Management of Heparin-Induced Thrombocytopenia With Plasmapheresis and IVIG Prior to Heart Transplantation: A Case Report.
TL;DR
This case demonstrates that combined PLEX and IVIG can effectively lower pathogenic HIT antibodies, permitting necessary heparin administration in critical settings like heart transplantation, and highlights a promising strategy to mitigate risks.
Abstract
Background: Heparin-Induced Thrombocytopenia (HIT) is a serious immune-mediated complication characterized by anti-platelet factor 4 (PF4)/heparin antibodies that activate platelets, causing thrombocytopenia and a paradoxical prothrombotic state. Management requires immediate heparin discontinuation and alternative anticoagulation due to thrombotic risks. Case Presentation: We report a 36-year-old pregnant female with heart failure who developed HIT after heparin exposure during extracorporeal membrane oxygenation (ECMO) support and was subsequently evaluated for heart transplantation. Confirmed HIT led to switching anticoagulation to bivalirudin. Prior to transplantation, where intraoperative heparin is standard, she underwent plasmapheresis (PLEX) followed by intravenous immunoglobulin (IVIG) and corticosteroids to reduce circulating HIT antibodies. This immune-modulating approach enabled safe intraoperative heparin use without thrombotic complications. Post-transplant HIT assays were negative, with platelet recovery and stable coagulation parameters. Discussion: This case demonstrates that combined PLEX and IVIG can effectively lower pathogenic HIT antibodies, permitting necessary heparin administration in critical settings like heart transplantation. Conclusion: Given the lack of standardized guidelines for managing HIT when heparin exposure is unavoidable, this report highlights a promising strategy to mitigate risks and underscores the need for further research to optimize care in such complex clinical scenarios.