• 中國醫(yī)學(xué)科學(xué)院北京協(xié)和醫(yī)學(xué)院　阜外心血管病醫(yī)院　心血管病研究所　體外循環(huán)科，北京　100037;

肝素誘導(dǎo)的血小板減少癥患者預(yù)后差，病死率高，大大增加了體外循環(huán)手術(shù)的風(fēng)險。對其早期診斷和選擇一種安全有效的藥物替代肝素抗凝是這類患者接受體外循環(huán)手術(shù)的關(guān)鍵。我們對肝素誘導(dǎo)的血小板減少癥發(fā)病機(jī)制、實驗室檢查、診斷以及體外循環(huán)抗凝管理進(jìn)行綜述。

引用本文： 周伯頤,龍村. 肝素誘導(dǎo)的血小板減少癥患者體外循環(huán)抗凝管理. 中國胸心血管外科臨床雜志, 2012, 19(5): 559-562. doi: 復(fù)制

1. duced thrombocytopenia in a high-risk cardiac surgical patient. Ann Thorac Surg, 2003, 75 （5）：1622-1624.
2. cardiopulmonary bypass surgery in a patient with heparin-induced thrombocytopenia. J Extra Corpor Technol, 2004, 36：174-177.
3. aggregation. J Thorac Cardiovasc Surg, 1984, 87 （5）：673-677.
4. 　Warkentin TE. Clinical presentation of heparin-induced thrombocytopenia. Semin Hematol, 1998, 35 （4 Suppl 5）：9-16.
5. 　Gurbuz AT, Elliott WG, Zia AA. Heparin-induced thrombocytopenia in the cardiovascular patient：diagnostic and treatment guidelines. Eur J Cardiothorac Surg, 2005, 27 （1）：138-149.
6. 　Hirsh J, Heddle N, Kelton JG, et al. Treatment of heparin-induced thrombocytopenia：a critical review. Arch Intern Med, 2004, 164：361-369.
7. 　Theodore E, Jo-Ann I, Jane C, et al. Laboratory testing for the antibodies that cause heparin-induced thrombocytopenia：how much do we need ? J Lab Clin Med, 2005, 146：341-346.
8. 　Greinacher A, Warkentin TE. Recognition, treatment, and prevention of heparin-induced thrombocytopenia：review and update. Thromb Res, 2006, 118 （2）：165-176.
9. 　Denys B, Devreese K. A clinical-laboratory approach contributing to a rapid and reliable diagnosis of heparin-induced thrombocytopenia：An update. Thromb Res, 2009, 124 （5）：642-643.
10. 　Warkentin TE. New approaches to the diagnosis of heparin-induced thrombocytopenia. Chest, 2005, 127 （2 Suppl）：35S-45S.
11. 　Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia：recognition, treatment, and prevention：the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 2004, 1263 （Suppl）：311S-337S.
12. 　Warkentin TE, Sheppard JA, Moore JC, et al. Laboratory testing for the antibodies that cause heparin-induced thrombocytopenia：how much class do we need ? J Lab Clin Med, 2005, 146 （6）：341-346.
13. 　Lo GK, Juhl D, Warkentin TE, et al. Evaluation of pretest clinical score （4Ts）for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost, 2006, 4 （4）：759-765.
14. 　Aouifi A, Blanc P, Piriou V, et al. Cardiac surgery with cardiopulmonary bypass in patients with type II heparin-induced thrombocytopenia. Ann Thorac Surg, 2001, 71 （2）：678-683.
15. 　Dyke CM, Smedira NG, Koster A, et al. A comparison of bivalirudin to heparin with protamine eversal in patients undergoing cardiac surgery with ardiopulmonary bypass：The EVOLUTION-ON study. J Thorac Cardiovasc Surg, 2006, 131 （3）：533-539.
16. 　Crespo EM, Oliveira GB, Honeycutt EF．Evaluation and management of thrombocytopenia and suspected heparin-induced thrombocytopenia in hospitalized patients：The Complications After Thrombocytopenia Caused by Heparin （CATCH） registry. Am Heart J, 2009, 157 （4）：651-657.
17. 　Koster A, Dyke CM, Aldea G, et al. Bivalirudin during cardiopulmonary bypass in patients with previous or acute heparin-induced thrombocytopenia and heparin antibodies：results of the CHOOSEON　trial. Ann Thorac Surg, 2007, 83 （2）：572-577.
