HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Zev Davis Richard Anderson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Davis, Z. Articles by Valgiusti, A. Search for Related Content PubMed PubMed Citation Articles by Davis, Z. Articles by Valgiusti, A. Related Collections Extracorporeal circulation

Ann Thorac Surg 2003;75:264-265
© 2003 The Society of Thoracic Surgeons

---

Case report

Favorable outcome with bivalirudin anticoagulation during cardiopulmonary bypass

^a Edward Hospital, Naperville, Illinois, USA

Accepted for publication August 14, 2002.

* Address reprint requests to Dr Davis, Cardiac Surgery Associates, 120 Spalding Dr, Suite 209, Naperville, IL 60540, USA
e-mail: zdavis{at}openheart.net

	Abstract

Top Abstract Introduction Comment References

 
An 81-year-old man with previous syncopal episodes, progressive shortness of breath, pulmonary edema, severe calcific aortic stenosis, and a history of heparin-induced thrombocytopenia required aortic valve replacement. Bivalirudin, a thrombin-specific anticoagulant, was used in place of heparin. The patient received a 50 mg bivalirudin bolus followed by an infusion between 1.5 mg · kg^-1 · h^-1 and 1.75 mg · kg^-1 · h^-1. Adequate anticoagulation was readily obtained resulting in an uneventful cardiopulmonary bypass. Activated clotting time (ACT) values steadily declined after discontinuation of the bivalirudin infusion. Bivalirudin is a practical alternative to heparin during cardiac surgical procedures.

	Introduction

Top Abstract Introduction Comment References

 
Heparin remains the anticoagulant of choice for cardiopulmonary bypass despite distinct disadvantages. Protamine, used to reverse heparin action, is also associated with undesirable side effects. We describe a patient with a remote history of heparin-induced thrombocytopenia who underwent successful cardiopulmonary bypass (CPB) for aortic valve replacement and coronary artery bypass graft (CABG) with bivalirudin (Angiomax; The Medicines Company, Parsippany, NJ) anticoagulation. Bivalirudin is approved as an anticoagulant in percutaneous coronary intervention. It is a small synthetic 20 amino acid peptide modeled after the hirudin molecule yet is structurally, pharmacologically, and clinically distinct.

An 81-year-old man presented with multiple syncopal episodes and a history of gastric extra nodal marginal zone lymphoma. He was treated with cycles of a CHOP and Rituxan regimen. After the second cycle and before the third thrombocytopenia developed with heparin-induced platelet antibodies by platelet aggregation and serotonin release assay testing. Subsequently deep vein thrombosis developed in the right lower extremity followed by pulmonary embolization despite treatment with Refludan (lepirudin). An inferior vena cava filter was placed. The patient continued to convalesce satisfactorily at home, gained weight, and had no evidence of recurrent lymphoma.

Because of progressive shortness-of-breath and an episode of pulmonary edema the patient underwent cardiac catheterization with 50% left main coronary artery stenosis. The right coronary artery was diffusely diseased with 70% midportion stenosis. Echocardiography demonstrated severe calcific aortic stenosis. A repeat enzyme-linked immunosorbent assay (ELISA)–based anti-PF4 (GTI; Brookfield, WS) assay was negative but because of a previous positive assay for anti-PF4 the use of heparin as an anticoagulant for the CPB was considered inappropriate. Our hospital policy allows the use of an approved drug for an unapproved indication in an individual case (an institutional review board–approved study of this medication in this clinical setting is now ongoing). The patient was informed and consented to the use of bivalirudin as an alternative anticoagulant.

The patient underwent cardiac surgical intervention. Monitoring included standard anesthesia monitors plus a radial arterial line and pulmonary artery catheter. General anesthesia was induced and maintained with etomidate, rocuronium, fentanyl (20 µg/kg), midazalam (0.35 mg/kg), and desflurane. Cefazolin (2,000 mg) and solumedrol (250 mg) were also administered. Epsilon-aminocaproic acid (75 mg/kg) was administered as a loading dose soon after induction and a maintenance dose of 15 mg · kg^-1 · h^-1 was continued until after discontinuation of cardiopulmonary bypass. Cardiopulmonary bypass was initiated in the usual fashion using bivalirudin for anticoagulation instead of heparin. The anticoagulant protocol with bivalirudin and concurrent activated clotting time levels are noted in Figure 1.

View larger version (16K): [in this window] [in a new window]   Fig 1. The goal of anticoagulation with bivalirudin was to maintain the activated clotting time (ACT) at 480 seconds. Bivalirudin infusion was titrated between 1.5 mg · kg-1 · h-1 and 1.75 mg · kg-1 · h-1 with measured ACTs ranging from 450 to more than 999 seconds. ACT measurements were taken every 15 minutes and were made on ACT II analyzer (Medtronic, Minneapolis, MN).

No clot was seen in the CPB circuit after blood was pumped to the cell-saving device. After 45 minutes the CPB circuit was broken down and some clot was noted in the bases of the heat exchanger. No other clot was observed in the venous reservoir, oxygenator, or arterial filter. A 50-mg bivalirudin bolus before CPB was followed by a 1.5 to 1.75 mg · kg^-1 · h^-1 infusion through the oxygenator during CPB. Postpump all blood collected was processed through the cell-saving device. No clot was noted in the reservoir after blood processing.

The patient was given a transfusion of 3 U packed red blood cells when a hemoglobin of 6.1 and hematocrit of 16.7 were noted 6 hours postoperatively. Other blood products administered during the first 24 hours postoperatively included 7 U fresh frozen plasma, 2 apheresis units of platelets, and an additional unit of packed red blood cells. Hematologic variables are given in Table 1. Chest tube drainage was discontinued 48 hours postoperatively and totaled 3033 mL. A single large drainage dump (1,190 mL) was noted between 24 and 28 hours postoperativley and was likely an old collection that was mobilized and drained. The patient convalesced satisfactorily and was discharged home on day 5.

