Alternative Anticoagulation Strategies Research Articles

Efficacy and safety of DOACs versus LMWH for elderly patients with active cancer: A meta-analysis.

e13776 Background: Anticoagulant treatment in patients with cancer aims to reduce the high risk of thromboembolism. Direct oral anticoagulants (DOACs) and low-molecular-weight heparin (LMWH) are currently approved for the treatment of cancer-related thrombosis. However, there is limited data comparing the efficacy and safety of these two antithrombotic therapies among elderly patients with cancer. Methods: PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were systematically searched for studies comparing DOACs with LMWH in cancer patients with newly diagnosed venous thromboembolism (VTE) or pulmonary embolism (PE). Both solid tumors and hematologic malignancies were included. Outcomes of interest were recurrent VTE and major bleeding. Odds ratio (OR) with 95% confidence intervals (CI) were pooled with a random-effects model. Statistical analysis was performed with Review Manager 5.4.1. Heterogeneity was assessed using the I2 statistic and chi-squared test. Results: Four studies, three randomized controlled trials (RCTs) and one observational, were included. A total of 3,266 patients older than 65 years who underwent anticoagulation with DOACs (35%) or LMWH (65%) were incorporated in the analysis. There was no statistically significant difference between anticoagulation therapies for recurrent VTE (OR, 0.68; 95% CI, 0.41-1.11; p = 0.13; I² = 56%; Table) or major bleeding (OR, 1.18; 95% CI, 0.61-2.25; p = 0.08; I² = 60%; Table). Conclusions: Our findings suggest no statistically significant differences in recurrent VTE or major bleeding between DOACs and LMWH in elderly oncologic patients with newly diagnosed VTE or PE. Given the practical challenges of using LMWH, DOACs may be considered an alternative anticoagulation strategy for these patients. [Table: see text]

Author Response: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Author Response: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Editors' Note: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Editors' Note: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Reader Response: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Reader Response: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Reader Response: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Reader Response: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Author Response: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Author Response: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Editors' Note: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Editors' Note: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Meta-Analysis Assessing Efficacy and Safety of Vitamin K Antagonists Versus Direct Oral Anticoagulants for Atrial Fibrillation After Transcatheter Aortic Valve Implantation

Patients who underwent transcatheter aortic valve implantation (TAVI) with concomitant atrial fibrillation (AF) are at a higher risk for thromboembolic and bleeding events. The optimal antithrombotic strategy for patients with AF after TAVI remains unclear. We sought to determine the comparative efficacy and safety of direct oral anticoagulants (DOAC) versus oral vitamin K antagonists (VKAs) in these patients. Electronic databases such as PubMed, Cochrane, and Embase databases were searched till January 31, 2023, for relevant studies evaluating clinical outcomes of VKA versus DOAC in patients with AF after TAVI. Outcomes assessed were (1) all-cause mortality, (2) stroke, (3) major/life-threatening bleeding, and (4) any bleeding. Hazard ratios (HRs) were pooled in meta-analysis using random effect model. Nine studies (2 randomized and 7 observational) were included in systematic review, and 8 studies with 25,769 patients were eligible to be included in the meta-analysis. The mean age of the patients was 82.1years, and 48.3% were male. Pooled analysis using random-effects model showed no statistically significant difference in all-cause mortality (HR 0.91, 95% confidence interval [CI] 0.76 to 1.10, p=0.33), stroke (HR 0.96, 95% CI 0.80 to 1.16, p=0.70), and major/life-threatening bleeding (HR 1.05, 95% CI 0.82 to 1.35, p=0.70) in patients that received DOAC compared with oral VKA. Risk of any bleeding was lower in the DOAC group compared with oral VKA (HR 0.83, 95% CI 0.76 to 0.91, p=0.0001). In patients with AF, DOACs appear to be a safe alternative oral anticoagulation strategy to oral VKA after TAVI. Further randomized studies are required to confirm the role of DOACs in those patients.

Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant.

