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HIT in OPCAB surgery

Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover 30625, Germany

Different anticoagulation strategies in off-pump coronary artery bypass operations: a European survey

Given the fact that 78% of the respondent surgeons use low or high molecular weight heparin for perioperative prophylaxis of thrombosis, potential adverse effects of heparin should be considered [1].

As such, thrombocytopenia is a common problem in cardiovascular patients, and heparin-induced thrombocytopenia (HIT) is therefore frequently suspected following cardiac surgery. Currently, is it not clear whether OPCAB surgery is associated with the same or a different incidence of HIT I or HIT II in contrast to on-pump cardiac surgery.

It has been suggested that both functional (platelet activation tests) and immunologic assays (antigen assays) are necessary in every patient to establish the diagnosis of HIT. Screening with thromboelastography has been proposed recently [2]. The prevalence of heparin/platelet factor 4 antibodies is currently under investigation. As far as cardiac surgery is concerned, the high prevalence of antibodies to the heparin/PF4 complex after cardiac surgery and the low rate of thromboembolic complications in this population suggest that the antibody alone does not confer an increased risk of thrombotic complications [3]. This is supported by a recent retrospective analysis [4]. The authors concluded that postoperative platelet count fall between days 5 and 10 increases diagnostic specificity for HIT, irrespective of whether this platelet count fall occurs after postoperative platelet count recovery or is superimposed upon persisting postoperative thrombocytopenia.

A recent survey among 487 cardiac surgery patients with postoperative thrombocytopenia (50% drop in platelet count or absolute count <100,000/µl) at least one enzyme-linked immunosorbent assay for HIT platelet factor 4 antibodies was performed [5]. Postoperative infections occurred more frequently in HITq patients, including sepsis and pneumonia. The HIT+ patients also had a higher rate of renal failure requiring hemodialysis and acute limb ischemia. Thirty-day mortality was significantly higher in the HIT+ group (24.8% vs. 15.2%, P=0.019). Postoperative HIT emerged as an independent predictor of renal failure (OR=1.73, P<0.001) and thromboembolic complications (OR=2.39, P=0.02). In conclusion, greater awareness of the potential devastating sequelae may allow earlier detection of HIT in OPCAB as well as in on-pump cardiac surgery.

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1. Englberger L, Streich M, Tevaearai HT, Carrel TP. Different anticoagulation strategies in off-pump coronary artery bypass operations: a European survey. Interact Cardiovasc Thorac Surg 2008;7:378–383.[Abstract/Free Full Text]
2. Kouerinis IA, Kourtesis A, El-Ali M, Sergentanis T, Plagou A, Argiriou M, Theakos N, Giannakopoulou A. Heparin induced thrombocytopenia diagnosis in cardiac surgery: is there a role for thromboelastography? Interact Cardiovasc Thorac Surg, doi: 10.1510/icvts.2007.161679.[Abstract]
3. Everett BM, Yeh R, Foo SY, Criss D, Van Cott EM, Laposata M, Avery EG, Hoffman WD, Walker J, Torchiana D, Jang IK. Prevalence of heparin/platelet factor 4 antibodies before and after cardiac surgery. Ann Thorac Surg 2007;83:592–597.[Abstract/Free Full Text]
4. Selleng S, Selleng K, Wollert HG, Muellejans B, Lietz T, Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia in patients requiring prolonged intensive care unit treatment after cardiopulmonary bypass. J Thromb Haemost 2008;6:428–435.[CrossRef][Medline]
5. Kerendi F, Thourani VH, Puskas JD, Kilgo PD, Osgood M, Guyton RA, Lattouf OM. Impact of heparin-induced thrombocytopenia on postoperative outcomes after cardiac surgery. Ann Thorac Surg 2007;84:1548–1553.[Abstract/Free Full Text]

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