Thromboembolism related to heparin-induced thrombocytopenia during Impella support after cardiac surgery for free wall rupture: a case report

BACKGROUND: Left ventricular free wall rupture (LVFWR) is a severe complication of acute myocardial infarction that frequently leads to cardiac tamponade and circulatory collapse. Prompt surgical repair and mechanical circulatory support are essential for patient survival. The Impella device provides left ventricular unloading and is increasingly used after cardiac surgeries. However, it carries the risks of bleeding and thromboembolism. Heparin-induced thrombocytopenia (HIT) may be an important contributor to thromboembolic risk. Diagnosing HIT in an acute postoperative setting using the Impella support is particularly challenging. Herein, we present a case of thromboembolism associated with HIT following Impella support after surgical repair of an LVFWR. CASE DESCRIPTION: A 72-year-old man presented with chest pain. During preparation for percutaneous coronary intervention, the patient developed cardiac arrest and was resuscitated using extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP). Coronary angiography revealed left circumflex artery occlusion, and echocardiography revealed pericardial effusion. Surgical repair was performed using cardiopulmonary bypass. Intraoperative findings revealed left ventricular rupture in the circumflex artery area. Due to severe ventricular dysfunction, ECMO was continued, and IABP was initially chosen. On postoperative day (POD) 1, after stabilization of bleeding, the IABP was upgraded to Impella for ventricular unloading. ECMO was discontinued on POD 3, and Impella was maintained until POD 9. After Impella was removed, angiography revealed occlusion of both iliac arteries. Bilateral surgical thrombectomy was performed. A latex immunoturbidimetric assay confirmed HIT antibody positivity. Anticoagulation therapy was subsequently switched from heparin to argatroban. CONCLUSIONS: This case illustrates the difficulty in diagnosing HIT in patients on Impella support in the acute postoperative period after cardiac surgery. Clinicians should be vigilant for Impella-associated thromboembolism and understand its possible mechanisms to ensure appropriate diagnosis and prevention.

Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.

Case of bilateral iliac artery occlusion from HIT during Impella support after surgical repair of LV free-wall rupture; heparin was switched to argatroban after HIT antibody confirmation, illustrating the challenges of diagnosing HIT in acute postoperative settings.

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