platelet activation by HIT antibody was evaluated using the serotonin release assay (SRA). More than 20% and 50% release of serotonin was obtained from 12 patients (20.3%) and 8 patients (13.6%), respectively. The levels of d-dimer were significantly different on postoperative day 14 between SRA-positive and SRA-negative groups; however, postoperative thrombus complication was not detected using sonography in the patients with positive serotonin release at all. After being decreased by the operation, their platelet count recovered within 2 weeks in both groups equally. In our study, although the patients were positive in the platelet activating HIT antibody assay, they remained free from thrombosis and their platelet count recovered after early postoperative platelet decrease. Therefore, in addition to the SRA, monitoring of platelet count might be still considered an indispensable factor to facilitate the prediction of HIT thrombosis prior to manifestation in the patients undergoing cardiac surgery using CPB.
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Affiliation(s)
- Shinya Motohashi
- 1 Department of Cardiovascular Surgery, Hachioji Medical Center, Tokyo Medical University, Hachioji, Japan
| | | | - Hidenori Inoue
- 1 Department of Cardiovascular Surgery, Hachioji Medical Center, Tokyo Medical University, Hachioji, Japan
| | - Makoto Kaneko
- 3 Division of Transfusion Medicine and Cell Therapy, University of Yamanashi Hospital, Chuo, Japan
| | - Shunya Shindo
- 1 Department of Cardiovascular Surgery, Hachioji Medical Center, Tokyo Medical University, Hachioji, Japan
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Karhausen JA, Smeltz AM, Akushevich I, Cooter M, Podgoreanu MV, Stafford-Smith M, Martinelli SM, Fontes ML, Kertai MD. Platelet Counts and Postoperative Stroke After Coronary Artery Bypass Grafting Surgery. Anesth Analg 2017. [PMID: 28632537 DOI: 10.1213/ane.0000000000002187] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Declining platelet counts may reveal platelet activation and aggregation in a postoperative prothrombotic state. Therefore, we hypothesized that nadir platelet counts after on-pump coronary artery bypass grafting (CABG) surgery are associated with stroke. METHODS We evaluated 6130 adult CABG surgery patients. Postoperative platelet counts were evaluated as continuous and categorical (mild versus moderate to severe) predictors of stroke. Extended Cox proportional hazard regression analysis with a time-varying covariate for daily minimum postoperative platelet count assessed the association of day-to-day variations in postoperative platelet count with time to stroke. Competing risks proportional hazard regression models examined associations between day-to-day variations in postoperative platelet counts with timing of stroke (early: 0-1 days; delayed: ≥2 days). RESULTS Median (interquartile range) postoperative nadir platelet counts were 123.0 (98.0-155.0) × 10/L. The incidences of postoperative stroke were 1.09%, 1.50%, and 3.02% for platelet counts >150 × 10/L, 100 to 150 × 10/L, and <100 × 10/L, respectively. The risk for stroke increased by 12% on a given postoperative day for every 30 × 10/L decrease in platelet counts (adjusted hazard ratio [HR], 1.12; 95% confidence interval [CI], 1.01-1.24; P= .0255). On a given day, patients with moderate to severe thrombocytopenia were almost twice as likely to develop stroke (adjusted HR, 1.89; 95% CI, 1.13-3.16; P= .0155) as patients with nadir platelet counts >150 × 10/L. Importantly, such thrombocytopenia, defined as a time-varying covariate, was significantly associated with delayed (≥2 days after surgery; adjusted HR, 2.83; 95% CI, 1.48-5.41; P= .0017) but not early postoperative stroke. CONCLUSIONS Our findings suggest an independent association between moderate to severe postoperative thrombocytopenia and postoperative stroke, and timing of stroke after CABG surgery.
