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

BACKGROUND Acute coronary syndrome is the most common cause of death in the United States. Successful intervention often requires a multi-therapeutic approach, including percutaneous coronary intervention (PCI) and antiplatelet agents such as ticagrelor. However, the use of antiplatelet agents can cause life-threatening bleeding, particularly during emergency procedures. Therapeutic plasma exchange (TPE) is a procedure that selectively removes the patient's plasma to eliminate harmful substances. Here, we present 2 cases of novel TPE implementation in the setting of uncontrolled ticagrelor-induced bleeding. CASE REPORT Our first case was a 52-year-old man who presented with ST-elevation myocardial infarction. He underwent emergency percutaneous coronary intervention and was started on dual antiplatelet therapy (aspirin 81 mg/day, and ticagrelor 90 mg twice daily). A post-infarction ventricular septal defect required emergency surgical repair. After the surgery, uncontrolled bleeding persisted despite all conventional treatment methods. Following TPE, the bleeding was controlled, hemostasis was achieved, and platelet function was increased within days. Our second case was a 66-year-old man who received single doses of ticagrelor (180 mg) and eptifibatide (180 mcg/kg) during an attempted PCI. After complication by left main coronary artery dissection, emergency 2-vessel coronary artery bypass surgery was performed. In the immediate postoperative period, TPE was performed for persistent uncontrolled bleeding. Platelet reactivity increased immediately following the procedure; bleeding was stabilized, and no further blood products were required after postoperative day 1. CONCLUSIONS TPE may be an effective novel option for emergency removal of circulating ticagrelor in refractory bleeding cases.