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CC BY 4.0 · TH Open 2024; 08(01): e141-e145
DOI: 10.1055/a-2277-4404
Case Report

Challenges in the Monitoring of Therapeutic Plasma Exchange during Acute Heparin-Induced Thrombocytopenia in Adults under ECMO

Nicolas Gendron 
1   Innovative Therapies in Haemostasis, Paris Cité University, INSERM, Paris, France
2   Hematology Department, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP-CUP), Paris, France
,
Candice Cavalie‡   *
3   Université de Paris, INSERM U1148, LVTS, F-75018, Paris, France
4   Laboratoire d’Hématologie Biologique, AP-HP, Hôpital Bichat, F-75018, Paris, France
,
Elie Kantor
5   Anesthesiology Department and Surgical Intensive Care, DMU PARABOL, AH-HP, Bichat–Claude Bernard Hospital, Paris, France
,
Sophie Provenchère
5   Anesthesiology Department and Surgical Intensive Care, DMU PARABOL, AH-HP, Bichat–Claude Bernard Hospital, Paris, France
,
Romain Sonneville
6   Laboratory of Vascular Translational Science, Paris Cité University, INSERM, Paris, France
7   Intensive Care Medicine, AP-HP, Hôpital Bichat - Claude Bernard, Paris, France
,
Vasiliki Gkalea
4   Laboratoire d’Hématologie Biologique, AP-HP, Hôpital Bichat, F-75018, Paris, France
,
Marie-Charlotte Bourrienne 
3   Université de Paris, INSERM U1148, LVTS, F-75018, Paris, France
4   Laboratoire d’Hématologie Biologique, AP-HP, Hôpital Bichat, F-75018, Paris, France
,
Dorothée Faille
3   Université de Paris, INSERM U1148, LVTS, F-75018, Paris, France
4   Laboratoire d’Hématologie Biologique, AP-HP, Hôpital Bichat, F-75018, Paris, France
,
Nadine Ajzenberg
3   Université de Paris, INSERM U1148, LVTS, F-75018, Paris, France
4   Laboratoire d’Hématologie Biologique, AP-HP, Hôpital Bichat, F-75018, Paris, France
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Abstract

Therapeutic plasma exchange (TPE) has been proposed to remove heparin-induced thrombocytopenia (HIT) antibodies before planned thoracic surgery in patients with acute HIT and to allow brief re-exposure to heparin during surgery. In patients on extracorporeal membrane oxygenation (ECMO), simultaneous administration of TPE and alternative nonheparin anticoagulant therapies is challenging.

We report 2 patients on ECMO with acute HIT who underwent repeated TPE to enable cardiothoracic surgery with the use of heparin. In both cases, serial monitoring of HIT antibody titer and heparin-induced platelet activation assay (HIPA) was performed. The effect of adding exogenous platelet factor 4 (PF4) in the HIPA was also tested.

Negative anti-PF4/H IgG levels were achieved after 5 and 3 TPE sessions, respectively and patients could beneficiate from surgery with brief heparin re-exposure without any thrombotic complication. Negative HIPA results were obtained before negative anti-PF4/H IgG in one patient but remained positive in the other despite very low antibody titers. The addition of PF4 in HIPA led to more contrasted results for the two patients.

Serial HIT screening including immunological and functional assays is necessary to closely monitor TPE in acute HIT patients on ECMO who require surgery. The addition of PF4 in HIPA could help detect clinically relevant platelet-activating antibodies and guide re-exposure to heparin.

Keywords

heparin-induced thrombocytopenia - therapeutic plasma exchange - platelet factor 4 - platelet activation - extracorporeal membrane oxygenation

Authorship Contributions

N.G., C.C., E.K., S.P., R.S., V.G., M.-C.B., D.F., and N.A. were involved in the clinical management of the reported study. N.G., C.C., D.F., and N.A. perform the experiments. N.G., C.C., D.F., and N.A. analyzed the data and wrote the manuscript.


* These two authors contributed equally to the work.




Publication History

Received: 30 September 2023

Accepted: 23 January 2024

Accepted Manuscript online:
27 February 2024

Article published online:
28 March 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

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