Heparin-induced thrombocytopenia type II with early aortocoronary bypass occlusion and stent thrombosis after PTCA of the RCA-treatment with Lepirudin (Refludan (R)) and Abciximab (Reo pro (R)) during recanalization of the RCA

Heparin-induced thrombocytopenia type TT (HIT type II) is the most serious complication of heparin treatment apart from bleeding, which is the most co mmon side effect.. Eleven days after coronary bypass grafting, a 71 year ol d patient showed a posterolateral myocardial infarction and a thrombocytope nia of 80,000/,mu l. This was considered a postoperative thrombocytopenia. Coronary angiography revealed closed venous bypass grafts. The right corona ry artery (RCA) was revascularized by percutaneous transluminal coronary an gioplasty (PTCA) and stent placement. During both coronary angiography and PTCA, heparin was administered to the patient. The platelet number did not change. Four days later the patient showed an inferior myocardial infarctio n and an AV-block III degrees and a syncope. The following coronary angiogr aphy revealed RCA stent occlusion. HIT type TI was presumed and recanalizat ion was carried out using Lepirudin (Refludan(R)) as the anticoagulant. Aft er placing the guide wire, thrombi could be seen in the proximal RCA. Abcix imab (Reo pro(R)), a monoclonal antibody against the glycoprotein IIb/IIIa receptor was additionally administered. Coronary angiography on the next da y revealed only a small remaining thrombus. The AV-block disappeared immedi ately after revascularization. The diagnosis of HIT type IT was confirmed t hrough heparin-induced-platelet-activation-test (Hipa-test) and immunoassay (PF4/heparin-ELISA). This case report illustrates the complicated diagnosi s of HIT type II and the successful simultaneous use of Lepirudin (Refludan (R)) and Abciximab (Reo pro(R)). The number of platelets should be checked daily during heparin treatment. In the case of a thrombocytopenia, the trea tment should be stopped immediately, and Hipa-test and PF4/heparin-ELISA sh ould be carried out.