	Comment

Top Abstract Introduction Comment References

Practical concerns arise during CPB with bivalirudin anticoagulation: the pump circuit clots shortly after discontinuation from bypass if the pump sucker is used. It is therefore advisable to add bivalirudin to the circuit when using a cell-saving device. A prospective multicenter trial of bivalirudin use in cardiac surgery seems warranted [5].

	References

Top Abstract Introduction Comment References

 

1. Bittl J.A., Chaitman B.R., Feit F., Kimball W., Topol E.J. Bivalirudin versus heparin during coronary angioplasty for unstable or postinfarction angina: final report reanalysis of the Bivalirudin Angioplasty Study. Am Heart J 2001;142:952-959.[Medline]
2. Fox I., Dawson A., Loynds P., et al. Anticoagulant activity of Hirulog, a direct thrombin inhibitor, in humans. Thromb Haemost 1993;69:157-163.[Medline]
3. Bates S.M., Weitz J.L. Direct thrombin inhibitors for treatment of arterial thrombosis: potential differences between bivalirudin and hirudin. Am J Cardiol 1998;82(8B):12P-18P.[Medline]
4. Maraganore J.M., Adelman B.A. Hirulog: a direct thrombin inhibitor for management of acute coronary syndromes. Cor Artery Dis 1996;7:438-448.[Medline]
5. Robson R. The use of bivalirudin in patients with renal impairment. J Invas Cardiol 2000;12(suppl F):33F-36F.

This article has been cited by other articles:

				Q. A Czosnowski, S. W Finks, and K. C Rogers Bivalirudin for Patients with Heparin-Induced Thrombocytopenia Undergoing Cardiovascular Surgery Ann. Pharmacother., September 1, 2008; 42(9): 1304 - 1309. [Abstract] [Full Text] [PDF]

				T. E. Warkentin, A. Greinacher, A. Koster, and A. M. Lincoff Treatment and Prevention of Heparin-Induced Thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 340S - 380S. [Abstract] [Full Text] [PDF]

				A. Vincentelli, B. Jude, and S. Belisle Antithrombotic therapy in cardiac surgery: [Traitement antithrombotique en chirurgie cardiaque]. Can J Anesth, June 1, 2006; 53(6_suppl): S89 - S102. [Abstract] [Full Text] [PDF]

				M. Wasowicz, A. Vegas, M. A. Borger, and S. Harwood Bivalirudin anticoagulation for cardiopulmonary bypass in a patient with heparin-induced thrombocytopenia: [L'anticoagulation avec la bivalirudine pour la circulation extracorporelle chez un patient atteint de thrombocytopenie immunitaire a l'heparine (TIH)] Can J Anesth, December 1, 2005; 52(10): 1093 - 1098. [Abstract] [Full Text] [PDF]

				K. Hassell The Management of Patients With Heparin-Induced Thrombocytopenia Who Require Anticoagulant Therapy Chest, February 1, 2005; 127(2_suppl): 1S - 8S. [Abstract] [Full Text] [PDF]

				A. T. Gurbuz, W. G. Elliott, and A. A. Zia Heparin-induced thrombocytopenia in the cardiovascular patient: diagnostic and treatment guidelines Eur. J. Cardiothorac. Surg., January 1, 2005; 27(1): 138 - 149. [Abstract] [Full Text] [PDF]

				S. B. Clayton, J. R. Acsell, A. J. Crumbley III, A. G. Shackelford, and W. E. Uber Cardiopulmonary Bypass With Bivalirudin in Type II Heparin-Induced Thrombocytopenia Ann. Thorac. Surg., December 1, 2004; 78(6): 2167 - 2169. [Abstract] [Full Text] [PDF]

				T. E. Warkentin and A. Greinacher Heparin-Induced Thrombocytopenia: Recognition, Treatment, and Prevention: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 311S - 337S. [Abstract] [Full Text] [PDF]

				L. Shore-Lesserson New anticoagulants and antiplatelet agents Can J Anesth, June 1, 2004; 51(suppl_1): R9 - R9. [Full Text] [PDF]

				A. F. Merry, P. J. Raudkivi, N. G. Middleton, J. M. McDougall, P. Nand, B. P. Mills, B. J. Webber, C. M. Frampton, and H. D. White Bivalirudin versus heparin and protamine in off-pump coronary artery bypass surgery Ann. Thorac. Surg., March 1, 2004; 77(3): 925 - 931. [Abstract] [Full Text] [PDF]

				A. Koster and T. Fischer Management of Patients with Heparin-Induced Thrombocytopenia During Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2003; 7(4): 411 - 416. [Abstract] [PDF]

				T. E. Warkentin and A. Greinacher Heparin-induced thrombocytopenia and cardiac surgery Ann. Thorac. Surg., December 1, 2003; 76(6): 2121 - 2131. [Abstract] [Full Text] [PDF]

				M. Carrier Reply to the Editor: J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 2109 - 2109. [Full Text] [PDF]

				T. E. Warkentin and A. Greinacher Heparin-induced thrombocytopenia and cardiac surgery Ann. Thorac. Surg., August 1, 2003; 76(2): 638 - 648. [Abstract] [Full Text] [PDF]

				B. M. Alving, C. W. Francis, W. R. Hiatt, and M. R. Jackson Consultations on Patients with Venous or Arterial Diseases Hematology, January 1, 2003; 2003(1): 540 - 558. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Zev Davis Richard Anderson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Davis, Z. Articles by Valgiusti, A. Search for Related Content PubMed PubMed Citation Articles by Davis, Z. Articles by Valgiusti, A. Related Collections Extracorporeal circulation