The use of direct thrombin inhibitors in cardiovascular surgery in patients with heparin-induced thrombocytopenia
The use of direct thrombin inhibitors in cardiovascular surgery in patients with heparin-induced thrombocytopenia
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DOI：
10.1055/s-2004-831044
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发表时间：
2004-06-01
影响因子：
5.7
通讯作者：
Greinacher, A
中科院分区：
文献类型：
--
作者：
Greinacher, A
医生遇到的最重要的不良反应之一是危及生命和肢体的血栓前综合征，即肝素诱导的血小板减少症(HIT)。普通肝素(UFH)在体外循环(CPB)期间使用，具有高度的免疫原性。在接受UFH治疗的心脏手术患者中，25%到50%的人可以在5到10天内产生肝素依赖抗体。这些抗体可以激活血小板，被认为是HIT的病原体。HIT是一种相对常见的并发症，发生在1-3%的心血管手术患者术后继续使用UFH时。它与导致截肢和死亡的新的血栓栓塞性事件密切相关。在急性或近期(100天)发作时，CPB手术期间需要替代抗凝方案以预防HLT相关的血栓形成。此类患者现在的治疗选择一般包括使用替代抗凝剂，如来皮鲁丁、比伐卢定或达那普利，以及与血小板功能抑制剂和肝素的联合治疗。在有HIT病史且未检测到抗体的患者中，肝素是目前CPB期间大剂量抗凝最安全的方法。然而，在手术前后，应该使用替代的抗凝剂。心脏手术后使用低分子肝素用于术后抗凝，可能会降低临床打击的风险。
One of the most important adverse drug reactions that physicians encounter is the life- and limb-threatening prothrombotic syndrome known as heparin-induced thrombocytopenia (HIT). Unfractionated heparin (UFH), administered during cardiopulmonary bypass (CPB), is highly immunogenic. Heparin-dependent antibodies can develop in 25 to 50% of UFH-treated cardiac surgery patients within 5 to 10 days. These antibodies can activate platelets and are considered the causative agents of HIT. HIT is a relatively common complication, occurring in 1 to 3% of cardiovascular surgery patients when UFH administration is continued postoperatively. It is strongly associated with new thromboembolic events leading to limb amputation and death. In acute or recent (< 100 days) HIT, alternative anticoagulatory regimens are needed during CPB surgery for prevention of HlT-related thrombosis. Treatment options for such patients now generally include the use of alternative anticoagulants such as lepirudin, bivalirudin, or danaparoid, as wen as a combined treatment with platelet- function inhibitors and heparin. In patients with a history of HIT and no detectable antibodies, heparin is currently the safest approach for high-dose anticoagulation during CPB. Before and after surgery, however, alternative anticoagulants should be used. The risk of clinical HIT after heart surgery could potentially be reduced by using low-molecular-weight heparins for postsurgery anti coagulation.