Title : Intra-cardiac thrombosis in the setting of
heparin-induced thrombocytopenia
Author : Mohamed Amr, MD
Affiliation : Department of Internal Medicine, Rochester General
Hospital, Rochester, NY.
Corresponding Author : Mohamed Amr, MD
Contact number : 718-764-7202
Affiliation Address : 1425 Portland Avenue, Rochester, NY,
14621.
Email address : amrelwagdycardiol@gmail.com
Funding source : none
Conflict of interest : none
Article type : Clinical image
Word count : 242.
key clinical message is to know that HIT is a massive
thrombotic storm. Atrial fibrillation cardioversion might not be safe in
HIT using the standard 48-hour cutoff from arrhythmia onset. Also, the
case serves as a reminder of how to suspect, diagnose and treat HIT.
56-year-old male had been admitted to the hospital with heart failure
exacerbation. He had been on telemetry since admission and had been in
sinus rhythm. He had a loop recorder for the last three months with no
evidence of atrial fibrillation. He had acute onset atrial fibrillation
in the hospital, off-note he had been on enoxaparin for
thromboprophylaxis since admission. He complained of calf pain on day 8,
and a duplex lower extremities showed right common femoral deep venous
thrombosis. Laboratory work is significant for a platelet count drop
from 400 on day 4 to 130 on day 8 of hospital stay. The rest of the
laboratory work was unremarkable.
Despite the concise duration of atrial fibrillation, we decided against
cardioversion without a transoesophageal echo(TEE) as we were suspecting
heparin-induced thrombocytopenia(HIT), and we were afraid of thrombotic
complications. TEE showed a massive left atrial thrombus, as shown in
Figure 1.
His 4T score was eight, which is a high probability, and platelet factor
4 ELISA IgG optical density came back positive at 2.2, which confirms a
diagnosis of HIT. He was started on bivalirudin and was later shifted to
apixaban for chronic atrial fibrillation anticoagulation.
The key clinical message is to know that HIT is a massive
thrombotic storm[1]. Atrial fibrillation cardioversion might not be
safe in HIT using the standard 48-hour cutoff from arrhythmia onset.
Also, the case serves as a reminder of how to suspect, diagnose and
treat HIT.