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Ann Thorac Surg 2006;81:1944
© 2006 The Society of Thoracic Surgeons
a Department of Clinical Haematology, Royal Children's Hospital, Flemington Rd, Parkville, Victoria, 3052 Australia
b Murdoch Children's Research Institute, Flemington Rd, Parkville, Victoria, 3052 Australia
c Department of Pathology, The University of Melbourne, Royal Pde, Carlton, 3053 Australia
(Email: fiona.newall{at}rch.org.au; verai{at}unimelb.edu.au; paul.monagle{at}rch.org.au).
We would like to comment on the article by Böning and colleagues discussing the incidence of heparin-induced thrombocytopenia in pediatric patients undergoing cardiothoracic surgery [1]. The authors present a study whereby children who have undergone previous cardiopulmonary bypass (CPB) are screened for the presence of anti-heparin-PF4 antibodies prior to undergoing repeat CPB. Pediatric patients who have undergone CPB, necessitating supra-therapeutic heparin doses, represent a likely cohort in which heparin-induced thrombocytopenia may occur. However, the methodology used by these authors to screen for the presence of anti-heparin-PF4 antibodies seems to be flawed.
The authors identified 144 patients who had previously undergone CPB during surgical correction of congenital heart lesions and who required repeat cardiac surgery. These children were screened for the presence of anti-heparin-PF4 antibodies prior to reoperation using a heparin-induced platelet activation assay (Asserachrom HPIA [Roche Diagnostics, Mannheim, Germany]). At the time of screening, the mean number of postoperative days that first exposure to heparin therapy was reported was 266 days (± 168 days). Two patients were found to be anti-heparin-PF4 antibody positive.
We question the timing of anti-heparin-PF40 antibody screening. Warkentin and Kelton [2] conducted a comprehensive prospective study of 243 adult patients with confirmed heparin-induced thrombocytopenia. One of their aims was to determine the persistence of circulating heparin-dependent antibodies in patients with confirmed heparin-induced thrombocytopenia. They found the median time to a negative antigen assay (GTI-PF4 [Genetic Testing Institute, Brookfield, WI]) in this cohort of patients was 85 days (95% confidence interval, 64 to 124 days). Thus it is unlikely that any patient who may have once been antibody positive would continue to have detectable levels of circulating heparin-dependent antibodies on an average of 266 days after their last heparin exposure.
We acknowledge the difficulty of conducting robust research into the epidemiology and management of heparin-induced thrombocytopaenia in children. Although numerous case reports of heparin-induced thrombocytopenia in children have been reported, our understanding of the timing of onset, management, and sequelae of heparin-induced thrombocytopenia in children remains unclear. The Böning study has not helped to clarify our understanding as it is likely that Böning and colleagues have underestimated the incidence of heparin-induced thrombocytopenia in children post-CPB.
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  A. Boning and J. T. Cremer Reply. Ann. Thorac. Surg., May 1, 2006; 81(5): 1944 - 1945. [Full Text] [PDF]
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