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J Thorac Cardiovasc Surg 2005;130:1455-1456
© 2005 The American Association for Thoracic Surgery
Brief Communication |
a Department of Surgery, Division of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
b Department of Medicine, Division of Allergy and Immunology, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
c Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
Received for publication March 16, 2005; revisions received April 16, 2005; accepted for publication May 2, 2005. * Address for reprints: Harold M. Burkhart, MD, Department of Surgery, Division of Cardiothoracic Surgery, 200 Hawkins Dr, Iowa City, IA 52242. (Email: harold-burkhart{at}uiowa.edu).
Heparin remains the drug of choice required for anticoagulation during cardiopulmonary bypass. Advantages of heparin over other drugs are its rapid onset of action after intravenous administration and its rapid reversibility with protamine. Heparin-induced anaphylaxis, although rare, has been reported.
1
We report successful desensitization to heparin in a patient requiring pulmonary valve replacement.
Clinical Summary
A 55-year-old woman with a history of a tetralogy of Fallot repair done at age 10 years presented with congestive heart failure. Transesophageal echocardiography and cardiac catheterization revealed free pulmonary valve insufficiency requiring replacement. The medical history was significant for heparin allergy first observed at the time of the original cardiac surgery in 1959. She had generalized hives and itching immediately after surgical intervention that was thought to be attributable to heparin infusion. In 1970, she experienced pulmonary embolism and was re-exposed to intravenous heparin, triggering immediate onset of generalized hives, itching, and chest tightness. Over the years, routine intravenous line flushes triggered localized self-limited urticaria and pruritus extending up the arm. Our preoperative evaluation uncovered a convincing history for heparin allergy that was thought to be anaphylactoid in nature on the basis of existing literature and the lack of a defined, pathophysiologic, immunoglobulin E (IgE)–mediated mechanism. In the absence of a standardized skin test for heparin hypersensitivity, the options available were to either desensitize to heparin or use an alternate anticoagulant. In view of the anticipated reoperative operation, it was decided to perform cautious intravenous desensitization as the optimal strategy to decrease the potential risk for significant side effects.
Al-Eryani and colleagues
2
reported heparin desensitization before cardiopulmonary bypass by gradually increasing the dose of heparin intravenously, starting with 100 U in 1 L of saline over 24 hours. We adapted their dosing protocol by premedicating with acetaminophen (INN: paracetamol) and diphenhydramine (Benadryl, Pfizer) and keeping intramuscular (0.3 mL, 1:1000 concentration) epinephrine available at the bedside. When the infusion containing 100 U of heparin in 1000 mL of saline was started, she experienced generalized itching, shortness of breath, diarrhea, and chest tightness within 10 minutes. The infusion was stopped, and intramuscular epinephrine and an oral H1 antagonist were administered, which alleviated the symptoms. On the following day, 10 U of heparin in 1000 mL of saline was infused over 24 hours. The patient tolerated the heparin concentration well, without allergic side effects. The heparin concentration was subsequently increased to 100 U of heparin in 1000 mL of saline and infused over the next 24 hours, which was well tolerated. On day 3, the 24-hour infusion consisted of 1000 U of heparin, and on day 4, 5000 U of heparin was infused. By the fifth day, the patient was tolerating 500 U/h of heparin. On the sixth day, the heparin infusion was temporarily reduced to 100 U/h to accommodate intraoperative monitoring catheters. Full heparinization was initiated with cardiopulmonary bypass, and pulmonary valve replacement was performed successfully with a No. 29 Mosaic valve (Medtronic, Inc, Minneapolis, Minn). The postoperative course was uneventful, and she was discharged on postoperative day 5. Table 1
depicts the heparin desensitization protocol used preoperatively.
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Heparin-induced IgE-mediated hypersensitivity and anaphylactoid reactions, although rare, can pose a serious clinical problem for patients requiring cardiopulmonary bypass.
3
Standardized skin tests with heparin components are not available to investigate for IgE-mediated heparin allergy, nor are they as reliable as standard penicillin skin tests with major and minor determinant components of the penicillin molecule. Typically, the most commonly encountered adverse reactions to heparin are hemorrhage, delayed hypersensitivity reactions, and heparin-induced thrombocytopenia (HIT). HIT is an autoimmune-mediated reaction whereby IgG and IgM antibodies are directed against heparin and platelet factor.
4
Desensitization is not a therapeutic option for acute or delayed HIT. Cases have been reported in which alternative drugs, such as bovine heparin, ancrod, and argatroban, have been used in place of heparin when anaphylactoid reactions are suspected; however, their efficacy has been anecdotal and needs further investigation.
4
Two reports exist in the literature in which desensitization for heparin allergy was attempted before cardiopulmonary bypass.
2,5
Until more experience is gained with the use of alternative anticoagulation agents for cardiopulmonary bypass, we advocate the use of heparin desensitization as successfully performed in this case.
References
This article has been cited by other articles:
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  F. Pappalardo, A. Franco, G. Crescenzi G, A. Poli, A. Zangrillo, and A. Koster Successful use of bivalirudin for cardiopulmonary bypass in a patient with heparin allergy Perfusion, January 1, 2007; 22(1): 67 - 69. [Abstract] [PDF]
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