The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology

Clinical Practice Guidelines—Anticoagulation During Cardiopulmonary Bypass

Linda Shore-Lesserson, MD; Robert A. Baker, PhD, CCP; Victor A. Ferraris, MD, PhD; Philip E. Greilich, MD; David Fitzgerald, MPH, CCP; Philip Roman, MD, MPH; John W. Hammon, MD


Anesth Analg. 2018;126(2):413-424. 

In This Article

Other Alternatives to Heparin

Other strategies for anticoagulation treatment of patients with HIT consist of reintroduction of heparin after either the removal of PF4-heparin antibodies (plasmapheresis), administration of intravenous antiplatelet therapy, or use of argatroban. The use of plasmapheresis is generally limited to patients with weakly positive ELISA results requiring urgent cardiac procedures.[73–75] Although each approach appears to be safe and effective, there is insufficient evidence for a recommendation in the setting of CPB.

In a small case series by Welsby and colleagues,[74] 11 patients with recent (less than 2 months) diagnosis of HIT received therapeutic plasma volume exchange after induction of anesthesia. All patients had a reduction in antibody titers (range of reduction, 50% to 84%). Of these 11 patients, 2 patients had positive HIT antibodies at the time of operation. One patient had an ischemic foot, likely related to an intraaortic balloon pump. Three patients (27%) died during the postoperative period (range, 3 months to 1 year) although none of the deaths was attributed to HIT thrombosis. Other case reports and smaller series are summarized in a practice guideline by the American Society for Apheresis, although recommendations regarding CPB are limited.[52,73]

Iloprost (prostacyclin analogue) was used in several studies of HIT patients to inhibit platelet activation during cardiac surgery.[76] In a large retrospective analysis of 1,518 consecutive cardiac surgery patients, Palatianos and associates[77] identified 10 patients with clinical symptoms of HIT with PF4-heparin antibodies and compared them with 10 randomly selected control subjects. Patients presenting with HIT received a protocol of iloprost infusion, supplemented with norepinephrine as needed, in conjunction with heparin. The postoperative reduction in platelet count was less in the iloprost group (12.5% ± 8.7%) versus the control group (38.1% ± 15.2%), and no thrombotic complications were detected. In another small study (n = 10) by Koster and associates,[78] heparin was used in conjunction with a tirofiban infusion during CPB. There was no clinical or laboratory (D-dimer) evidence of thrombosis or excessive bleeding.

The use of argatroban has been reported with patients requiring renal replacement therapy. Given that renal clearance is an important means of bivalirudin excretion and inactivation, argatroban should be limited to these exceptional circumstances, given that excessive bleeding is the norm.[79–83]

Patients who are seropositive for heparin antibodies are at increased risk of both thrombosis and bleeding (associated with heparin alternatives). Given the potentially catastrophic thrombotic complication associated with rapid-onset HIT in patients with a recent history of HIT, a very high level of vigilance is recommended in patients reexposed to heparin. These patients warrant careful surveillance, thromboprophylaxis, and possibly other special treatments to manage the increased risk.