Download management of heparin induced thrombocytopenia and left

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Cat: Mechanical support, left ventricular assist devices
MANAGEMENT OF HEPARIN INDUCED THROMBOCYTOPENIA AND LEFT
VENTRICULAR THROMBUS IN A PATIENT WITH CARDIOGENIC SHOCK
H. Keshmiri1, B. Mohamedali2, G. Bhat2, A. Tatooles3, G. Sayer2
1. University of Illinois at Chicago/ Advocate Christ Medical Center Department of Internal
Medicine, Chicago, IL, USA
2. University of Illinois at Chicago/ Advocate Christ Medical Center Department of Cardiology,
Chicago, IL, USA
3. Advocate Christ Medical Center, Department of Cardiothoracic Surgery, Oak Lawn, IL, USA
Background: Anticoagulation with heparin is the standard of care during
cardiopulmonary bypass (CPB) for mechanical circulatory support (MCS) surgery.
However, patients with active Left Ventricular (LV) apical thrombus and heparininduced thrombocytopenia (HIT) pose a special challenge. We report a case of a patient
with LV thrombus and HIT who required MCS.
Case: Forty-year-old female presented with cardiogenic shock secondary to ST-elevation
myocardial infarction. She was treated with thrombectomy and drug eluting stent (DES)
of the left main coronary artery. She was anticoagulated with intravenous heparin, as well
as aspirin and clopidogrel for her DES. Initial transthoracic echocardiogram (TTE)
indicated an ejection fraction of 10% and no evidence of LV apical thrombus. Her
clinical condition continued to deteriorate requiring inotropes and an intraaortic balloon
pump (IABP). Repeat TTE demonstrated a large LV apical thrombus. Decision was made
to place a left-sided centrifugal pump. Postoperatively, however, patient was found to be
HIT positive with an optical density of 2.6. Heparin was discontinued and patient was
started on argatroban. A month later, after her optical density came down to 0.6, she was
implanted with a HeartMate II left ventricular assist device (LVAD). Intraoperative
heparin was utilized again and patient was immediately started on postoperative
argatroban bridging with coumadin. She made progressive recovery and underwent heart
transplantation.
Conclusion: To the best of our knowledge, this is the first reported case of a patient with
HIT and LV thrombus, who underwent sequential temporary and durable LVAD
placement while receiving intraoperative heparin. We demonstrate that patients who are
HIT positive with an LV apical thormbi requiring an LVAD may still undergo CPB on
heparin anticoagulation.