{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,21]],"date-time":"2026-10-21T14:58:57Z","timestamp":1792594737828,"version":"4.5.0"},"reference-count":47,"publisher":"American Society of Hematology","issue":"1","content-domain":{"domain":["ashpublications.org"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2024,12,6]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:p>Although heparin-induced thrombocytopenia (HIT) presents management challenges for any population, it adds complexity to the management of certain patient populations, including those undergoing cardiac surgery and those with refractory HIT and\/or acute bleeding. For each of these scenarios, we review alternative management strategies when standard therapies\u2014heparin cessation and the initiation of a nonheparin anticoagulant\u2014are either insufficient or not practicable. In patients with HIT undergoing cardiac surgery, we review the clinical experience for heparin reexposure using therapeutic plasma exchange (TPE) or antiplatelet therapy. In patients with refractory HIT despite adequate nonheparin anticoagulation, we address the use of intravenous immune globulin, TPE, and rituximab. Finally, in patients with active bleeding, we discuss bleeding management and the risks associated with platelet transfusion. Although they may facilitate a patient-centered approach, most of these strategies are supported by limited evidence.<\/jats:p>","DOI":"10.1182\/hematology.2024000564","type":"journal-article","created":{"date-parts":[[2024,12,6]],"date-time":"2024-12-06T15:04:10Z","timestamp":1733497450000},"page":"396-402","update-policy":"https:\/\/doi.org\/10.1182\/blood.2019cm0000","source":"Crossref","is-referenced-by-count":6,"title":["Approaches to management of HIT in complex scenarios, including cardiac surgery"],"prefix":"10.1182","volume":"2024","author":[{"given":"Oluwatayo","family":"Adeoye","sequence":"first","affiliation":[{"name":"1 Department of Medicine, St Elizabeth's Medical Center, Boston, MA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Guoliang","family":"Zheng","sequence":"additional","affiliation":[{"name":"2 Division of Hematology, Department of Medicine, Virginia Commonwealth University Health, Richmond, VA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oluwatoyosi A.","family":"Onwuemene","sequence":"additional","affiliation":[{"name":"3 Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"234","published-online":{"date-parts":[[2024,12,6]]},"reference":[{"issue":"4","key":"2024121115504829800_hem2024000564C1","doi-asserted-by":"crossref","first-page":"759","DOI":"10.1111\/j.1538-7836.2006.01787.x","article-title":"Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings","volume":"4","author":"Lo","year":"2006","journal-title":"J Thromb Haemost"},{"issue":"11","key":"2024121115504829800_hem2024000564C2","doi-asserted-by":"crossref","first-page":"4150","DOI":"10.1053\/j.jvca.2022.06.021","article-title":"Heparin resistance during cardiopulmonary bypass in adult cardiac surgery","volume":"36","author":"Chen","year":"2022","journal-title":"J Cardiothorac Vasc Anesth"},{"issue":"2","key":"2024121115504829800_hem2024000564C3","doi-asserted-by":"crossref","first-page":"232","DOI":"10.1016\/S1010-7940(01)01099-5","article-title":"Cardiopulmonary bypass induced inflammation: pathophysiology and treatment. An update","volume":"21","author":"Paparella","year":"2002","journal-title":"Eur J Cardiothorac Surg"},{"issue":"1","key":"2024121115504829800_hem2024000564C4","doi-asserted-by":"crossref","first-page":"536","DOI":"10.1182\/hematology.2021000289","article-title":"Heparin-induced thrombocytopenia and cardiovascular surgery","volume":"2021","author":"Pishko","year":"2021","journal-title":"Hematology Am Soc Hematol Educ Program"},{"issue":"1","key":"2024121115504829800_hem2024000564C5","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1161\/ATVBAHA.120.315445","article-title":"Heparin-induced thrombocytopenia: a focus on