Antoine Kimmoun1, Walid Oulehri2, Romain Sonneville3, Paul-Henri Grisot1, Elie Zogheib4, Julien Amour5, Nadia Aissaoui6, Bruno Megarbane7, Nicolas Mongardon8, Amelie Renou9, Matthieu Schmidt10, Emmanuel Besnier11, Clément Delmas12, Geraldine Dessertaine13, Catherine Guidon14, Nicolas Nesseler15, Guylaine Labro16, Bertrand Rozec17, Marc Pierrot18, Julie Helms19, David Bougon20, Laurent Chardonnal21, Anne Medard22, Alexandre Ouattara23, Nicolas Girerd24, Zohra Lamiral24, Marc Borie25, Nadine Ajzenberg26, Bruno Levy27. 1. Medical Intensive Care Unit Brabois, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, INSERM U1116, Université de Lorraine, Vandoeuvre-les-Nancy, 54511, Nancy, France. 2. Department of Anesthesiology and Surgical Critical Care, Nouvel Hôpital Civil, CHU Strasbourg, Strasbourg, France. 3. Department of Intensive Care Medicine and Infectious Diseases, Hôpital Bichat Claude Bernard, Assistance Publique, Hôpitaux de Paris, INSERM, UMR 1148, Université Paris Diderot, Paris, France. 4. Cardiothoracic and Vascular Intensive Care Unit, Amiens University Hospital, INSERM U1088, Jules Verne University of Picardy, Amiens, France. 5. Department of Anesthesiology and Surgical Critical Care, Institut Hospitalo-Universitaire de Cardiométabolisme et Nutrition, Hôpital Pitié-Salpêtrière, Assistance Publique, Hôpitaux de Paris, UMR INSERM 1166, Université Sorbonne, Paris, France. 6. Critical Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, INSERM U970, Université Paris-Descartes, Paris, France. 7. Department of Medical and Toxicological Critical Care, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, INSERM UMRS-1144, Université Paris Diderot, Paris, France. 8. Department of Anesthesiology and Surgical Critical Care, CHU Henri Mondor, Assistance Publique-Hôpitaux de Paris, INSERM U955 Team 3, Université Paris Est, Paris, France. 9. Department of Anesthesiology and Surgical Critical Care, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris-Descartes, Paris, France. 10. Medical Intensive Care Unit, Institut Hospitalo-Universitaire de Cardiométabolisme et Nutrition, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, UMR INSERM 1166, Université Sorbonne, Paris, France. 11. Department of Anesthesiology and Surgical Critical Care, Hôpital de Rouen, Université de Rouen, Rouen, France. 12. Intensive Cardiac Care Unit, Hôpital de Rangueil, Université de Toulouse 3 Paul Sabatier, Toulouse, France. 13. Intensive Cardiac Care Unit, Hôpital de Grenoble, Université de Grenoble Alpes, Grenoble, France. 14. Department of Cardiac Surgery, Hôpital La Timone, Marseille, France. 15. Department of Anesthesiology and Surgical Critical Care, Hôpital de Pontchaillou, INSERM, UMR 1214 and INSERM 1414, Université de Rennes 1, Rennes, France. 16. Medical Intensive Care Unit, Hôpital Jean Minjoz, Université de Franche-Comté, Besançon, France. 17. Department of Anesthesiology and Surgical Critical Care, Hôpital Guillaume et René Laennec, CHRU Nantes, Institut du Thorax, Université de Nantes, Nantes, France. 18. Department of Medical Intensive Care and Hyperbaric Medicine, Hôpital d'Angers, Université d' Angers, Angers, France. 19. Medical Intensive Care Unit, Nouvel Hôpital Civil, CHU de Strasbourg, INSERM, UMR_S1109, Université de Strasbourg, Strasbourg, France. 20. Intensive Care Unit, Hôpital Annecy Genevois, Annecy, France. 21. Department of Anesthesiology and Surgical Critical Care, Hôpital Cardiologique Louis Pradel, Hospices Civils de Lyon, Lyon, France. 22. Department of Anesthesiology and Surgical Critical Care, CHU de Clermont-Ferrand, Clermont-Ferrand, France. 23. Department of Anesthesiology and Surgical Critical Care, Centre Médico-Chirurgical Magellan, CHU de Bordeaux, INSERM, UMR 1034, Université de Bordeaux, Bordeaux, France. 24. INSERM CIC1433, CHRU de Nancy, Université de Lorraine, Nancy, France. 25. PARC, CHRU de Nancy, Nancy, France. 26. Department of Hematology, Hôpital Bichat Claude Bernard, Assistance Publique, Hôpitaux de Paris, INSERM, UMR 1148, Université Paris Diderot, Paris, France. 27. Medical Intensive Care Unit Brabois, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, INSERM U1116, Université de Lorraine, Vandoeuvre-les-Nancy, 54511, Nancy, France. b.levy@chru-nancy.fr.