Ischemic stroke despite a direct oral anticoagulant (DOAC) is increasingly common and portends a high risk of subsequent ischemic stroke. The efficacy and safety of antithrombotic regimens after the condition are unclear. We aimed to compare the outcomes of patients with ischemic stroke despite DOACs with and without an alternative antithrombotic regimen and determine the risk factors of recurrent ischemic stroke while on anticoagulation. In a population-based, propensity score-weighted, retrospective cohort study, we compared the clinical outcomes of DOAC-to-warfarin switch, DOAC-to-DOAC switch (DOACswitch), or addition of antiplatelet agents, with those of unchanged DOAC regimen (DOACsame) among patients with nonvalvular atrial fibrillation (NVAF) who developed the first ischemic stroke despite a DOAC from January 1, 2015, to December 31, 2020, in Hong Kong. The primary outcome was recurrent ischemic stroke. Secondary outcomes were intracranial hemorrhage, acute coronary syndrome, and death. We performed competing risk regression analyses to compare the clinical endpoints and determined the predictors of recurrent ischemic stroke in an unweighted multivariable logistic regression model. During the 6-year study period, among 45,946 patients with AF on a DOAC as stroke prophylaxis, 2,908 patients developed ischemic stroke despite a DOAC. A total of 2,337 patients with NVAF were included in the final analyses. Compared with DOACsame, warfarin (aHR 1.96, 95% CI 1.27-3.02, p = 0.002) and DOACswitch (aHR 1.62, 95% CI 1.25-2.11, p < 0.001) were associated with an increased risk of recurrent ischemic stroke. In the DOACsame group, adjunctive antiplatelet agent was not associated with a reduced risk of recurrent ischemic stroke. Diabetes mellitus, concurrent cytochrome P450/P-glycoprotein (CYP/P-gp) modulators, and large artery atherosclerotic disease (LAD) were predictors of recurrent ischemic stroke. In patients with NVAF with ischemic stroke despite a DOAC, the increased risk of recurrent ischemic stroke with switching to warfarin called for caution against such practice, while the increased ischemic stroke with DOAC-to-DOAC switch demands further studies. Adjunctive antiplatelet agent did not seem to reduce ischemic stroke relapse. Because diabetes mellitus, the use of CYP/P-gp modulators, and LAD were predictors of recurrent ischemic stroke, further investigations should evaluate whether strict glycemic control, DOAC level monitoring, and routine screening for carotid and intracranial atherosclerosis may reduce ischemic stroke recurrence in these patients. This study provides Class II evidence that in patients with NVAF experiencing an ischemic stroke while being treated with a DOAC, continuing treatment with that DOAC is more effective at preventing recurrent ischemic stroke than switching to a different DOAC or to warfarin.

Missense VKOR mutants exhibit severe warfarin resistance but lack VKCFD via shifting to an aberrantly reduced state.

Missense vitamin K epoxide reductase (VKOR) mutations in patients cause resistance to warfarin treatment but not abnormal bleeding due to defective VKOR activity. The underlying mechanism of these phenotypes remains unknown. Here we show that the redox state of these mutants is essential to their activity and warfarin resistance. Using a mass spectrometry-based footprinting method, we found that severe warfarin-resistant mutations change the VKOR active site to an aberrantly reduced state in cells. Molecular dynamics simulation based on our recent crystal structures of VKOR reveals that these mutations induce an artificial opening of the protein conformation that increases access of small molecules, enabling them to reduce the active site and generating constitutive activity uninhibited by warfarin. Increased activity also compensates for the weakened substrate binding caused by these mutations, thereby maintaining normal VKOR function. The uninhibited nature of severe resistance mutations suggests that patients showing signs of such mutations should be treated by alternative anticoagulation strategies.

Does An Alternative Anticoagulation Strategy For LVAD Patients Who Have Had Complications Improve Time-in-therapeutic Range?

Does An Alternative Anticoagulation Strategy For LVAD Patients Who Have Had Complications Improve Time-in-therapeutic Range?

Anticoagulation on Extracorporeal Support: An Alternative Strategy.

