This protocol covers patients with acute HIT or subacute HIT A who have a concurrent requirement for cardiovascular surgery — a situation where the standard approach of deferring surgery may not be possible.
When feasible, deferring surgery until the patient has reached a later phase of HIT is the preferred path. The protocol below applies specifically to those cases where deferral is not feasible and surgery must proceed during active or recent HIT.
When surgery cannot wait, the guideline identifies specific intraoperative anticoagulation strategies as alternatives to standard anticoagulation — including at least one approach that avoids heparin entirely. The full protocol details which strategy applies and under what conditions.
In patients with acute HIT or subacute HIT A who require cardiovascular surgery, the ASH guideline panel agrees that surgery should be delayed until the patient has subacute HIT B or remote HIT (see recommendation 4.2), if feasible.
If delaying surgery is not feasible, the ASH guideline panel suggests one of the following: intraoperative anticoagulation with bivalirudin, intraoperative heparin after treatment with preoperative and/or intraoperative plasma exchange, or intraoperative heparin in combination with a potent antiplatelet agent (eg, prostacyclin analog or tirofiban) (conditional recommendation, low certainty in the evidence about effects).
DOI: 10.1182/bloodadvances.2018024489
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