Top

BMC Cardiovascular Disorders

Published in:

Open Access 01-12-2021 | Ventricular Flutter | Case report

Near fatal stent thrombosis in an aneurysmatic RCX as first manifestation of heparin induced thrombocytopenia (HIT) without thrombocytopenia

Authors: Marc Zoller, Iskandar Atmowihardjo, Jeanette Huch, Ines Albrecht, Dirk Habedank

Published in: BMC Cardiovascular Disorders | Issue 1/2021

Abstract

Background

Thrombosis resulting from heparin-induced thrombocytopenia (HIT) occurs in about 2% of patients without a significant decrease in platelet counts. We report on such a near fatal thrombotic event caused by coronary intervention.

Case presentation

A supposedly “completely healthy” 53-year-old patient was admitted to hospital with covered rupture of an aneurysm of the Aorta descendens. He was successfully operated on and underwent coronary angiography due to NSTEMI six days later. Immediately after intervention of a 90% RCX stenosis he developed ventricular flutter, was defibrillated, and re-angiography showed partial occlusion of the RCX stent. Lots of white thrombi could be retrieved by aspiration catheter and gave reason for a HIT without thrombocytopenia. The detection of platelet factor 4/heparin complex antibodies by immunoassay supported and the subsequent Heparin Induced Platelet Activation Assay proved this diagnosis.

Conclusions

The clinical event of an acute stent thrombosis should alarm the interventional team to the diagnosis of HIT even with a normal platelet count.

Greinacher A. Heparin-induced thrombocytopenia. N Engl J Med. 2015;373(3):252–61.CrossRef

Selleng S, Malowsky B, Strobel U, Wessel A, Ittermann T, Wollert H-G, Warkentin TE, Greinacher A. Early-onset and persisting thrombocytopenia in post-cardiac surgery patients is rarely due to heparin-induced thrombocytopenia even, when antibody tests are positive. J Thromb Haemost. 2010;8(1):30–6.CrossRef

Oikonomou EK, Repanas TI, Papanastasiou C, Kokkinidis DG, Miligkos M, Feher A, Gupta D, Kampaktsis PN. The effect of in-hospital acquired thrombocytopenia on the outcome of patients with acute coronary syndromes: A systematic review and meta-analysis. Thromb Res. 2016;147:64–71.CrossRef

Stoll F, Gödde M, Leo A, Katus HA, Müller OJ. Characterization of hospitalized cardiovascular patients with suspected heparin-induced thrombocytopenia. Clin Cardiol. 2018;41(12):1521–6.CrossRef

Greinacher A, Juhl D, Strobel U, Wessel A, Lubenow N, Selleng K, Eichler P, Warkentin TE. Heparin-induced thrombocytopenia: a prospective study on the incidence, platelet-activating capacity and clinical significance of antiplatelet factor 4/heparin antibodies of the IgG, IgM, and IgA classes. J Thromb Haemost. 2007;5(8):1666–73.CrossRef

Hermanns B, Janssens U, Handt S, Füzesi L. Pathomorphological aspects of heparin-induced thrombocytopenia II (HIT-II syndrome). Virchows Arch. 1998;432(6):541.CrossRef

Okamoto H, Kume T, Fukuhara K, Kobayashi Y, Kawamura A, Goryo Y, Koyama T, Tamada T, Yamada R, Imai K, Neishi Y, Uemura S. Optical coherence tomography findings in early stent thrombosis by heparin-induced thrombocytopenia. Int Heart J. 2016;57(6):763–5.CrossRef

Dai J, Madeeva D, Hayes V, Ahn HS, Tutwiler V, Arepally GM, Cines DB, Poncz M, Rauova L. Dynamic intercellular redistribution of HIT antigen modulates heparin-induced thrombocytopenia. Blood. 2018;132(7):727–34.CrossRef

Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis. Blood. 2005;106(8):2710–5.CrossRef

10.

Warkentin TE, Sheppard JA, Horsewood P, Simpson PJ, Moore JC, Kelton JG. Impact of the patient population on the risk for heparin-induced thrombocytopenia. Blood. 2000;96(5):1703–8.CrossRef

11.