thrombosis","volume":"41","author":"Arepally","year":"2021","journal-title":"Arterioscler Thromb Vasc Biol"},{"issue":"20","key":"2024121115504829800_hem2024000564C6","doi-asserted-by":"crossref","first-page":"5184","DOI":"10.1182\/bloodadvances.2020002963","article-title":"Management of heparin-induced thrombocytopenia: systematic reviews and meta-analyses","volume":"4","author":"Morgan","year":"2020","journal-title":"Blood Adv"},{"issue":"7","key":"2024121115504829800_hem2024000564C7","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1056\/NEJM200008173430718","article-title":"Use of heparin during cardiopulmonary bypass in patients with a history of heparin-induced thrombocytopenia","volume":"343","author":"P\u00f6tzsch","year":"2000","journal-title":"N. Engl. J. Med"},{"issue":"16","key":"2024121115504829800_hem2024000564C8","doi-asserted-by":"crossref","first-page":"2485","DOI":"10.1182\/blood-2013-10-533083","article-title":"Serological investigation of patients with a previous history of heparin-induced thrombocytopenia who are reexposed to heparin","volume":"123","author":"Warkentin","year":"2014","journal-title":"Blood"},{"issue":"5","key":"2024121115504829800_hem2024000564C9","doi-asserted-by":"crossref","first-page":"787","DOI":"10.1016\/0003-4975(92)91437-E","article-title":"Heparin-induced thrombocytopenia in open heart surgical patients: sequelae of late recognition","volume":"53","author":"Walls","year":"1992","journal-title":"Ann Thorac Surg"},{"issue":"2","key":"2024121115504829800_hem2024000564C10","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1016\/j.athoracsur.2006.09.038","article-title":"Bivalirudin during cardiopulmonary bypass in patients with previous or acute heparin-induced thrombocytopenia and heparin antibodies: results of the CHOOSE-ON trial","volume":"83","author":"Koster","year":"2007","journal-title":"Ann Thorac Surg"},{"issue":"3","key":"2024121115504829800_hem2024000564C11","doi-asserted-by":"crossref","first-page":"836","DOI":"10.1016\/j.athoracsur.2007.04.007","article-title":"Off-pump coronary artery bypass with bivalirudin for patients with heparin-induced thrombocytopenia or antiplatelet factor four\/heparin antibodies","volume":"84","author":"Dyke","year":"2007","journal-title":"Ann Thorac Surg"},{"issue":"1","key":"2024121115504829800_hem2024000564C12","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1213\/ANE.0b013e3181c3c1cd","article-title":"Plasmapheresis and heparin reexposure as a management strategy for cardiac surgical patients with heparin-induced thrombocytopenia","volume":"110","author":"Welsby","year":"2010","journal-title":"Anesth Analg"},{"issue":"2","key":"2024121115504829800_hem2024000564C13","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1111\/vox.13008","article-title":"Clinical outcomes of cardiac surgery patients undergoing therapeutic plasma exchange for heparin-induced thrombocytopenia","volume":"116","author":"Moreno-Duarte","year":"2021","journal-title":"Vox Sang"},{"issue":"7","key":"2024121115504829800_hem2024000564C14","doi-asserted-by":"crossref","first-page":"608","DOI":"10.1002\/ajh.24017","article-title":"Perioperative use of iloprost in cardiac surgery patients diagnosed with heparin-induced thrombocytopenia-reactive antibodies or with true HIT (HIT-reactive antibodies plus thrombocytopenia): an 11-year experience","volume":"90","author":"Palatianos","year":"2015","journal-title":"Am J Hematol"},{"issue":"4","key":"2024121115504829800_hem2024000564C15","doi-asserted-by":"crossref","first-page":"763","DOI":"10.1053\/j.semtcvs.2019.10.002","article-title":"Novel use of cangrelor with heparin during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia who require cardiovascular surgery: a case series","volume":"32","author":"Gernhofer","year":"2020","journal-title":"Semin Thorac Cardiovasc Surg"},{"issue":"1","key":"2024121115504829800_hem2024000564C16","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1016\/j.athoracsur.2017.06.031","article-title":"Abciximab\/heparin