Background: Haemorrhage is a significant risk during the Intra Aortic Balloon Pump (IABP) removal, with an increased risk in patients with Thromobocytopenia. However, the platelet count should not be the sole consideration in whether or not to remove the IABP before transfusion. Viscoelastic tests can provide a wider perspective about the patient’s capacity to form a clot, despite the platelet count.

Case Report: A woman in her 60s underwent a mechanical aortic valve replacement due to severe stenosis. This was complicated with an intraoperative isquemia and cardiac arrest, requiring an emergency bypass to the anterior descending coronary artery. Severe bleeding presented upon intensive care admission, requiring reintervention. In the immediate postoperative situation the patient developed cardiogenic shock associated with akinesia of the anterior wall and a new severe tricuspid insufficiency. Subsequently, emergency cardiac catheterization was performed, finding a left coronary sinus disection that mildly affected the ostium of the common trunk, without compromising the flow. Implantation of the IABP was considered necessary. The patient improved from the cardiogenic shock during the following 6 days, allowing for the removal of the IABP. At this point the patient had normal partial thromboplastin time and prothrombin time, but moderate thrombocytopenia (37x10E9/L) was present, which could be secondary to the device or to heparin-induced thrombocytopenia. This influcenced the decision to not transfuse platelets, and to initially study the clot formation with Tromboelastometry.

This test showed a normal maximum clot firmness, leading to the removal of the IABP, without platelet transfusion. The patient did not have any complications, during or after the procedure. 

Discussion: Thrombocytopenia is a significant risk factor for bleeding during the IABP removal, and therefore platelet transfusion prior to the procedure must be considered. However, the transfusion is not without risks, particularly if heparin-induced thrombocytopenia is suspected. Thromboelastometry may be able to predict more accurately the bleeding tendency, rather than the platelet count as an isolated test. This is due to Thromboelastometry being a global assay that determines whole blood clot formation, thus helping to decide whether or not to transfuse prior to an invasive procedure.

References: Shen. Viscoelastic testing inside and beyond operating room. J of Thor Disease S299 2017

05 / Influence of Thromboelastometry in making clinical decisions in a patient with an intra aortic balloon pump and severe Thrombocytopenia.