Treating Heparin-Induced Thrombocytopenia in Patients Undergoing HeartMate 3 Left Ventricular Assist Device Implantation
Review published in The Israel Medical Association journal : IMAJ (2023)
Abstract
BACKGROUND: Unfractionated heparin is the preferred anticoagulant used during open heart surgeries, including left ventricular assist device (LVAD) implantation. In cases in which patients are heparin-induced thrombocytopenia positive (HIT+), the accepted practice has been to substitute heparin with bivalirudin. This practice may be associated with significant bleeding and adverse outcomes. OBJECTIVES: To review our experience with HIT+ patients who were heparin-induced thrombocytopenia with thrombosis negative (HITT-) and who underwent HeartMate 3 LVAD implantation using heparin intraoperatively rather than bivalirudin. METHODS: From 2016 to 2022, 144 adult patients were implanted with HeartMate 3 LVAD at our center. Among them, 7 were detected as HIT+ but HITT- and therefore were prescribed intraoperatively with heparin and treated pre- and postoperatively with bivalirudin. We reviewed the preoperative, intraoperative, and postoperative characteristics as well as short-term mortality and the complication rates of these HIT+ patients. RESULTS: The median age of our cohort was 56 years (51-60), 71% were male (n=5), all were INTERMACS Level 1, and most were bridged to transplant (n=6, 86%). The 30-day mortality rate post-implantation was 0%. The average 24-hour chest drain postoperative output was 1502.86 ± 931.34 ml. There were no intraoperative pump thromboses, perioperative thromboses, cerebrovascular accidents, or gastrointestinal bleeding within the first 24 hours postoperative. One patient required a revision due to bleeding. CONCLUSIONS: Intraoperative unfractionated heparin may be administered to patients who are HIT+ and HITT- while undergoing LVAD implantation. However, further investigation is required.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
Unfractionated heparin is the preferred anticoagulant used during open heart surgeries, including left ventricular assist device (LVAD) implantation.
Why This Matters for Hirudotherapy
This single-center case series reviewed 7 patients who were heparin-induced thrombocytopenia positive but thrombosis negative (HITT-) and underwent HeartMate 3 LVAD implantation using intraoperative unfractionated heparin with pre- and postoperative bivalirudin, reporting 0% 30-day mortality, no perioperative thromboses, and one bleeding-related revision. The study is relevant to ASH/hirudotherapy because bivalirudin is a direct thrombin inhibitor modeled on hirudin from the medicinal leech secretome, and clinical data on its perioperative use in high-risk cardiac surgery directly inform understanding of how hirudin-class anticoagulants perform in practice. The findings suggest a potential strategy for limiting intraoperative bivalirudin exposure in this setting; however, the very small sample (n=7), observational design, single-center experience, and short follow-up render the results hypothesis-generating only, not proof of efficacy or safety.
Citation
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