therapy for left ventricular assist device implantation in patients with heparin-induced thrombocytopenia","volume":"105","author":"Lee","year":"2018","journal-title":"Ann Thorac Surg"},{"issue":"6","key":"2024121115504829800_hem2024000564C17","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1177\/026765910001500610","article-title":"Use of danaparoid sodium (Orgaran) as an alternative to heparin sodium during cardiopulmonary bypass: a clinical evaluation of six cases","volume":"15","author":"Fernandes","year":"2000","journal-title":"Perfusion"},{"issue":"3","key":"2024121115504829800_hem2024000564C18","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1053\/cr.2000.5861","article-title":"Recombinant hirudin as an alternative for anticoagulation during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II: a 1-year experience in 57 patients","volume":"14","author":"Koster","year":"2000","journal-title":"J Cardiothorac Vasc Anesth"},{"issue":"5","key":"2024121115504829800_hem2024000564C19","doi-asserted-by":"crossref","first-page":"1622","DOI":"10.1016\/S0003-4975(02)04782-3","article-title":"Successful use of argatroban as a heparin substitute during cardiopulmonary bypass: heparin-induced thrombocytopenia in a high-risk cardiac surgical patient","volume":"75","author":"Edwards","year":"2003","journal-title":"Ann Thorac Surg"},{"issue":"1","key":"2024121115504829800_hem2024000564C20","doi-asserted-by":"crossref","first-page":"106","DOI":"10.4103\/0970-9185.92458","article-title":"Challenges encountered with argatroban anticoagulation during cardiopulmonary bypass","volume":"28","author":"Agarwal","year":"2012","journal-title":"J Anaesthesiol Clin Pharmacol"},{"issue":"4","key":"2024121115504829800_hem2024000564C21","doi-asserted-by":"crossref","first-page":"592","DOI":"10.1510\/icvts.2009.215848","article-title":"Argatroban as a substitute of heparin during cardiopulmonary bypass: a safe alternative?","volume":"10","author":"Follis","year":"2010","journal-title":"Interact Cardiovasc Thorac Surg"},{"issue":"5","key":"2024121115504829800_hem2024000564C22","first-page":"1180","article-title":"Survey of practice pattern in patients with heparin-induced thrombocytopenia requiring cardiopulmonary bypass","volume":"133","author":"Wanat-Hawthorne","year":"2021","journal-title":"Anesth Analg"},{"issue":"3","key":"2024121115504829800_hem2024000564C23","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1016\/j.jtcvs.2005.09.057","article-title":"A comparison of bivalirudin to heparin with protamine reversal in patients undergoing cardiac surgery with cardiopulmonary bypass: the evolution-on study","volume":"131","author":"Dyke","year":"2006","journal-title":"J Thorac Cardiovasc Surg"},{"issue":"3","key":"2024121115504829800_hem2024000564C24","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1182\/blood-2016-01-635003","article-title":"How I treat patients with a history of heparin-induced thrombocytopenia","volume":"128","author":"Warkentin","year":"2016","journal-title":"Blood"},{"issue":"1","key":"2024121115504829800_hem2024000564C25","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1182\/blood-2014-07-590844","article-title":"Plasma exchange to remove HIT antibodies: dissociation between enzyme-immunoassay and platelet activation test reactivities","volume":"125","author":"Warkentin","year":"2015","journal-title":"Blood"},{"issue":"2","key":"2024121115504829800_hem2024000564C26","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1002\/jca.22043","article-title":"Guidelines on the use of therapeutic apheresis in clinical practice\u2014evidence-based approach from the Writing Committee of the American Society for Apheresis: the ninth special issue","volume":"38","author":"Connelly-Smith","year":"2023","journal-title":"J Clin Apher"},{"issue":"5","key":"2024121115504829800_hem2024000564C27","doi-asserted-by":"crossref","first-page":"545","DOI":"10.1002\/jca.21709","article-title":"Therapeutic plasma exchange for management of heparin-induced