Successful use of bivalirudin for cardiopulmonary bypass in a patient with heparin-induced thrombocytopenia.

PATIENTS WITH HEPARIN-induced thrombocytopenia (HIT) presenting for cardiac surgery requiring cardiopulmonary bypass (CPB) present a unique clinical challenge. Re-exposure to heparin carries significant risks such as increased bleeding or life-threatening thrombosis. 1 Natelson E.A. Lynch E.C. Alfrey Jr, C.P. Heparin-induced thrombocytopenia. An unexpected response to treatment of consumption coagulopathy. Ann Intern Med. 1969; 71: 1121-1125 Crossref PubMed Scopus (98) Google Scholar , 2 Weismann R.E. Tobin R.W. Arterial embolism occurring during systemic heparin therapy. Arch Surg. 1958; 76: 219-227 Crossref Scopus (264) Google Scholar , 3 Rhodes G.R. Dixon R.H. Silver D. Heparin-induced thrombocytopenia with thrombotic and hemorrhagic manifestations. Surg Gynecol Obstet. 1973; 136: 409-416 PubMed Google Scholar , 4 Bell W.R. Tomasulo P.A. Alving B.M. et al. Thrombocytopenia occurring during the administration of heparin. A prospective study in 52 patients. Ann Intern Med. 1976; 85: 155-160 Crossref PubMed Scopus (208) Google Scholar An alternative method of anticoagulation is essential when considering surgery in this group of patients. The options available for anticoagulation are multiple, and each has limitations depending on the drug and/or the patient’s comorbid conditions. These include but are not limited to sole or combination therapy with ancrod, danaproid (not available in the United States), lepirudin, argatroban, platelet IIb/IIIa inhibitors, prostacyclin, heparin, or low-molecular-weight heparin. A new alternative, bivalirudin (Angiomax, The Medicines Company, Cambridge, MA), is a thrombin-specific anticoagulant approved for use in percutaneous coronary angioplasty. Bivalirudin has a half-life of approximately 25 minutes and a rapid plasma clearance (∼3.4 mL/min) via a combination of renal and proteolytic mechanisms. 5 Maraganore J.M. Adelman B.A. Hirulog A direct thrombin inhibitor for the management of acute coronary syndromes. Coron Artery Dis. 1996; 7: 438-448 Crossref PubMed Scopus (39) Google Scholar , 6 Robson R. The use of bivalirudin in patients with renal impairment. J Invas Cardiol. 2000; 12: 33F-36F PubMed Google Scholar The authors present a case of a patient with severe aortic insufficiency, renal insufficiency, cirrhosis, and HIT who required aortic valve replacement and underwent successful CPB with bivalirudin anticoagulation.