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Affiliation(s)
- Jörn A Karhausen
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Alan M Smeltz
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina,Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | - Igor Akushevich
- Center for Population Health and Aging, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mihai V Podgoreanu
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mark Stafford-Smith
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Susan M Martinelli
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
| | - Manuel L Fontes
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Miklos D Kertai
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
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Besser MW, Vuylsteke A. Heparin-Induced Thrombocytopenia and Vascular Surgery. J Cardiothorac Vasc Anesth 2017; 31:1758-1759. [DOI: 10.1053/j.jvca.2017.06.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Indexed: 11/11/2022]
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Ranucci M, Baryshnikova E, Ranucci M, Silvetti S. Fibrinogen levels compensation of thrombocytopenia-induced bleeding following cardiac surgery. Int J Cardiol 2017; 249:96-100. [PMID: 28986056 DOI: 10.1016/j.ijcard.2017.09.157] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 08/18/2017] [Accepted: 09/15/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND After cardiopulmonary bypass (CPB) thrombocytopenia is a relatively common pattern which may trigger postoperative bleeding. The purpose of this study is to verify if the endogenous fibrinogen levels are independent determinants of chest drain blood loss and need for allogeneic blood products transfusions in a clinical model of post-CPB thrombocytopenia. METHODS Retrospective analysis on 445 consecutive patients having a platelet count <100×1000cells/μL after CPB. Based on the fibrinogen levels the patients were divided into three groups with similar platelet count and low (LF, median 170mg/dL), intermediate (IF, median 215mg/dL), and high (HF, median 280mg/dL), fibrinogen levels. Chest drain blood loss (mL/12h), transfusion rate of red blood cells (RBC), fresh frozen plasma (FFP) and platelet concentrates were assessed and compared between groups. RESULTS There was a significant (P=0.001) difference in chest drain blood loss with higher values in the LF group (487mL/12h, IQR 300-600mL/12h) than in the IF group (350mL/12h, IQR 200-500mL/12h) and the HF group (300mL/12h, IQR 200-475mL/12h). Transfusion rates of FFP significantly (P=0.014) differed between groups (LF: 18.4%, IF: 7.9%, HF: 9.2%) and platelet concentrate transfusions significantly (P=0.020) differed between groups (LF: 23.5%, IF: 16.5%, HF: 10.7%). In multivariable models, these differences were confirmed. Thromboelastography parameters showed an effective compensation of clot firmness in group HF vs. IF and LF. CONCLUSIONS Levels of fibrinogen >240mg/dL compensate the decrease in clot firmness observed in thrombocytopenic patients following CPB, and reduce bleeding and transfusion needs.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
| | - Ekaterina Baryshnikova
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Matteo Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Simona Silvetti
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Pishko AM, Cuker A. Heparin-Induced Thrombocytopenia in Cardiac Surgery Patients. Semin Thromb Hemost 2017; 43:691-698. [PMID: 28597462 DOI: 10.1055/s-0037-1602664] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Platelet Count Trends and Prevalence of Heparin-Induced Thrombocytopenia in a Cohort of Extracorporeal Membrane Oxygenator Patients. Crit Care Med 2017; 44:e1031-e1037. [PMID: 27441904 DOI: 10.1097/ccm.0000000000001869] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the prevalence of heparin-induced thrombocytopenia and to study platelet count trends potentially suggestive of heparin-induced thrombocytopenia in a population of extracorporeal membrane oxygenator patients. DESIGN Retrospective cohort study. SETTING A total of 926-bed teaching hospital. PATIENTS Extracorporeal membrane oxygenator patients who survived longer than 48 hours from extracorporeal membrane oxygenator initiation between January 1, 2009, and December 31, 2013. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and clinical data were collected prospectively on all extracorporeal membrane oxygenator patients. Heparin-induced thrombocytopenia testing results and platelet count variables were obtained from the electronic medical record. We used our institutional algorithm to interpret the results of heparin-induced thrombocytopenia testing. Ninety-six extracorporeal membrane oxygenator patients met the inclusion criteria. Eight patients met the algorithm criteria for heparin-induced thrombocytopenia diagnosis and seven of those had documented thromboembolic event while on extracorporeal membrane oxygenator (prevalence of heparin-induced thrombocytopenia and heparin-induced thrombocytopenia related thrombosis, 8.3 and 7.3, respectively). Heparin-induced thrombocytopenia positive patients were younger; all underwent venoarterial extracorporeal membrane oxygenator; spent more hours on extracorporeal membrane oxygenator; had significantly higher heparin-induced thrombocytopenia enzyme-linked immunosorbent assays optical density; had a higher prevalence of thromboembolic events and reached platelet count nadir later. There was no difference in mortality between heparin-induced thrombocytopenia positive and negative patients. Comparison of platelet count trends revealed that there was no statistically significant difference between the predefined study groups. CONCLUSIONS Prevalence of heparin-induced thrombocytopenia and heparin-induced thrombocytopenia-related thrombosis among extracorporeal membrane oxygenator patients at our institution is relatively high. Using platelet count trends to guide decision to test for heparin-induced thrombocytopenia is not an optimal strategy in extracorporeal membrane oxygenator patients. Without a validated pretest probability clinical score, serosurveillance in a defined high-risk group of extracorporeal membrane oxygenator patients may be needed.
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