thrombocytopenia: results of an international practice survey","volume":"34","author":"Onwuemene","year":"2019","journal-title":"J Clin Apher"},{"issue":"11","key":"2024121115504829800_hem2024000564C28","doi-asserted-by":"crossref","first-page":"2714","DOI":"10.1111\/trf.16018","article-title":"Therapeutic plasma exchange and intravenous immune globulin in the treatment of heparin-induced thrombocytopenia: a systematic review","volume":"60","author":"Onuoha","year":"2020","journal-title":"Transfusion"},{"issue":"6","key":"2024121115504829800_hem2024000564C29","doi-asserted-by":"crossref","first-page":"1254","DOI":"10.1067\/mtc.2001.118271","article-title":"One-year experience with the platelet glycoprotein IIb\/IIIa antagonist tirofiban and heparin during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II","volume":"122","author":"Koster","year":"2001","journal-title":"J Thorac Cardiovasc Surg"},{"issue":"8","key":"2024121115504829800_hem2024000564C30","doi-asserted-by":"crossref","first-page":"730","DOI":"10.1002\/ajh.24759","article-title":"Clinical outcomes in a cohort of patients with heparin-induced thrombocytopenia","volume":"92","author":"Kuter","year":"2017","journal-title":"Am J Hematol"},{"issue":"21","key":"2024121115504829800_hem2024000564C31","doi-asserted-by":"crossref","first-page":"6921","DOI":"10.3390\/jcm12216921","article-title":"Autoimmune heparin-induced thrombocytopenia","volume":"12","author":"Warkentin","year":"2023","journal-title":"J Clin Med"},{"issue":"3","key":"2024121115504829800_hem2024000564C32","doi-asserted-by":"crossref","first-page":"478","DOI":"10.1016\/j.chest.2017.03.050","article-title":"IVIg for treatment of severe refractory heparin-induced thrombocytopenia","volume":"152","author":"Padmanabhan","year":"2017","journal-title":"Chest"},{"issue":"16","key":"2024121115504829800_hem2024000564C33","doi-asserted-by":"crossref","first-page":"3716","DOI":"10.1182\/blood-2008-09-179754","article-title":"Specificity and affinity of human Fcgamma receptors and their polymorphic variants for human IgG subclasses","volume":"113","author":"Bruhns","year":"2009","journal-title":"Blood"},{"issue":"8","key":"2024121115504829800_hem2024000564C34","doi-asserted-by":"crossref","first-page":"685","DOI":"10.1080\/17474086.2019.1636645","article-title":"High-dose intravenous immunoglobulin for the treatment and prevention of heparin-induced thrombocytopenia: a review","volume":"12","author":"Warkentin","year":"2019","journal-title":"Expert Rev Hematol"},{"issue":"4","key":"2024121115504829800_hem2024000564C35","doi-asserted-by":"crossref","first-page":"525","DOI":"10.1016\/j.transci.2019.06.030","article-title":"Inpatient management strategies in a severe case of heparin-induced thrombocytopenia","volume":"58","author":"Shmookler","year":"2019","journal-title":"Transfus Apher Sci"},{"issue":"6","key":"2024121115504829800_hem2024000564C36","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1182\/blood-2017-08-803031","article-title":"Normal plasma IgG inhibits HIT antibody-mediated platelet activation: implications for therapeutic plasma exchange","volume":"131","author":"Jones","year":"2018","journal-title":"Blood"},{"issue":"5","key":"2024121115504829800_hem2024000564C37","doi-asserted-by":"crossref","first-page":"e44","DOI":"10.1111\/bjh.17917","article-title":"Therapeutic plasma exchange in severe refractory autoimmune heparin-induced thrombocytopenia with thrombosis","volume":"196","author":"Bavli","year":"2022","journal-title":"Br J Haematol"},{"issue":"suppl 1","key":"2024121115504829800_hem2024000564C38","doi-asserted-by":"crossref","first-page":"11339","DOI":"10.1182\/blood-2022-170542","article-title":"Rituximab in the treatment of refractory heparin induced thrombocytopenia","volume":"140","author":"Batra","year":"2022","journal-title":"Blood"},{"issue":"2","key":"2024121115504829800_hem2024000564C39","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1016\/j.transci.2013.01.007","article-title":"Refractory