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J Thorac Cardiovasc Surg 2006;131:1373-1381
© 2006 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

Heparin-induced thrombocytopenia in patients receiving mechanical circulatory support

Soren Schenk, MD a , Aly El-Banayosy, MD a , * , Wolfgang Prohaska, MD b , Latif Arusoglu, MD a , Michiel Morshuis, MD a , Wilhelm Koester-Eiserfunke, PhD b , Lukasz Kizner, MD a , Edward Murray, MD a , Petra Eichler, PhD c , Reiner Koerfer, MD a , Andreas Greinacher, MD c

a Thoracic and Cardiovascular Surgery, Heart Center North Rhine-Westphalia, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
b Laboratory and Transfusion Medicine, Heart Center North Rhine-Westphalia, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
c Immunology and Transfusion Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany.

Received for publication May 2, 2005; revisions received December 18, 2005; accepted for publication January 10, 2006.

* Address for reprints: Aly El-Banayosy, MD, Heart Center NRW, Georgstrasse 11, Bad Oeynhausen, Germany, 32545. (Email: abanayosy{at}hdz-nrw.de).

OBJECTIVES: Patients receiving mechanical circulatory support are at risk for the development of heparin-induced thrombocytopenia due to the prolonged postoperative use of heparin. We evaluated their antibody status and outcome.

METHODS: Between 2003 and 2004, 115 patients received mechanical circulatory support for more than 5 days. Blood samples from postoperative day 7 were retrospectively analyzed for anti–platelet factor 4/heparin antibodies and heparin-induced platelet activation.

RESULTS: Overall, 12 (10.6%) patients had heparin-induced thrombocytopenia as defined by in vitro platelet activation, 28 (24.8%) had nonactivating antibodies, and 73 (64.6%) were classified as negative for antibodies. Patients positive for heparin-induced thrombocytopenia had the highest levels of anti–platelet factor 4/heparin immunoglobulin G antibodies. Freedom from thromboembolism was 33%, 33%, and 16% at 1, 3, and 6 months for positive patients, 77%, 68%, and 55% for negative patients (P < .001), and 70%, 53%, and 53% for patients with nonactivating antibodies (P = .068), respectively. The relative risk for thromboembolism in antibody positive patients peaked in the first month of support (odds ratio 7.46, P = .002). Independent risk factors for thromboembolic events included higher anti–platelet factor 4/heparin antibody titers, female gender, and higher fibrinogen levels.

CONCLUSION: Heparin-induced thrombocytopenia was more prevalent in patients receiving mechanical circulatory support than in other cardiac patients. Frequent antibody screening is recommended due to the increased risk of thromboembolism. Heparin alternatives should be subjected to clinical trials in these high-risk patients.

Abbreviations and Acronyms aPTT = activated partial thromboplastin time; CAA = column agglutination assay; EIA = enzyme immunoassay; HGW = Hansestadt Greifswald; HIPA = heparin-induced platelet activation assay; HIPA+&id/ IgG+ = heparin-induced platelet activation assay positive or indeterminate with IgG titers of OD > 1.0; HIPA–/IgG,A,M+ = heparin-induced thrombocytopenia platelet activation assay negative and IgG, IgA, and IgM antibodies; HIT = heparin-induced thrombocytopenia; Ig = immunoglobulin; INR = international normalized ratio; MCS = mechanical circulatory support; OD = optical density; PF4 = platelet factor 4; POD = postoperative day; TIA = transient ischemic attack




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