Management of heparin-induced thrombocytopenia: a cardiovascular surgeon's perspective

Three areas involved with heparin-induced platelet activation (HIPA) need to be discussed from a cardiovascular surgeon's perspective. These include the clinical presentation and management of HIPA-associated events, preparation for surgery in patients with existing HIPA, and medical-legal considerations surrounding HIPA-associated events and treatment. The incidence of heparin-induced thrombocytopenia (HIT) is approximately 1% to 5% of surgical patients. As many as 35% of these patients experience heparin-induced thrombocytopenia and thrombosis syndrome (HITTS), which generally results in devastating outcomes. The initial management of all patients with HIT and HITTS involves withdrawal of heparin. Thereafter, treatment of HITTS should include aggressive interventions with antithrombin agents, plasmapheresis, and possibly thrombolytic agents. Surgery for patients with existing HIPA needs to be carefully planned. Once all nonsurgical avenues have been explored, surgery should be performed following proper planning and education of patient and family. Finally, the number of lawsuits directly related to outcomes in cases involving HIT and HITTS is increasing. Cardiovascular surgeons should be well prepared, limiting their exposure to potential litigation with good clinical management and complete clinical and laboratory documentation.