Management of Patients with Heparin-Induced Thrombocytopenia During Cardiac Surgery

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The role of heparin-induced thrombocytopenia and its possibly severe complications in patients undergoing cardiac surgery is increasingly appreciated. Increasing evidence indicates that in patients without the presence of antibodies, unfractionated heparins can be safely used during cardiopulmonary bypass, if their employment is restricted to this short period. This strategy is the first choice in patients with a current negative status of antibodies and in patients in whom surgery can be delayed until antibodies cannot be detected by laboratory tests. To date, however, no alternative anticoagulant to heparin during cardiopulmonary bypass has been approved. With the introduction of the class of direct thrombin inhibitors, effective anticoagulants have become available; however, they have no antidote and require specific monitoring. The availability of direct thrombin inhibitors is currently restricted. The administration of unfractionated heparin with anti-platelet agents such as prostaglandins or the short-acting platelet glycoprotein llb/Illa antagonist tirofiban is another option. Despite successful use of these strategies in fairly large numbers of patients, recent information suggests that in the case of tirofiban, renal failure may cause persistence of the agent with subsequent severe hemorrhage. If surgery is restricted to coronary artery bypass grafting, recent data show that off-pump strategies with use of the direct thrombin inhibitor bivalirudin appear to be a promising option. Therefore, if surgery cannot be postponed, the anticoagulation protocol and the surgical strategy must be adjusted to the condition of the patient and the experience of the center in order to reduce the risk of these “offlabel” strategies.