18. 　Bucci C, Geerts WH, Sinclair A, et al. Comparison of the effectiveness and safety of low-molecular weight heparin versus unfractionated heparin anticoagulation after heart valve surgery. Am J Cardiol, 2011, 107 （4）：591-594.
19. 　Marion D, Marie TL. Heparin-induced thrombocytopenia and cardiopulmonary bypass：anticoagulation with unfractionated heparin and he GPIIb/Ⅲa inhibitor tiro?ban and successful use of rFⅦa for post-protamine bleeding due to ersistent platelet blockade. Eur J　Cardiothorac Surg, 2008, 34：687-689.
20. 　Furukawa K, Ohteki H, Hirahara K, et al. The use of argatroban as an anticoagulant for cardiopulmonary bypass in cardiac operations. J Thorac Cardiovasc Surg, 2001, 122 （6）：1255-1256.
21. 　Edwards JT, Hambly JK, Worrall NK. Successful use of argatroban as a heparin substitute during　cardiopulmonary bypass：Heparin-in.
22. 　Meuleman DG, Hobbelen PMJ, Van Dedem G, et al. A novel antithrombotic heparinoid （Org 10172） devoid of bleeding inducing capacity：A survey of pharmacological properties in experimental animal models. Thromb Res, 1982, 27 （3）：353-363.
23. 　Newman PM, Swansson RL, Chong BH. Heparin-induced thrombocytopenia：IgG binding to PF4-heparin complexes in the ?uid phase and cross-reactivity with low-molecular-weight heparin and heparinoid. Thromb Haemost, 1999, 80：292-297.
24. 　Grocott HP, Root J, Berkowitz SD, et al. Coagulation complicating cardiopulmonary bypass in a patient with heparin-induced thrombocytopenia receiving the heparinoid, danaparoid sodium. J Cardiothorac Vasc Anesth, 1997, 11 （7）：875-877.
25. 　Nuttall GA, Oliver WC, Santrach PJ, et al. Patients with a history of type II heparin-induced thrombocytopenia requiring cardiac surgery with cardiopulmonary bypass：A prospective observational case　series. Anesth Analg, 2003, 96 （2）：344-350.
26. 　Despotis GJ, Hogue CW, Saleem R, et al. The relationship between hirudin and activated clotting time：Implications for patients with heparin-induced thrombocytopenia undergoing cardiac surgery.Anesth Analg, 2001, 93 （1）：28-32.
27. 　Jabr K, Johnson JH, McDonald MH, et al. Plasma-modi?ed ACT can be used to monitor bivalirudin （Angiomax） anticoagulation for on-pump.
28. 　Poetzsch B, Madlener K. Management of cardiopulmonary bypass anticoagulation in patients with heparin-induced thrombocytopenia. In Warkentin TE, Greinacher A, Chief editor. Heparin-Induced Thrombocytopenia （ed 3）. New York：NY, Marcel Dekker, Inc, 2004. 531-551.
29. 　Greinacher A, Eichler P, Lubenow N. Anaphylactic reactions associated with lepirudin in patients with heparin-induced thrombocytopenia （HIT）. Circulation, 2003, 108：2062-2065.
30. 　Koster A, Chew D, Grundel M. An assessment of different ?lter systems for extracorporeal elimination of bivalirudin：An in vitro study. Anesth Analg, 2003, 96：1316-1319.
31. 　Koster A, Spiess B, Chew DP, et al. Effectiveness of bivalirudin as a replacement for heparin during　cardiopulmonary bypass in patients undergoing coronary artery bypass grafting. Am J Cardio, 2004, 93 （3）：356-359.
32. 　Olinger GN, Hussey CV, Olive JA, et al. Cardiopulmonary bypass for patients with previously documented heparin-induced platelet.
33. 　Antoniou T, Kapetanakis E, heodoraki K, et al. Cardiac surgery in patients with heparin-induced thrombocytopenia using preoperatively determined dosages of iloprost. Heart Surg Forum, 2002, 5 （4）：354-357.
34. 　Koster A, Kukucka M, Bach F, et al. Anticoagulation during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II and renal impairment using heparin and the platelet glycoprotein IIb/IIIa antagonist tiro?ban. Anesthesiology, 2001, 94：245-251.
35. 　Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia and cardiac surgery. Ann Thorac Surg, 2003, 76 （6）：2121-2131.
