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Published on: June 23, 2022
Cardiac transplantation after heparin-induced thrombocytopenia: A systematic review
Diana C Jimenez1, Eric D Warner1, Danial Ahmad1
1Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
Insights
Heparin-induced thrombocytopenia (HIT) management during heart transplants is challenging. Unfractionated heparin (UFH) use in orthotopic heart transplantation (OHT) may lead to fewer complications than alternative anticoagulants, with similar 30-day mortality.
Area of Science:
- Cardiology
- Transplantation Medicine
- Hematology
Background:
- Heparin-induced thrombocytopenia (HIT) poses significant risks for patients undergoing orthotopic heart transplantation (OHT).
- Effective anticoagulation strategies are crucial for managing HIT patients during OHT to prevent thrombotic and bleeding complications.
Purpose of the Study:
- To systematically review existing evidence on the management of OHT in patients with HIT.
- To compare outcomes associated with unfractionated heparin (UFH) versus alternative anticoagulants in this patient population.
Main Methods:
- A systematic electronic search identified studies reporting on OHT in patients with HIT.
- Patient-level data from 33 patients across 21 studies were extracted for analysis.
- Outcomes were compared between patients receiving UFH and those receiving alternative anticoagulants.
Main Results:
- The study included 33 patients (75.8% male, median age 51 years) with diagnosed HIT and positive anti-PF4/Heparin antibodies.
- Patients receiving alternative anticoagulants experienced higher rates of antifibrinolytic use (54% vs. 10%), clotting factor administration (69.2% vs. 15%), perioperative thrombosis (53.8% vs. 0%), and post-operative transfusions (54% vs. 0%).
- Thirty-day mortality was comparable between the UFH and alternative anticoagulant groups (15.2% overall).
Conclusions:
- Perioperative use of unfractionated heparin (UFH) in OHT patients with HIT may be associated with fewer adverse events compared to alternative anticoagulants.
- Despite increased complications, alternative anticoagulants did not significantly alter 30-day mortality in this cohort.
- Further research is warranted to optimize anticoagulation strategies for HIT patients undergoing OHT.
Purpose:
Heparin-induced thrombocytopenia (HIT) presents a unique challenge in patients requiring orthotopic heart transplantation (OHT). We sought to pool the existing evidence in a systematic review.
Methods:
Electronic search was performed to identify all relevant studies on OHT in patients with HIT. Patient-level data for 33 patients from 21 studies were extracted for statistical analysis.
Results:
Median patient age was 51 [IQR 41, 55] years, with 75.8% (25/33) males. All patients had a clinical diagnosis of HIT, and anti-PF4/Heparin antibodies were positive in 87.9% (29/33). Median lowest reported platelet count was 46 × 109 /L [27.2, 73.5]. Intraoperatively, 61% (20/33) of patients were given unfractionated heparin (UFH), while 39% (13/33) were given alternative anticoagulants. The alternative agent subgroup required more antifibrinolytics [54% (7/13) vs 10% (2/20), P = .02] and clotting factors [69.2% (9/13) vs 15.0% (3/20), P < .01]. Perioperative thrombosis occurred more [53.8% (7/13) vs 0% (0/20, P < .01) in alternate agent subgroup. More patients in the alternate agent subgroup required post-operative transfusions [54% (7/13) vs 0% (0/20), P < .01]. Thirty-day mortality of 15.2% (5/33) was comparable between the subgroups.
Conclusion:
Heparin use during OHT may be associated with less adverse effects compared to use of other anticoagulants with no difference in 30-day mortality.
