Heparin-induced Thrombocytopenia Type II after Cardiac Surgery: Predictors and Outcome[*]

Abstract

Background: Heparin-induced thrombocytopenia (HIT) is a serious complication after cardiac surgery. The aim of the present study was to identify pre- and intraoperative predictors for the postoperative occurrence of HIT. The study additionally focused on the impact of HIT on postoperative outcome. Methods: Retrospective analysis was performed for 5073 patients who had required extracorporeal circulation during cardiac surgery. Patients were divided into 3 groups: 1) patients who had postoperative HIT (HIT+); 2) patients with postoperative thrombocytopenia but without HIT (HIT−); and 3) patients with normal platelet count (C). The groups were statistically compared with regard to pre-, intra- and postoperative parameters. Results: Statistically significant predictors were renal insufficiency, intravenous application of heparin for more than 3 days, previous percutaneous coronary intervention within the last 4 weeks, urgency/emergency operation, combined surgery, prolonged extracorporeal circulation or cross-clamping time, and low cardiac output syndrome. Postoperative HIT was associated with an enhanced risk of renal failure, infectious and thromboembolic complications and in-hospital mortality. Conclusion: Postoperative HIT increases morbidity and mortality. The predictors presented in this study can be used to identify patients at risk of developing HIT.

Key words

cardiac surgery - thrombocytopenia - HIT - predictors - heparin‐induced thrombocytopenia - predictor - postoperative complication - outcome - cardiac surgery

1 The content of this paper was presented at the 39^th annual meeting of the German Society for Thoracic and Cardiovascular Surgery, Stuttgart, February 2010.

References

• 1 Warkentin T E, Sheppard J A, Horsewood P, Simpson P J, Moore J C, Kelton J G. Impact of the patient population on the risk for heparin-induced thrombocytopenia.  Blood. 2000;  96 (5) 1703-1708
• 2 Foo S Y, Everett B M, Yeh R W, Criss D, Laposata M, Van Cott E M, Jang I K. Prevalence of heparin-induced thrombocytopenia in patients undergoing cardiac catheterization.  Am Heart J. 2006;  152 (2) 290.e1-e7
• 3 Everett B M, Yeh R, Foo S Y, Criss D, Van Cott E M, Laposata M, Avery E G, Hoffman W D, Walker J, Torchiana D, Jang I K. Prevalence of heparin/platelet factor 4 antibodies before and after cardiac surgery.  Ann Thorac Surg. 2007;  83 (2) 592-597
• 4 Greinacher A, Amiral J, Dummel V, Vissac A, Kiefel V, Mueller-Eckhardt C. Laboratory diagnosis of heparin-associated thrombocytopenia and comparison of platelet aggregation test, heparin-induced platelet activation test, and platelet factor 4/heparin enzyme-linked immunosorbent assay.  Transfusion. 1994;  34 (5) 381-385
• 5 Greinacher A, Juhl D, Strobel U, Wessel A, Lubenow N, Selleng K, Eichler P, Warkentin T E. Heparin-induced thrombocytopenia: a prospective study on the incidence, platelet-activating capacity and clinical significance of antiplatelet factor 4/heparin antibodies of the IgG, IgM, and IgA classes.  J Thromb Haemost. 2007;  5 (8) 1666-1673
• 6 Lo G K, Juhl D, Warkentin T E, Sigouin C S, Eichler P, Greinacher A. Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings.  J Thrombosis and Haemostasis. 2006;  4 759-765
• 7 Pouplard C, May M A, Lochmann S, Amiral J, Vissac A M, Marchand M, Gruel Y. Antibodies to platelet factor 4-heparin after cardiopulmonary bypass in patients anticoagulated with unfractionated heparin or a low-molecular-weight heparin: clinical implications for heparin-induced thrombocytopenia.  Circulation. 1999;  99 (19) 2530-2536
• 8 Mattioli A V, Bonetti L, Carletti U, Ambrosio G, Mattioli G. Thrombotic events in patients with antiplatelet factor 4/heparin antibodies.  Heart. 2009;  95 (16) 1350-1354
• 9 Yeh R W, Everett B M, Foo S Y, Dorer D J, Laposata M, Van Cott E M, Jang I K. Predictors for the development of elevated anti-heparin/platelet factor 4 antibody titers in patients undergoing cardiac catheterization.  Am J Cardiol. 2006;  98 (3) 419-421
• 10 Walls J T, Boley T M, Curtis J J, Silver D. Heparin induced thrombocytopenia in patients undergoing intra-aortic balloon pumping after open heart surgery.  ASAIO J. 1992;  38 (3) M574-M576
• 11 Thielmann M, Bunschkowski M, Tossios P, Selleng S, Marggraf G, Greinacher A, Jakob H, Massoudy P. Perioperative thrombocytopenia in cardiac surgical patients – incidence of heparin-induced thrombocytopenia, morbidities and mortality.  Eur J Cardiothorac Surg. 2010;  37 1391-1395
• 12 Crowther M A, Cook D J, Meade M O, Griffith L E, Guyatt G H, Arnold D M, Rabbat C G, Geerts W H, Warkentin T E. Thrombocytopenia in medical-surgical critically ill patients: prevalence, incidence, and risk factors.  J Crit Care. 2005;  20 (4) 348-353
• 13 Selleng S, Malowsky B, Strobel U, Wessel A, Ittermann T, Wollert H G, Warkentin T E, Greinacher A. Early-onset and persisting thrombocytopenia in post-cardiac surgery patients is rarely due to heparin-induced thrombocytopenia, even when antibody tests are positive.  J Thromb Haemost. 2010;  8 (1) 30-36
• 14 Kerendi F, Thourani V H, Puskas J D, Kilgo P D, Osgood M, Guyton R A, Lattouf O M. Impact of heparin-induced thrombocytopenia on postoperative outcomes after cardiac surgery.  Ann Thorac Surg. 2007;  84 (5) 1548-1553
• 15 Mattioli A V, Bonetti L, Zennaro M, Ambrosio G, Mattioli G. Heparin/PF4 antibodies formation after heparin treatment: temporal aspects and long-term follow-up.  Am Heart J. 2009;  157 (3) 589-595
• 16 Kuitunen A, Suojaranta-Ylinen R, Raivio P, Kukkonen S, Lassila R. Heparin-induced thrombocytopenia following cardiac surgery is associated with poor outcome.  J Cardiothorac Vasc Anesth. 2007;  21 (1) 18-22
• 17 Kress D C, Aronson S, McDonald M L, Malik M I, Divgi A B, Tector A J, Downey 3rd F X, Anderson A J, Stone M, Clancy C. Positive heparin-platelet factor 4 antibody complex and cardiac surgical outcomes.  Ann Thorac Surg. 2007;  83 (5) 1737-1743
• 18 Pouplard C, Gueret P, Fouassier M, Ternisien C, Trossaert M, Régina S, Gruel Y. Prospective evaluation of the '4Ts' score and particle gel immunoassay specific to heparin/PF4 for the diagnosis of heparin-induced thrombocytopenia.  J Thromb Haemost. 2007;  5 (7) 1373-1379

1 The content of this paper was presented at the 39^th annual meeting of the German Society for Thoracic and Cardiovascular Surgery, Stuttgart, February 2010.