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

Nicolas Gendron; Candice Cavalie; Elie Kantor; Sophie Provenchère; Romain Sonneville; Vasiliki Gkalea; Marie-Charlotte Bourrienne; Dorothée Faille; Nadine Ajzenberg

doi:10.1055/a-2277-4404

TH Open, Table of Contents

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

¹Innovative Therapies in Haemostasis, Paris Cité University, INSERM, Paris, France

²Hematology Department, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP-CUP), Paris, France

,

Candice Cavalie‡^*

³Université de Paris, INSERM U1148, LVTS, F-75018, Paris, France

⁴Laboratoire d’Hématologie Biologique, AP-HP, Hôpital Bichat, F-75018, Paris, France

,

Elie Kantor

⁵Anesthesiology Department and Surgical Intensive Care, DMU PARABOL, AH-HP, Bichat–Claude Bernard Hospital, Paris, France

,

Sophie Provenchère

⁵Anesthesiology Department and Surgical Intensive Care, DMU PARABOL, AH-HP, Bichat–Claude Bernard Hospital, Paris, France

,

Romain Sonneville

⁶Laboratory of Vascular Translational Science, Paris Cité University, INSERM, Paris, France

⁷Intensive Care Medicine, AP-HP, Hôpital Bichat - Claude Bernard, Paris, France

,

Vasiliki Gkalea

⁴Laboratoire d’Hématologie Biologique, AP-HP, Hôpital Bichat, F-75018, Paris, France

,

Marie-Charlotte Bourrienne

³Université de Paris, INSERM U1148, LVTS, F-75018, Paris, France

⁴Laboratoire d’Hématologie Biologique, AP-HP, Hôpital Bichat, F-75018, Paris, France

,

Dorothée Faille

³Université de Paris, INSERM U1148, LVTS, F-75018, Paris, France

⁴Laboratoire d’Hématologie Biologique, AP-HP, Hôpital Bichat, F-75018, Paris, France

,

Nadine Ajzenberg

³Université de Paris, INSERM U1148, LVTS, F-75018, Paris, France

⁴Laboratoire d’Hématologie Biologique, AP-HP, Hôpital Bichat, F-75018, Paris, France

› Author Affiliations

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

Full Text

References

References
1 Cuker A, Arepally GM, Chong BH. et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv 2018; 2 (22) 3360-3392
2 Greinacher A. Heparin-induced thrombocytopenia. J Thromb Haemost 2009; 7 (Suppl. 01) 9-12
3 Koster A, Faraoni D, Levy JH. Argatroban and bivalirudin for perioperative anticoagulation in cardiac surgery. Anesthesiology 2018; 128 (02) 390-400
4 Scala E, Pitta-Gros B, Pantet O. et al. Cardiac surgery successfully managed with cangrelor in a patient with persistent anti-PF4/heparin antibodies 8 years after heparin-induced thrombocytopenia. J Cardiothorac Vasc Anesth 2019; 33 (11) 3073-3077
5 Pishko AM, Cuker A. Heparin-induced thrombocytopenia and cardiovascular surgery. Hematology (Am Soc Hematol Educ Program) 2021; 2021 (01) 536-544
6 Godier A, Boucebci K-J, Delhaye N, Gendron N, Achouh P, Hamada SR. Cangrelor for cardiopulmonary bypass in patients with heparin-induced thrombocytopenia: it is not so easy. Blood Coagul Fibrinolysis 2023; 34 (03) 224-227
7 Warkentin TE, Sheppard J-AI, Chu FV, Kapoor A, Crowther MA, Gangji A. Plasma exchange to remove HIT antibodies: dissociation between enzyme-immunoassay and platelet activation test reactivities. Blood 2015; 125 (01) 195-198
8 Welsby IJ, Um J, Milano CA, Ortel TL, Arepally G. Plasmapheresis and heparin reexposure as a management strategy for cardiac surgical patients with heparin-induced thrombocytopenia. Anesth Analg 2010; 110 (01) 30-35
9 Onuoha C, Barton KD, Wong ECC. et al. Therapeutic plasma exchange and intravenous immune globulin in the treatment of heparin-induced thrombocytopenia: a systematic review. Transfusion 2020; 60 (11) 2714-2736
10 Nazi I, Arnold DM, Warkentin TE, Smith JW, Staibano P, Kelton JG. Distinguishing between anti-platelet factor 4/heparin antibodies that can and cannot cause heparin-induced thrombocytopenia. J Thromb Haemost 2015; 13 (10) 1900-1907
11 Vayne C, Guery E-A, Kizlik-Masson C. et al. Beneficial effect of exogenous platelet factor 4 for detecting pathogenic heparin-induced thrombocytopenia antibodies. Br J Haematol 2017; 179 (05) 811-819
12 Arangalage D, Lepage L, Faille D. et al. Presentation, management and outcome of heparin-induced thrombocytopenia after valvular heart surgery. Eur J Cardiothorac Surg 2016; 50 (06) 1132-1138
13 Gonthier M-C, Gendron N, Eloy P. et al. Heparin-induced thrombocytopenia diagnosis: a retrospective study comparing heparin-induced platelet activation test to ¹⁴ C-serotonin release assay. TH Open 2021; 5 (04) e507-e512
14 Le Pavec J, Pison C, Hirschi S. et al. 2022 Update of indications and contraindications for lung transplantation in France. Respir Med Res 2023; 83: 100981
15 Jones CG, Pechauer SM, Curtis BR, Bougie DW, Aster RH, Padmanabhan A. Normal plasma IgG inhibits HIT antibody-mediated platelet activation: implications for therapeutic plasma exchange. Blood 2018; 131 (06) 703-706
16 Arachchillage DJ, Thachil J, Anderson JAM. et al. Diagnosis and management of heparin-induced thrombocytopenia: Third edition. Br J Haematol 2024; 204 (02) 459-475
17 Gruel Y, De Maistre E, Pouplard C. et al; Members of the French Working Group on Perioperative Haemostasis Groupe d'intérêt en hémostase périopératoire GIHP. Diagnosis and management of heparin-induced thrombocytopenia. Anaesth Crit Care Pain Med 2020; 39 (02) 291-310