A 52-year-old man presented in acute decompensated
heart failure. His admission laboratory studies were consistent with
cardiogenic shock with a
lactate of 6.1 mmol/L (ref range 0.50-1.99 mmol/L). Echocardiogram and CT scan demonstrated severe biventricular dysfunction and a left ventricular ejection fraction of 10%, as well as left upper lobe segmental
pulmonary embolism. He was started on inotropes,
diuretics, and a
heparin infusion. Following
heparin initiation, his platelets had decreased by 63% to a nadir of 39 000/µL (ref range 150 000-450 000/µL) and testing confirmed a diagnosis of HIT. His
shock state worsened to INTERMACS 1 necessitating escalation of mechanical support. In preparation for HeartMate 3 LVAD implantation, he received 3 cycles of
plasmapheresis with one session of
IVIG perioperatively, resulting in a 60% reduction in the titre of
heparin-dependent platelet
antibodies. He underwent successful LVAD implantation including usage of intraoperative
heparin, and was discharged home on post-operative Day 17, where he has remained stable on LVAD support.
Discussion: Limited data exist on the perioperative management of patients with HIT undergoing LVAD implantation.
Heparin is preferred to other
antithrombin agents during surgery due to the availability of an immediate reversal agent.
Plasmapheresis with
IVIG is a potential management option to decrease
heparin-dependent platelet
antibodies in patients with HIT to allow for successful LVAD implantation.