36. 　Warkentin TE, Greinacher A, Koster A, et al. Treatment and prevention of heparin-induced thrombocytopenia：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines （8th Edition）. Chest, 2008, 133 （6 Suppl）：340S-380S.
  1. 1. duced thrombocytopenia in a high-risk cardiac surgical patient. Ann Thorac Surg, 2003, 75 （5）：1622-1624.
  2. 2. cardiopulmonary bypass surgery in a patient with heparin-induced thrombocytopenia. J Extra Corpor Technol, 2004, 36：174-177.
  3. 3. aggregation. J Thorac Cardiovasc Surg, 1984, 87 （5）：673-677.
  4. 4. 　Warkentin TE. Clinical presentation of heparin-induced thrombocytopenia. Semin Hematol, 1998, 35 （4 Suppl 5）：9-16.
  5. 5. 　Gurbuz AT, Elliott WG, Zia AA. Heparin-induced thrombocytopenia in the cardiovascular patient：diagnostic and treatment guidelines. Eur J Cardiothorac Surg, 2005, 27 （1）：138-149.
  6. 6. 　Hirsh J, Heddle N, Kelton JG, et al. Treatment of heparin-induced thrombocytopenia：a critical review. Arch Intern Med, 2004, 164：361-369.
  7. 7. 　Theodore E, Jo-Ann I, Jane C, et al. Laboratory testing for the antibodies that cause heparin-induced thrombocytopenia：how much do we need ? J Lab Clin Med, 2005, 146：341-346.
  8. 8. 　Greinacher A, Warkentin TE. Recognition, treatment, and prevention of heparin-induced thrombocytopenia：review and update. Thromb Res, 2006, 118 （2）：165-176.
  9. 9. 　Denys B, Devreese K. A clinical-laboratory approach contributing to a rapid and reliable diagnosis of heparin-induced thrombocytopenia：An update. Thromb Res, 2009, 124 （5）：642-643.
  10. 10. 　Warkentin TE. New approaches to the diagnosis of heparin-induced thrombocytopenia. Chest, 2005, 127 （2 Suppl）：35S-45S.
  11. 11. 　Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia：recognition, treatment, and prevention：the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest, 2004, 1263 （Suppl）：311S-337S.
  12. 12. 　Warkentin TE, Sheppard JA, Moore JC, et al. Laboratory testing for the antibodies that cause heparin-induced thrombocytopenia：how much class do we need ? J Lab Clin Med, 2005, 146 （6）：341-346.
  13. 13. 　Lo GK, Juhl D, Warkentin TE, et al. Evaluation of pretest clinical score （4Ts）for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost, 2006, 4 （4）：759-765.
  14. 14. 　Aouifi A, Blanc P, Piriou V, et al. Cardiac surgery with cardiopulmonary bypass in patients with type II heparin-induced thrombocytopenia. Ann Thorac Surg, 2001, 71 （2）：678-683.
  15. 15. 　Dyke CM, Smedira NG, Koster A, et al. A comparison of bivalirudin to heparin with protamine eversal in patients undergoing cardiac surgery with ardiopulmonary bypass：The EVOLUTION-ON study. J Thorac Cardiovasc Surg, 2006, 131 （3）：533-539.
  16. 16. 　Crespo EM, Oliveira GB, Honeycutt EF．Evaluation and management of thrombocytopenia and suspected heparin-induced thrombocytopenia in hospitalized patients：The Complications After Thrombocytopenia Caused by Heparin （CATCH） registry. Am Heart J, 2009, 157 （4）：651-657.
  17. 17. 　Koster A, Dyke CM, Aldea G, et al. Bivalirudin during cardiopulmonary bypass in patients with previous or acute heparin-induced thrombocytopenia and heparin antibodies：results of the CHOOSEON　trial. Ann Thorac Surg, 2007, 83 （2）：572-577.
  18. 18. 　Bucci C, Geerts WH, Sinclair A, et al. Comparison of the effectiveness and safety of low-molecular weight heparin versus unfractionated heparin anticoagulation after heart valve surgery. Am J Cardiol, 2011, 107 （4）：591-594.
  19. 19. 　Marion D, Marie TL. Heparin-induced thrombocytopenia and cardiopulmonary bypass：anticoagulation with unfractionated heparin and he GPIIb/Ⅲa inhibitor tiro?ban and successful use of rFⅦa for post-protamine bleeding due to ersistent platelet blockade. Eur J　Cardiothorac Surg, 2008, 34：687-689.