heparin induced thrombocytopenia with thrombosis (HITT) treated with therapeutic plasma exchange and rituximab as adjuvant therapy","volume":"49","author":"Schell","year":"2013","journal-title":"Transfus Apher Sci"},{"issue":"15","key":"2024121115504829800_hem2024000564C40","doi-asserted-by":"crossref","first-page":"4112","DOI":"10.1182\/bloodadvances.2023009661","article-title":"Treatment of thrombocytopenia and thrombosis in HIT in mice using deglycosylated KKO: a novel therapeutic?","volume":"7","author":"Sarkar","year":"2023","journal-title":"Blood Adv"},{"issue":"10","key":"2024121115504829800_hem2024000564C41","doi-asserted-by":"crossref","first-page":"2209","DOI":"10.1182\/blood-2011-11-376293","article-title":"How I treat heparin-induced thrombocytopenia","volume":"119","author":"Cuker","year":"2012","journal-title":"Blood"},{"issue":"9","key":"2024121115504829800_hem2024000564C42","doi-asserted-by":"crossref","first-page":"1470","DOI":"10.1182\/blood-2014-10-605493","article-title":"Platelet transfusions in platelet consumptive disorders are associated with arterial thrombosis and in-hospital mortality","volume":"125","author":"Goel","year":"2015","journal-title":"Blood"},{"issue":"11","key":"2024121115504829800_hem2024000564C43","doi-asserted-by":"crossref","first-page":"1956","DOI":"10.1111\/jth.14587","article-title":"The risk of major bleeding in patients with suspected heparin-induced thrombocytopenia","volume":"17","author":"Pishko","year":"2019","journal-title":"J Thromb Haemost"},{"issue":"6","key":"2024121115504829800_hem2024000564C44","doi-asserted-by":"crossref","first-page":"1419","DOI":"10.1111\/j.1538-7836.2010.03861.x","article-title":"Outcomes after platelet transfusion in patients with heparin-induced thrombocytopenia","volume":"8","author":"Refaai","year":"2010","journal-title":"J Thromb Haemost"},{"issue":"10","key":"2024121115504829800_hem2024000564C45","doi-asserted-by":"crossref","first-page":"2128","DOI":"10.1111\/j.1537-2995.2008.01822.x","article-title":"Platelet transfusions in heparin-induced thrombocytopenia: a report of four cases and review of the literature","volume":"48","author":"Hopkins","year":"2008","journal-title":"Transfusion"},{"key":"2024121115504829800_hem2024000564C46","doi-asserted-by":"crossref","first-page":"S490","DOI":"10.14309\/00000434-201310001-01634","article-title":"Mortality in acute upper gastrointestinal bleeding is uncommonly due to persistent hemorrhage: 1634","volume":"108","author":"Chason","year":"2013","journal-title":"Am J Gastroenterol"},{"issue":"8","key":"2024121115504829800_hem2024000564C47","doi-asserted-by":"crossref","first-page":"1038","DOI":"10.1016\/j.healun.2018.04.016","article-title":"Plasma exchange to remove heparin-induced thrombocytopenia antibodies and the use of heparin during cardiopulmonary bypass in critically ill cardiac patients","volume":"37","author":"Ramu","year":"2018","journal-title":"J Heart Lung Transplant"}],"container-title":["Hematology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/ashpublications.org\/hematology\/article-pdf\/2024\/1\/396\/2346516\/396adeoye.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/ashpublications.org\/hematology\/article-pdf\/2024\/1\/396\/2346516\/396adeoye.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,12,11]],"date-time":"2024-12-11T20:21:00Z","timestamp":1733948460000},"score":1,"resource":{"primary":{"URL":"https:\/\/ashpublications.org\/hematology\/article\/2024\/1\/396\/526209\/Approaches-to-management-of-HIT-in-complex"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,6]]},"references-count":47,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2024,12,6]]},"published-print":{"date-parts":[[2024,12,6]]}},"URL":"https:\/\/doi.org\/10.1182\/hematology.2024000564","relation":{},"ISSN":["1520-4391","1520-4383"],"issn-type":[{"value":"1520-4391","type":"print"},{"value":"1520-4383","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2024,12,6]]},"published":{"date-parts":[[2024,12,6]]}}}