Management of heparin-induced thrombocytopenia in impella-supported cardiac surgery: A comprehensive four-patient case series with novel anticoagulation strategies

Abstract Background: Heparin-induced thrombocytopenia (HIT) complicates mechanical circulatory support with Impella devices, creating a paradoxical pro-thrombotic state in patients requiring continuous anticoagulation. Evidence-based management strategies remain limited. Methods: We retrospectively analyzed four consecutive patients (2022-2024) who developed laboratory-confirmed HIT while receiving Impella support during cardiac surgery. Each patient received a distinct: ultra-low-dose argatroban purge, bivalirudin purge with systemic therapy, therapeutic plasma exchange (TPE) plus intravenous immunoglobulin (IVIg) enabling UFH re-exposure, and heparin-free bicarbonate purge. Results: Median age was 58 years (range 47-71). All patients experienced ≥55% platelet decline over 4-9 days of UFH exposure with positive PF4-ELISA and confirmatory functional assays. Case A (mitral repair + Impella 5.5) received argatroban purge (0.05 mg/mL) achieving ACT 180-220s without bleeding. Case B (redo-CABG + Impella CP) utilized titrated bivalirudin purge bridging to heart transplant. Case C (LVAD implantation) underwent triple TPE and high-dose IVIg enabling safe intra-operative UFH. Case D (high-risk PCI) employed sodium bicarbonate purge with systemic argatroban. All patients survived to discharge without device thrombosis, major bleeding, or stroke. Platelets normalized (median >150×10³/μL) within 6 days. Conclusions: Individualized, guideline-concordant anticoagulation strategies—including novel purge solutions and immunomodulatory approaches—enable safe Impella support in HIT patients undergoing complex cardiac surgery.