Warkentin TE, Kelton JG. A 14-year study of heparin-induced thrombocytopenia. Am J Med. 1996;101(5):502–7.CrossRef

12.

Almeqdadi M, Aoun J, Carrozza J. Native coronary artery thrombosis in the setting of heparin-induced thrombocytopenia: a case report. Eur Heart J Case Rep. 2018;2(1):138.

13.

Warkentin TE, Kelton JG. Temporal aspects of heparin-induced thrombocytopenia. N Engl J Med. 2001;344(17):1286–92.CrossRef

14.

Voudris V, Georgiadou P, Kalogris P, Kostelidou T, Karabinis A, Gerotziafas G. Missed heparin-induced thrombocytopenia (HIT) diagnosis in a patient with acute stent thrombosis. Am J Case Rep. 2019;20:753–7.CrossRef

15.

Mele M, Iacoviello M, Casavecchia G, Tricarico L, Brunetti ND. Coronary thrombosis due to heparin-induced thrombocytopenia after percutaneous coronary intervention: easy to miss, uneasy to prevent. Clin Case Rep. 2020;9(1):90–2.CrossRef

16.

Souteyrand G, Amabile N, Mangin L, Chabin X, Meneveau N, Cayla G, Vanzetto G, Barnay P, Trouillet C, Rioufol G, Rangé G, Teiger E, Delaunay R, Dubreuil O, Lhermusier T, Mulliez A, Levesque S, Belle L, Caussin C, Motreff P. Mechanisms of stent thrombosis analysed by optical coherence tomography: insights from the national PESTO French registry. Eur Heart J. 2016;37(15):1208–16.CrossRef

17.

Rauova L, Zhai L, Anna Kowalska M, Arepally GM, Cines DB, Poncz M. Role of platelet surface PF4 antigenic complexes in heparin-induced thrombocytopenia pathogenesis: diagnostic and therapeutic implications. Blood. 2006;107(6):2346–53.CrossRef

18.

Farner B, Kroll H, Kohlmann T, Warkentin TE, Eichler P, Greinacher A. Clinical features of heparin-induced thrombocytopenia including risk factors for thrombosis. Thromb Haemost. 2005;94(07):132–5.CrossRef

19.

Cuker A, Arepally G, Crowther MA, Rice L, Datko F, Hook K, Propert KJ, Kuter DJ, Ortel TL, Konkle BA, Cines DB. The HIT expert probability (HEP) score: a novel pre-test probability model for heparin-induced thrombocytopenia based on broad expert opinion. J Thromb Haemost. 2010;8(12):2642–50.CrossRef

Title: Near fatal stent thrombosis in an aneurysmatic RCX as first manifestation of heparin induced thrombocytopenia (HIT) without thrombocytopenia
Authors: Marc Zoller
Iskandar Atmowihardjo
Jeanette Huch
Ines Albrecht
Dirk Habedank
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Ventricular Flutter
Angiography
Aneurysm
Aneurysm
Thrombocytopenia
Thrombosis
Heparin
Heparin-Induced Thrombocytopenia
Published in: BMC Cardiovascular Disorders / Issue 1/2021
Electronic ISSN: 1471-2261
DOI: https://doi.org/10.1186/s12872-021-02442-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Near fatal stent thrombosis in an aneurysmatic RCX as first manifestation of heparin induced thrombocytopenia (HIT) without thrombocytopenia

Abstract

Background

Case presentation

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Case presentation

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2021

Independent and joint effects of high-sensitivity c-reactive protein and hypoalbuminemia on long-term all-cause mortality among coronary artery disease: a prospective and multicenter cohort study

Correction to: Adherence to prescription guidelines and achievement of treatment goals among persons with coronary heart disease in Tromsø 7

Increased ratio of sST2/LVMI predicted cardiovascular mortality and heart failure rehospitalization in heart failure with reduced ejection fraction patients: a prospective cohort study

Chronotherapy for morning blood pressure surge in hypertensive patients: a systematic review and meta-analysis

Hemodynamic change in patients with hypertrophic obstructive cardiomyopathy before and after alcohol septal ablation using 4D flow magnetic resonance imaging: a retrospective observational study

Association of atrial arrhythmias with thrombospondin-1 in patients with acute myocardial infarction