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CARDIOVASCULAR ANESTHESIOLOGY

The Incidence and Implications of Anti-Heparin-Platelet Factor 4 Antibody Formation in a Pediatric Cardiac Surgical Population

Mary P. Mullen, MD, PhD^*, David L. Wessel, MD^*, Kristen C. Thomas, MS, RN^*, Kimberlee Gauvreau, ScD^*, Ellis J. Neufeld, MD, PhD^*, Francis X. McGowan, Jr, MD^*, and James A. DiNardo, MD^*

From the *Children's Hospital Boston and Harvard Medical School, Harvard School of Public Health, Boston, Massachusetts.

Address correspondence and reprint requests to James A. DiNardo, MD, Department of Anesthesia, Children's Hospital Boston, 300 Longwood Ave., Boston, MA 02115. Address e-mail to james.dinardo{at}childrens.harvard.edu.

Abstract

BACKGROUND: The incidence and implications of anti-heparin-platelet factor 4 (PF4) antibody seroconversion in the pediatric cardiac surgical population remain largely unexplored. We sought to prospectively characterize the incidence of seroconversion in two populations: neonates undergoing primary cardiac surgery and children undergoing reoperative cardiac surgery with a history of unfractionated heparin (UFH) exposure.

METHODS: One hundred and thirty-five consecutive patients were studied: Neonatal = 60 neonates, first time cardiac surgery. Reoperative (ReOp) = 75 children, reoperative cardiac surgery. Preoperative and postoperative day (POD) 5 and 10 blood samples were used to determine the presence of PF4 immunoglobulin (Ig)G, IgA, and IgM antibodies with enzyme-linked immunosorbent assay.

RESULTS: No anti-heparin/PF4 antibodies were detected preoperatively in either group. On POD 5, antibodies were present in 1 of 60 (1.7%) Neonatal; and in 12 of 75 (16%) ReOp; P = 0.006. On POD 10, antibodies were present in 1 of 60 (1.7%) Neonatal; and in 39 of 75 (52%) ReOp; P < 0.001. Seroconversion in ReOp patients on POD 10 was significantly associated (P = 0.03) with previous UFH exposures. Heparin-induced thrombocytopenia (HIT) was not diagnosed in any Neonatal patients. One ReOp patient (1.3%) seroconverted and developed HIT without thrombosis or skin lesions.

CONCLUSIONS: HIT is a rare occurrence in pediatric cardiac surgical patients. The incidence of anti-heparin-PF4 antibody seroconversion in children undergoing reoperation is approximately 50% at 10 days postoperatively, a finding similar to that reported in adult cardiac surgical patients. Both age and previous UFH exposure correlate with this rate of seroconversion. In contrast, the rate of seroconversion in neonates undergoing first time surgery is substantially lower.

This article has been cited by other articles:

				A. Greinacher and J. H. Levy HIT Happens: Diagnosing and Evaluating the Patient with Heparin-Induced Thrombocytopenia Anesth. Analg., August 1, 2008; 107(2): 356 - 358. [Full Text] [PDF]

Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999