To the Editor, We read with extreme interest the updated Extracorporeal Life Support (ELSO) guidelines for anticoagulation during extracorporeal membrane anticoagulation (ECMO)1 and would like to integrate this valuable document with a potential alternative therapeutic anticoagulation strategy for patients requiring veno-venous ECMO. This approach is based on subcutaneous administration of low-molecular-weight heparin (LMWH) 3 times a day, paired with antifactor Xa (anti-Xa) assay monitoring, 3 times a day, each sample equidistant between two administrations of LMWH. Anticoagulation monitoring is integrated on a regular schedule with additional blood tests, including hemoglobin and hematocrit, platelets count, Fibrinogen, D-dimers, haptoglobin levels, and with full coagulation tests and point-of-care viscoelastic testing on an as needed basis. We designed and started implementing an algorithmic protocol (detailed in Figure, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A838) to standardize dosage adjustment based on anti-Xa value, potential evidence of clinically significant bleeding or prothrombotic states, and eventual need for surgical interventions or other invasive procedures. Despite paucity of literature related to anticoagulation management based on LMWH only during ECMO support,2–4 we decided to introduce this approach since the second wave of Coronavirus disease 2019 (COVID-19) pandemic, to simplify and standardize anticoagulation management, reducing the strain on the team members, particularly on most recently recruited, and less experienced ones, involved to expand ECMO capacity. The rationale for the off-label three-daily dosing (despite the commonly recommended once/twice daily dosing) is to achieve and constantly maintain a therapeutic level of anticoagulation, avoiding excessive peaks and minimizing peak-to-trough variability, with the aim of effective prevention of thrombosis without increasing bleeding risk.5 The rationale for anti-Xa assessment 4 hours after LMWH administration is to thoroughly evaluate its effect, including peak, occurring 3–5 hours after subcutaneous administration, being able to properly adapt subsequent dosing. During the run, the protocol anticipates some conditions which demand to modify LMWH administration (dose or timing): need for invasive elective or emergent procedures; we do not consider percutaneuos central venous catheter, pulmonary artery catheter and arterial line placement, nor percutaneous tracheostomy among procedures requiring dosing adjustment; evidence of clinically significant bleeding defined (as per ELSO Registry definition); evidence of thrombotic complications (both intracircuit or patient complications). Since the implementation of this protocol, we did not notice increased ratio of thrombotic events; no patient required the circuit to be replaced more than once during the run (mean duration 19 days [6–52]). No cannula thrombosis, nor thrombosis involving the cannula or cannulated vessels have been observed, despite the high risk profile of this patient population. No brain hemorrhages, nor GI or cannulation site bleedings requiring more than medical approach were observed; and increased incidence of pulmonary hemorrhages was noticed: clinical evidence suggested these as presumably disease, rather than anticoagulation, related. We recognize that such an algorithm significantly deviates from conventional clinical practice and from guidelines, but in our limited, single center experience, its application in a population of COVID-19 patients requiring V-V ECMO was feasible and safe (unpublished data, manuscript in preparation), and easy to be implemented at bedside, in selected settings.

Direct Thrombin Inhibition in Extracorporeal Membrane Oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a widely used technique to provide circulatory and/or respiratory support in critically ill patients. ECMO treatment usually necessitates systemic anticoagulation. Unfractionated Heparin (UFH) is a commonly used anticoagulant in patients on ECMO support. In situations where UFH is contraindicated, alternative anticoagulation strategies can be applied, such as the use of direct thrombin inhibitors (DTI). Bivalirudin and argatroban are the most widely used DTIs. In this report we give account of the current evidence regarding dosing, monitoring and complications associated with the use of these agents in ECMO dependent patients.

Anti-Xa Directed Thromboprophylaxis in Critically Ill Patients with Coronavirus Disease 2019.

Objective: To compare Anti-Xa directed thromboprophylaxis using low molecular weight heparin (LMWH) (anti-Xa peak goal 0.2-0.5 IU/mL) to alternative anticoagulation strategies in critically ill COVID-19 patients. Methods: This was a retrospective, multicenter, single health-system study. Primary outcomes were thromboembolic events and clinically important bleeding events. Secondary outcomes included dosing comparisons between LMWH cohorts. Main Results: A total of 695 patients were included. No differences were found in the incidence of thrombotic events with any of the dosing strategies. The incidence of major bleeding was significantly higher in the standard dose thromboprophylaxis, intermediate dose subcutaneous heparin (SQH), and therapeutic anticoagulation cohorts. Forty-nine percent of patients within the anti-Xa directed group had their first anti-Xa peak at goal, while 43% were above goal. Patients who had levels above goal had dose modifications made, therefore anti-Xa directed LMWH resulted in significantly lower total daily doses compared to intermediate dose LMWH. Conclusions: Anti-Xa directed LMWH dosing provided comparable thromboprophylaxis with lower total daily doses of LMWH in critically ill COVID-19 patients. Further randomized controlled trials are needed to confirm our findings.

