Increased Incidence of Thrombosis in Patients at Risk of Heparin-Induced Thrombocytopenia Receiving Epoprostenol for Cardiac Surgery

OBJECTIVE: Heparin-induced thrombocytopenia (HIT) is a serious concern in cardiac surgery, as heparin use in the at-risk patient can lead to devastating thrombosis. Management strategies for patients with confirmed or suspected HIT include using alternative anticoagulants, such as bivalirudin, but heparin administration in the presence of a potent antiplatelet agent, such as a prostacyclin analogue, has been reported as a safe approach. This retrospective study aimed to evaluate the incidence of thromboembolism in patients with confirmed or suspected HIT who received heparin with intravenous epoprostenol for anticoagulation during cardiac surgery. DESIGN: A single-center retrospective observational study. SETTING: An adult tertiary care referral center. PARTICIPANTS: Sixteen patients who underwent cardiac surgery between 2014 and 2024. All patients had a suspicion of HIT or confirmed HIT by testing. INTERVENTIONS: Patients presenting for cardiac surgery with confirmed or suspected HIT received heparin with intravenous epoprostenol intraoperatively according to an institutional protocol. MEASUREMENTS AND MAIN RESULTS: Collected data included preoperative testing for HIT antibody and serotonin release assay results, as well as whether a thromboembolic event was diagnosed postoperatively. Of the 9 patients who had a positive HIT antibody, 6 had a positive serotonin release assay. Of these 6 patients, 4 had a confirmed thromboembolic event (66.7%). CONCLUSIONS: The rate of thrombosis in our review was considerably higher than the published data on the use of prostacyclin analogues with heparin in patients with HIT, suggesting that this strategy may not be as effective for preventing thrombosis as previously thought. Until larger studies can be conducted, it may be in the best interest of patients with HIT for surgical teams to utilize alternative agents, such as bivalirudin, for anticoagulation in cardiac surgery.

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In this single-center retrospective series, 16 cardiac surgery patients with suspected or confirmed heparin-induced thrombocytopenia received heparin plus intravenous epoprostenol; four of six serotonin-release-assay-positive patients suffered thromboembolic events, prompting a call to consider bivalirudin instead.

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