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T Kostelidou MD1, T Kanellopoulou MD1, M Stratinaki MD2, G Soufla1, E Iliopoulou1,

S Georgantis1, S Adamopoulos MD3

1Division of Thrombosis and Hemostasis, Onassis Cardiac Surgery Center, Athens Greece

2 Division of Interventional Cardiology, Onassis Cardiac Surgery Center, Athens Greece

3 Department of Cardiac Failure, Onassis Cardiac Surgery Center, Athens Greece

Background: A 52-year-old woman with DCM was admitted for heart failure decompensation and
electrical storm arrhythmia and was treated with LMWH. An immunizing UFH exposure six months
earlier was reported. A week after admission, a low anti HIT titer was observed in laboratory
testing, with 4T score 2, and enoxaparin was replaced with fondaparinux. Despite the absence of
infection, the HIT-ab titer increased progressively and HIT diagnosis was made. The deterioration of
her clinical conditions imposed an urgent solution: L-VAD implantation while waiting for a heart
transplant. Because of the high intraoperative hemorrhagic risk of Bivalirudin, the recommended
anticoagulating agent to be used, the decision for an alternative solution to the patient’s clinical
management and the intraoperative use of UFH was made.

Materials and Methods: HIT testing was performed by three different methods: a) an
immunoassay: ELISA (IgG) – (Asserachrom HPIA-IgG), b) an automated assay (LIA),HemosIL® HIT
Ab(PF4\\H), I.L), c) a functional assay, Heparin Induced-Platelet Aggregation Assay (HIPA).The
patient was treated with IV-IG and Plasma Exchange. A heart transplant became available and high
dose UFH was administered during the extracorporeal circulation. After transplantation, the patient
has never been exposed to UFH or LMWH.

Results: Initial HIT testing: ELISA (IgG): OD 2,020 (ref. OD 0,231 ), HemosIL: 6,0 U/ml , HIPA assay:
negative. After the last course of IVIG and Plasma Exchange, just before the heart transplantation
ELISA (IgG) titer was : OD 0,248 (ref. OD 0,267 ). A week after transplantation the ELISA (IgG) titer was : OD 0,721
(ref. OD 0,218 ) and in day +50 the titer was: ELISA (IgG): OD 0,336 (ref. OD 0,187), HemosIL: 0,4 U/ml , HIPA
assay: negative.

Conclusions: The presence of HIT syndrome could complicate heart transplantation and condemn
it to a poor outcome. The use of Plasma Exchange combined with IVIG is a challenging and
effective treatment to manage this clinical situation, leading to a successful transplantation.