Ljajikj Edis, Zittermann Armin, Morshuis Michiel, Börgermann Jochen, Ruiz-Cano Maria, Schoenbrodt Michael, Gummert Jan, Koster Andreas
Department of Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University of Bochum, Bad Oeynhausen, Germany.
Institute of Anaesthesiology, Herz- und Diabeteszentrum NRW, Ruhr-University of Bochum, Bad Oeynhausen, Germany.
Interact Cardiovasc Thorac Surg. 2017 Dec 1;25(6):898-904. doi: 10.1093/icvts/ivx251.
Heparin-induced thrombocytopenia (HIT) requires alternative anticoagulation strategies. We investigated outcomes in patients with HIT antibodies undergoing low-dose bivalirudin anticoagulation during left ventricular assist device implantation on an extracorporeal life support system (ECLS) and compared the results with non-HIT patients treated with heparin and receiving left ventricular assist device implantation with ECLS support.
The institutional ventricular assist device database was searched for the period from March 2012 to March 2016. The primary end-point was the need for early (<7 days) surgical re-exploration due to persistent haemorrhage or cardiac tamponade postoperatively. The secondary clinical end-points were delayed chest closure, stroke, intracranial bleeding, re-thoracotomy >7 days and mortality up to 1 year. Unadjusted comparison was used for the entire groups. Because of non-random group assignment, propensity score matching was also performed to compare treatment effects.
Twenty-one patients were treated with bivalirudin and 36 patients with heparin. INTERMACS levels were lower, inotropic score was higher and the prevalence of mechanical ventilation and preoperative ECLS implants was also significantly higher in the heparin group than in the bivalirudin group (P-values <0.05). The primary end-point was reached by 19% in the bivalirudin group and 16.7% in the heparin group (bivalirudin group: odds ratio 1.18, 95% confidence interval 0.29-4.76; P = 0.820). The propensity score-matched groups also showed no difference in this regard (P = 0.455). All secondary clinical end-points were comparable between groups, both in the unadjusted analysis and in the propensity score-matched groups.
In patients with HIT antibodies, low-dose bivalirudin anticoagulation on ECLS support appears to be a feasible option for left ventricular assist device implantation.
肝素诱导的血小板减少症（HIT）需要采用替代抗凝策略。我们调查了在体外生命支持系统（ECLS）上进行左心室辅助装置植入期间接受低剂量比伐卢定抗凝的HIT抗体患者的结局，并将结果与接受肝素治疗且在ECLS支持下进行左心室辅助装置植入的非HIT患者进行比较。
检索2012年3月至2016年3月期间机构心室辅助装置数据库。主要终点是术后因持续出血或心脏压塞而需要早期（<7天）再次手术探查。次要临床终点是延迟关胸、中风、颅内出血、7天后再次开胸和1年内死亡率。对整个组进行未调整比较。由于未进行随机分组，还进行了倾向评分匹配以比较治疗效果。
21例患者接受比伐卢定治疗，36例患者接受肝素治疗。肝素组的INTERMACS水平较低，肌力评分较高，机械通气和术前ECLS植入的发生率也显著高于比伐卢定组（P值<0.05）。比伐卢定组19%达到主要终点，肝素组为16.7%（比伐卢定组：比值比1.18，95%置信区间0.29 - 4.76；P = 0.820）。倾向评分匹配组在这方面也无差异（P = 0.455）。在未调整分析和倾向评分匹配组中，所有次要临床终点在组间均具有可比性。
对于有HIT抗体的患者，在ECLS支持下进行低剂量比伐卢定抗凝似乎是左心室辅助装置植入的可行选择。
