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The Annals of Thoracic Surgery, Vol 49, 714-722, Copyright © 1990 by The Society of Thoracic Surgeons
JR Kappa, CA Fisher, B Todd, N Stenach, P Bell, F Campbell, N Ellison and VP Addonizio
For 11 patients with confirmed heparin-induced thrombocytopenia, we used
reversible platelet inhibition with iloprost, a stable prostacyclin
analogue, to permit safe heparin administration for cardiac (n = 9) or
vascular (n = 2) operations. In vitro, iloprost (0.01 mumol/L) prevented
both heparin-induced platelet aggregation and 14C-serotonin release in all
patients. Therefore, intraoperatively, a continuous infusion of iloprost
was started before administration of heparin and was continued until 15
minutes after administration of protamine. For cardiac patients, after
heparin administration, the whole blood platelet count did not change
(171,000 +/- 29,000/microL versus 174,000 +/- 29,000/microL, mean +/-
standard error of the mean); no spontaneous platelet aggregation was
observed, and plasma levels of the alpha-granule constituents platelet
factor 4 and beta- thromboglobulin increased from 38 +/- 14 and 140 +/- 18
ng/mL to 591 +/- 135 and 235 +/- 48 ng/mL, respectively. Fibrinopeptide A
levels actually decreased from 287 +/- 150 to 27 +/- 6 ng/mL. Furthermore,
adenosine diphosphate-induced platelet activation was preserved,
postoperative bleeding times were unchanged, and no heparin-related deaths
occurred. Similar results were obtained in both vascular patients. We
conclude that temporary platelet inhibition with iloprost now permits safe
heparin administration in all patients with heparin- induced
thrombocytopenia who require a cardiac or vascular operation.
ARTICLES
Intraoperative management of patients with heparin-induced thrombocytopenia
Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia.
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