A Scoping Review of Alternative Anticoagulation Strategies for Hemodialysis Patients with a Mechanical Heart Valve

Introduction: Patients with end-stage renal disease (ESRD) have high rates of cardiac valvulopathy but can develop contraindications for vitamin K antagonist (VKA) therapy. We explored the evidence for alternative anticoagulation strategies in patients with ESRD with a contraindication for VKA therapy. Methods: A scoping review was completed, searching MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Conference abstracts from inception to March 30, 2021. The study population was patients with ESRD who were on VKA therapy and developed a contraindication to VKA therapy use. All data regarding studies, patient characteristics, anticoagulation strategy, and clinical outcomes were summarized. Results: Twenty-three articles met inclusion criteria. These articles included 57 patients. Contraindications to VKA therapy included calcific uremic arteriolopathy (CUA) (n = 55) and warfarin-induced skin necrosis (n = 2). All studies were either case reports or case series. There were 10 anticoagulation strategies identified. Continuation of VKA therapy was associated with increased death and decreased rates of CUA resolution (80.0% and 10.0%, respectively), compared to apixaban (24.0% and 70.8%), subcutaneous (SC) low-molecular-weight heparin (LMWH) (14.3%, 85.7%), and SC unfractionated heparin (0.0%, 100.0%). While only 5 patient cases were reported with mechanical heart valves, SC LMWH use has been reported in this context with good outcomes. Conclusions: In patients with ESRD who develop a contraindication to VKA therapy, several alternative anticoagulation strategies have been reported with superior outcomes to VKA continuation. While outcomes appear superior to continuation of VKA therapy, more data are required before definitive recommendations can be made for the patient with ESRD and a mechanical heart valve.

Survey of Practice Pattern in Patients With Heparin-Induced Thrombocytopenia Requiring Cardiopulmonary Bypass.

Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse reaction to heparin. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are routinely anticoagulated with heparin before the initiation of bypass. Heparin is contraindicated, however, in patients with acute HIT, and alternatives to routine practice are often used. While guidelines have recently been published addressing this topic 10, there remains variance between institutions in how these cases are treated. Our goal was to better delineate practice trends in the diagnosis and management of HIT patients requiring CPB. We surveyed members of the Society of Cardiovascular Anesthesiologists (SCA) and the American Society for Extracorporeal Technology (AmSECT) using an online survey tool. We received 304 completed surveys (5.8% response rate), 75% completed by an anesthesiologist, and 24% by a perfusionist. The majority of respondents used clinical history and/or antibody testing (71% and 63%, respectively) to diagnose HIT. Seventy-five percent of respondents reported using an institutional protocol for HIT-CPB cases. Most respondents (89%) reported having at least 1 case in the last 3 years, with a total case experience of at least 785 cases (785 = the minimum number of cases in each case volume category × the number of respondents choosing that category). The strategy recommended in published guidelines, bivalirudin, was the most commonly reported alternative anticoagulation strategy (75%) used by respondents in HIT cases, with most (83%) using the activated clotting time (ACT) to monitor anticoagulation. Most responding SCA and AmSECT members reported that their institution used a protocol or guideline for HIT/CPB cases, and most guidelines directed the use of bivalirudin as an alternative anticoagulant. Various other methods such as plasmapheresis are also being used with success in this patient population. Further research, including comparison studies of alternative anticoagulant strategies, is required to elucidate the best approach to these difficult cases.

Meta-analysis of controlled studies on minimally interrupted vs. continuous use of non-vitamin K antagonist oral anticoagulants in catheter ablation for atrial fibrillation.

