Therapeutic Plasma Exchange for Uncontrollable Bleeding After Platelet Inhibition with Ticagrelor: A Report of 2 Cases.

Therapeutic plasma exchange successfully controlled uncontrolled bleeding in a 52-year-old man with ticagrelor-induced bleeding following emergency surgical repair of a post-infarction ventricular septal defect.

• Patient presented with ST-elevation myocardial infarction and underwent emergency percutaneous coronary intervention.
• Dual antiplatelet therapy consisted of aspirin 81 mg/day and ticagrelor 90 mg twice daily.
• Uncontrolled bleeding persisted despite all conventional treatment methods prior to TPE.
• Following TPE, bleeding was controlled, hemostasis was achieved, and platelet function was increased within days.

Therapeutic plasma exchange immediately increased platelet reactivity and stabilized bleeding in a 66-year-old man who received ticagrelor and eptifibatide prior to emergency coronary artery bypass surgery.

• Patient received single doses of ticagrelor 180 mg and eptifibatide 180 mcg/kg during an attempted PCI.
• Surgery was complicated by left main coronary artery dissection requiring emergency 2-vessel coronary artery bypass surgery.
• TPE was performed in the immediate postoperative period for persistent uncontrolled bleeding.
• Platelet reactivity increased immediately following TPE, and no further blood products were required after postoperative day 1.

Conventional treatment methods were insufficient to control ticagrelor-induced bleeding in both cases prior to TPE intervention.

• In the first case, uncontrolled bleeding persisted despite all conventional treatment methods following emergency surgical repair.
• In the second case, bleeding was persistent and uncontrolled in the immediate postoperative period before TPE was performed.
• TPE selectively removes the patient's plasma to eliminate harmful substances, providing a mechanism for ticagrelor removal.

Acute coronary syndrome management with antiplatelet agents including ticagrelor can cause life-threatening bleeding, particularly during emergency procedures.

• Acute coronary syndrome is described as the most common cause of death in the United States.
• Successful intervention often requires a multi-therapeutic approach including PCI and antiplatelet agents such as ticagrelor.
• The use of antiplatelet agents can cause life-threatening bleeding particularly during emergency procedures.
• No established reversal agent for ticagrelor exists, creating a clinical need for alternative approaches such as TPE.