Staged Management of Heparin-Induced Thrombocytopenia for Renal
Cavo-Atrial Cancer Removal on Cardiopulmonary Bypass
Abstract
Management of patients with acute heparin-induced thrombocytopenia (HIT)
with cavo-atrial renal cancer requiring surgery on cardiopulmonary
bypass (CPB) and possible deep hypothermia circulatory arrest is a
challenge. A staged approach using Bivalirudin, plasmapheresis, and
intravenous immunoglobulin (IVIG) was used to preoperatively de-escalate
HIT guided by enzyme-linked immunosorbent assay (ELISA) and serotonin
release assay (SRA). Intraoperatively heparin was used as the
anticoagulant for CPB as DHCA was likely to be used to remove the
atrio-caval tumor. Heparin is effective in preventing clots in the
circuit during DHCA. To prevent HIT upon re-exposure to heparin during
CPB, a bolus of a Cangrelor (reversible P2Y12 platelet receptor
inhibitor) was given before heparin and during CPB whilst platelet
activity was monitored using platelet reactivity units (PRU).
Postoperatively, to prevent recurrence of HIT, plasmapheresis was used
until SRA and optical density (OD) resulted. The patient had a
successful outcome.