AimsAt present, there are no guideline recommendations for minimally interrupted use of non-vitamin K antagonist oral anticoagulants (mi-NOAC) during catheter ablation (CA) for atrial fibrillation (AF). Current evidence is predominantly based on observational studies, with continuous use of vitamin K antagonist in the control arm. This quantitative summary reflects the first high-level evidence on contemporary regimens, with continuous NOAC use (c-NOAC) as the current gold standard.Methods and resultsMeta-analysis (Pubmed, Embase, and Web of Science) on prospective, controlled studies comparing contemporary mi-NOAC (without bridging) with c-NOAC. Net adverse clinical events (major bleeding, thrombo-embolic events) were the primary outcome. In addition, we analysed total bleeding, minor bleeding, and silent cerebral embolism. Eight studies (six randomized, two observational) with 2168 patients were summarized. The primary endpoint occurred in 1.0% (18/1835): 1.1% (11/1005) vs. 0.8% (7/830) for the mi-NOAC and c-NOAC groups, respectively; odds ratio (OR) 1.20 [95% confidence interval (CI) 0.49–2.92, P = 0.64]. The OR for total bleeding on mi-NOAC was 1.26 (95% CI 0.97–1.63, P = 0.07). ORs for minor bleeding and silent cerebral embolism were 1.17 (95% CI 0.80–1.70, P = 0.34) and 2.62 (95% CI 0.54–12.61, P = 0.12), respectively.ConclusionThis synopsis provides a quantitative synthesis of high-level evidence on a contemporary strategy of mi-NOAC in CA for AF, and overall clinical outcomes were not different from continuous NOAC use. Despite preprocedural interruption, there was no sign of lower bleeding rates. Additional higher volume datasets are warranted for more precise treatment effect estimations of this everyday alternative anticoagulation strategy in AF ablation.

Outcomes of Systemic Anticoagulation with Bivalirudin for Impella 5.0

<h3>Purpose</h3> The Impella 5.0 (IMP5) is a surgically implanted axial flow pump used in cardiogenic shock. Anticoagulation (AC) strategy with unfractionated heparin (UFH) is used for pump patency. Alternative AC strategies have not been well defined. This study examines the outcomes of patients treated with bivalirudin (BIV) for AC during IMP5 utilization. <h3>Methods</h3> This single center, retrospective study included patients supported on IMP5 with BIV based AC. The primary end points were recovery, bridge to left ventricular assist device (LVAD), cardiac transplant (HTX), or death. Secondary end points included clinically significant bleeding (TIMI major or minor), incidence of tPA (Tissue Plasminogen Activator) use for suspected pump thrombosis, stroke, and device outcomes. <h3>Results</h3> 31 patients were included with a mean age of 57.4 years and 19.4% female. 26 patients (84%) received BIV purge solution. The median duration of IMP5 was 6 days. Most patients (38.7%) were bridged to LVAD; 16.1% were bridged to HTX, 16.1% recovered, and 29% died. 1 patient (3.2%) suffered ischemic stroke and 12 patients (38.7%) developed TIMI major or minor bleeding. . tPA was administered to 8/31 (25.8%) of patients. There was no difference in time to therapeutic AC between patients given or not given tPA(p=0.18). Of those given tPA, 37.5% had therapeutic aPTTs (61-75 seconds) immediately prior to tPA. 17/23 (73.9%) of patients not given tPA had therapeutic aPTTs (Fig. 1). Overall time to therapeutic range for all subjects is displayed in Figure 2. Logistic regression analysis demonstrated that duration of IMP5 was a significant predictor of tPA use (OR 1.28; 1.04-1.56). There were no cases of pump failure. <h3>Conclusion</h3> Use of BIV as an alternative to UFH for IMP5 was proven to be feasible with most patients surviving to recovery, LVAD, or HTX.