  20. 20. 　Furukawa K, Ohteki H, Hirahara K, et al. The use of argatroban as an anticoagulant for cardiopulmonary bypass in cardiac operations. J Thorac Cardiovasc Surg, 2001, 122 （6）：1255-1256.
  21. 21. 　Edwards JT, Hambly JK, Worrall NK. Successful use of argatroban as a heparin substitute during　cardiopulmonary bypass：Heparin-in.
  22. 22. 　Meuleman DG, Hobbelen PMJ, Van Dedem G, et al. A novel antithrombotic heparinoid （Org 10172） devoid of bleeding inducing capacity：A survey of pharmacological properties in experimental animal models. Thromb Res, 1982, 27 （3）：353-363.
  23. 23. 　Newman PM, Swansson RL, Chong BH. Heparin-induced thrombocytopenia：IgG binding to PF4-heparin complexes in the ?uid phase and cross-reactivity with low-molecular-weight heparin and heparinoid. Thromb Haemost, 1999, 80：292-297.
  24. 24. 　Grocott HP, Root J, Berkowitz SD, et al. Coagulation complicating cardiopulmonary bypass in a patient with heparin-induced thrombocytopenia receiving the heparinoid, danaparoid sodium. J Cardiothorac Vasc Anesth, 1997, 11 （7）：875-877.
  25. 25. 　Nuttall GA, Oliver WC, Santrach PJ, et al. Patients with a history of type II heparin-induced thrombocytopenia requiring cardiac surgery with cardiopulmonary bypass：A prospective observational case　series. Anesth Analg, 2003, 96 （2）：344-350.
  26. 26. 　Despotis GJ, Hogue CW, Saleem R, et al. The relationship between hirudin and activated clotting time：Implications for patients with heparin-induced thrombocytopenia undergoing cardiac surgery.Anesth Analg, 2001, 93 （1）：28-32.
  27. 27. 　Jabr K, Johnson JH, McDonald MH, et al. Plasma-modi?ed ACT can be used to monitor bivalirudin （Angiomax） anticoagulation for on-pump.
  28. 28. 　Poetzsch B, Madlener K. Management of cardiopulmonary bypass anticoagulation in patients with heparin-induced thrombocytopenia. In Warkentin TE, Greinacher A, Chief editor. Heparin-Induced Thrombocytopenia （ed 3）. New York：NY, Marcel Dekker, Inc, 2004. 531-551.
  29. 29. 　Greinacher A, Eichler P, Lubenow N. Anaphylactic reactions associated with lepirudin in patients with heparin-induced thrombocytopenia （HIT）. Circulation, 2003, 108：2062-2065.
  30. 30. 　Koster A, Chew D, Grundel M. An assessment of different ?lter systems for extracorporeal elimination of bivalirudin：An in vitro study. Anesth Analg, 2003, 96：1316-1319.
  31. 31. 　Koster A, Spiess B, Chew DP, et al. Effectiveness of bivalirudin as a replacement for heparin during　cardiopulmonary bypass in patients undergoing coronary artery bypass grafting. Am J Cardio, 2004, 93 （3）：356-359.
  32. 32. 　Olinger GN, Hussey CV, Olive JA, et al. Cardiopulmonary bypass for patients with previously documented heparin-induced platelet.
  33. 33. 　Antoniou T, Kapetanakis E, heodoraki K, et al. Cardiac surgery in patients with heparin-induced thrombocytopenia using preoperatively determined dosages of iloprost. Heart Surg Forum, 2002, 5 （4）：354-357.
  34. 34. 　Koster A, Kukucka M, Bach F, et al. Anticoagulation during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II and renal impairment using heparin and the platelet glycoprotein IIb/IIIa antagonist tiro?ban. Anesthesiology, 2001, 94：245-251.
  35. 35. 　Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia and cardiac surgery. Ann Thorac Surg, 2003, 76 （6）：2121-2131.
  36. 36. 　Warkentin TE, Greinacher A, Koster A, et al. Treatment and prevention of heparin-induced thrombocytopenia：American College of Chest Physicians Evidence-Based Clinical Practice Guidelines （8th Edition）. Chest, 2008, 133 （6 Suppl）：340S-380S.