PB0354 - Use of intraoperative heparin in combination with cangrelor in patients with acute heparin-induced thrombocytopenia undergoing cardiopulmonary bypass for heart transplantation: a case series

Background: Intraoperative anticoagulation is challenging in patients with acute heparin-induced thrombocytopenia (HIT) requiring cardiac surgery. Small case series recently reported the successful use of heparin administered in combination with cangrelor during cardiopulmonary bypass (CPB). Cangrelor is an intravenous, potent, ultra‐short‐acting and reversible P2Y12 receptor antagonist which can be used off-label to induce “platelet anaesthesia” and avoid thrombotic complications during CPB in patients with acute HIT requiring emergent cardiac surgery.

Aims: To report all consecutive patients with acute HIT who underwent urgent or emergent orthotopic heart transplantation (OHT) and received intraoperative heparin in combination with cangrelor during CPB at our institution from September 2022 to December 2022.

Methods: Demographic data, HIT-related profiles, and perioperative data were collected from electronic medical records.

Results: From September 2022 to December 2022, 3 urgent OHT were performed at our institution using heparin in combination with cangrelor for anticoagulation during CPB. Main characteristics of the patients are described in Table 1. The primary indication for OHT was cardiogenic shock complicating dilated cardiomyopathy in 2 patients and cardiogenic shock complicating acute myocardial infarction in one patient. All patients developed acute HIT during venoarterial extracorporeal membrane oxygenation support prior to OHT. Heparin was replaced with argatroban in all patients. Argatroban infusion was stopped on call to the operating room. Intraoperative heparin was administered in combination with cangrelor as previously described. The antiplatelet effect of cangrelor was monitored using the Multiplate ADP assay (Roche, Basel, Switzerland) prior to heparin administration. Anticoagulation with fondaparinux or argatroban was restarted on postoperative day 0. There was no major postoperative bleeding complication that required reoperation. One patient presented an ischemic stroke on postoperative day 1.

Conclusion(s): The use of intraoperative heparin in combination with cangrelor may represent a safe and effective alternative to non-heparin anticoagulants in patients with acute HIT who require urgent or emergent cardiac surgery.