Comparison of different anticoagulation strategies for renal replacement therapy in critically ill patients with COVID-19: a cohort study

BackgroundCritically ill coronavirus disease 2019 (COVID-19) patients have a high risk of acute kidney injury (AKI) that requires renal replacement therapy (RRT). A state of hypercoagulability reduces circuit life spans. To maintain circuit patency and therapeutic efficiency, an optimized anticoagulation strategy is needed. This study investigates whether alternative anticoagulation strategies for RRT during COVID-19 are superior to administration of unfractionated heparin (UFH).MethodsRetrospective cohort study on 71 critically ill COVID-19 patients (≥18 years), admitted to intensive care units at a tertiary health care facility in the southwestern part of Germany between February 26 and May 21, 2020. We collected data on the disease course, AKI, RRT, and thromboembolic events. Four different anticoagulatory regimens were administered. Anticoagulation during continuous veno-venous hemodialysis (CVVHD) was performed with UFH or citrate. Anticoagulation during sustained low-efficiency daily dialysis (SLEDD) was performed with UFH, argatroban, or low molecular weight heparin (LMWH). Primary outcome is the effect of the anticoagulation regimen on mean treatment times of RRT.ResultsIn patients receiving CVVHD, mean treatment time in the UFH group was 21.3 h (SEM: ±5.6 h), in the citrate group 45.6 h (SEM: ±2.7 h). Citrate anticoagulation significantly prolonged treatment times by 24.4 h (P = .001). In patients receiving SLEDD, mean treatment time with UFH was 8.1 h (SEM: ±1.3 h), with argatroban 8.0 h (SEM: ±0.9 h), and with LMWH 11.8 h (SEM: ±0.5 h). LMWH significantly prolonged treatment times by 3.7 h (P = .008) and 3.8 h (P = .002), respectively.ConclusionsUFH fails to prevent early clotting events in the dialysis circuit during COVID-19. For patients, who do not require effective systemic anticoagulation, regional citrate dialysis is the most effective strategy. For patients, who require effective systemic anticoagulation, the usage of LMWH results in the longest circuit life spans. The proposed anticoagulatory strategies are safe, can easily be monitored, and allow an individualized treatment.Graphical abstract

Cangrelor with Heparin for Patients with Heparin-Induced Thrombocytopenia Undergoing Pulmonary Thromboendarterectomy

Optimal intraoperative anticoagulation strategy for patients with heparin-induced thrombocytopenia (HIT) undergoing pulmonary thromboendarterectomy (PTE) that necessitates deep hypothermic circulatory arrest (DHCA) remains controversial. Cangrelor is an intravenous direct-acting P2Y12 platelet receptor antagonist that achieves therapeutic effect and eliminates rapidly. Its antiplatelet activity is unaffected by stagnation of blood, nor is it influenced by patient's age, renal status or hepatic function. We report our novel strategy and experience in utilizing cangrelor in combination with heparin for anticoagulation during cardiopulmonary bypass (CPB) and DHCA in HIT patients undergoing PTE. Retrospective chart review of 297 patients who underwent PTE from January 2018 through June 2019 was performed. Patients with suspected, acute, subacute A/B, and remote HIT at the time of procedure were identified (n=7). All 7 patients received cangrelor with heparin intraoperatively for anticoagulation during CPB and DHCA. Our institutional intraoperative anticoagulation strategy for HIT patients is to administer a loading dose of cangrelor (30 μg/kg) prior to giving full-dose heparin for CPB. Cangrelor infusion is initiated at 4 μg/kg/min and is adjusted throughout CPB depending on the intraoperative VerifyNow P2Y12 reaction unit values. Cangrelor infusion is stopped 10 minutes before heparin reversal with protamine. Postoperatively, bivalirudin and warfarin were used for anticoagulation. Of these 7 patients, HIT was suspected in 3 patients (43%) at the time of procedure, whilst 1 patient had subacute B HIT and 1 patient had remote HIT. Acute HIT was confirmed by serotonin release assay in 2 patients (29%) who underwent emergent PTE. All patients survived the procedure. Intraoperative platelet transfusion was required by 4 patients (57%). There were no serious postoperative thrombotic events nor major bleeding complications that required re-operation. One in-hospital death was associated with advanced intracardiac malignancy. The mean postoperative hospital stay was 10.6±5.5 days. In patients with various phases of HIT who require PTE, the use of cangrelor in combination with heparin may be a promising alternative intraoperative anticoagulation strategy providing acceptable outcomes.