Abstract
PURPOSE: Thrombocytopenia is a frequent and serious adverse event in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. Similarly to postcardiac surgery patients, heparin-induced thrombocytopenia (HIT) could represent the causative underlying mechanism. However, the epidemiology as well as related mortality regarding HIT and VA-ECMO remains largely unknown. We aimed to define the prevalence and associated 90-day mortality of HIT diagnosed under VA-ECMO. METHODS: This retrospective study included patients under VA-ECMO from 20 French centers between 2012 and 2016. Selected patients were hospitalized for more than 3 days with high clinical suspicion of HIT and positive anti-PF4/heparin antibodies. Patients were classified according to results of functional tests as having either Confirmed or Excluded HIT. RESULTS: A total of 5797 patients under VA-ECMO were screened; 39/5797 met the inclusion criteria, with HIT confirmed in 21/5797 patients (0.36% [95% CI] [0.21-0.52]). Fourteen of 39 patients (35.9% [20.8-50.9]) with suspected HIT were ultimately excluded because of negative functional assays. Drug-induced thrombocytopenia tended to be more frequent in Excluded HIT at the time of HIT suspicion (p = 0.073). The platelet course was similar between Confirmed and Excluded HIT (p = 0.65). Mortality rate was 33.3% [13.2-53.5] in Confirmed and 50% [23.8-76.2] in Excluded HIT (p = 0.48). CONCLUSIONS: Prevalence of HIT among patients under VA-ECMO is extremely low at 0.36% with an associated mortality rate of 33.3%, which appears to be in the same range as that observed in patients treated with VA-ECMO without HIT. In addition, HIT was ultimately ruled out in one-third of patients with clinical suspicion of HIT and positive anti-PF4/heparin antibodies.
PURPOSE:Thrombocytopenia is a frequent and serious adverse event in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock. Similarly to postcardiac surgery patients, heparin-induced thrombocytopenia (HIT) could represent the causative underlying mechanism. However, the epidemiology as well as related mortality regarding HIT and VA-ECMO remains largely unknown. We aimed to define the prevalence and associated 90-day mortality of HIT diagnosed under VA-ECMO. METHODS: This retrospective study included patients under VA-ECMO from 20 French centers between 2012 and 2016. Selected patients were hospitalized for more than 3 days with high clinical suspicion of HIT and positive anti-PF4/heparin antibodies. Patients were classified according to results of functional tests as having either Confirmed or Excluded HIT. RESULTS: A total of 5797 patients under VA-ECMO were screened; 39/5797 met the inclusion criteria, with HIT confirmed in 21/5797 patients (0.36% [95% CI] [0.21-0.52]). Fourteen of 39 patients (35.9% [20.8-50.9]) with suspected HIT were ultimately excluded because of negative functional assays. Drug-induced thrombocytopenia tended to be more frequent in Excluded HIT at the time of HIT suspicion (p = 0.073). The platelet course was similar between Confirmed and Excluded HIT (p = 0.65). Mortality rate was 33.3% [13.2-53.5] in Confirmed and 50% [23.8-76.2] in Excluded HIT (p = 0.48). CONCLUSIONS: Prevalence of HIT among patients under VA-ECMO is extremely low at 0.36% with an associated mortality rate of 33.3%, which appears to be in the same range as that observed in patients treated with VA-ECMO without HIT. In addition, HIT was ultimately ruled out in one-third of patients with clinical suspicion of HIT and positive anti-PF4/heparin antibodies.
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