2024 FSA Podium and Poster Abstracts

P073: A PATIENT WITH HEPARIN-INDUCED THROMBOCYTOPENIA REQUIRING PVC ABLATION: AN ANTICOAGULATION DILEMMA
Rupashi Mukhia, MBBS, MD; Ryan Chadha, MD; Mayo Clinic Graduate School of Medical Sciences

Introduction/Background: 52-year-old male with a history of nonischemic cardiomyopathy (LVEF 43%), left MCA stroke in the setting of LV thrombi in the past year presented for a PVC ablation. During the hospitalization for the acute stroke, he was diagnosed with heparin-induced thrombocytopenia (HIT) with initiation of heparin drip and the presence of a serotonin-release assay. Preoperative immunoassay with antibodies to PF4 was negative.After a discussion with the proceduralist, a plan was made to initiate systemic anticoagulation intraprocedurally with Bivalrudin 0.75mg/kg bolus with a subsequent infusion of 1.75mg/kg/hr to target an intraprocedural ACT > 300. In terms of anesthetic technique, the decision was to proceed with low dose sedation with Propofol to allow for ease of inducing PVCs with plan to convert to general anesthesia with any concern for bleeding. At the end of the case, the plan was to stop the Bivalrudin infusion with careful observation of the groin access sites and a modified percutaneous closure protocol to minimize risk of postoperative hematoma while in an anticoagulated state. Patient tolerated the procedure and had an unremarkable recovery.

Discussion/Results: In this particular case, the question arises whether a HIT diagnosed patient with a history of a positive serotonin release assay and a negative PF4 antibody can tolerate a short exposure of heparin to facilitate a procedure in which systemic anticoagulation is necessary.(e.g electophysiologic intervention, cardiopulmonary bypass, vascular procedure) It has been demonstrated that patients with a history of HIT and a negative PF4antibody on presentation can safely be exposed to short term heparin exposure, as long as it is not continued in the postoperative period for common indications like DVT prophylaxis ^1.  Conversely, like demonstrated in our case, direct thrombin inhibitors like Bivalrudin can be used, however some concerns with this include general lack of knowledge with the use of this drug in most settings for the general anesthesiologist, unclear established protocols for procedural anticoagulation, and the lack of a rapid reversal agent in the setting of a massive hemorrhage intraprocedurally. Therefore, the perioperative management of a patient with HIT for a procedure requiring anticoagulation requires a multidisciplinary discussion with to determine anticoagulation strategies, bleeding management, and appropriate postoperative care.

References:

1) Lee GM, Arepally GM. Heparin-induced thrombocytopenia. Hematology 2013, the American Society of Hematology Education Program Book. 2013 Dec 6;2013(1):668-74.