Preemptive Use of Bivalirudin for Urgent On-Pump Coronary Artery Bypass Grafting in Patients With Potential Heparin-Induced Thrombocytopenia

Emory University, Atlanta, Georgia, United States
The Annals of thoracic surgery (Impact Factor: 3.85). 08/2005; 80(1):299-303. DOI: 10.1016/j.athoracsur.2004.08.037
Source: PubMed


The use of heparin in patients with heparin-induced thrombocytopenia (HIT) may result in severe complications or death. The diagnosis of HIT is frequently uncertain, however. Alternative anticoagulants in at-risk patients undergoing cardiac surgery with cardiopulmonary bypass remain problematic. The novel short-acting, direct-thrombin inhibitor bivalirudin is the only alternative to heparin/protamine being used in elective non-HIT patients during CPB.
Four patients with severe thrombocytopenia after heparin exposure and suspected acute HIT underwent on-pump coronary artery bypass grafting surgery with preemptive use of bivalirudin. A continuous bivalirudin infusion was used during cardiopulmonary bypass, and activated clotting times were used to monitor anticoagulation.
Anticoagulation with bivalirudin during cardiopulmonary bypass was effective and uncomplicated. Duration of operation was not prolonged, and perioperative blood loss and transfusion rates were acceptable. Activated clotting times were helpful for monitoring anticoagulation in these patients.
These data provide further evidence of the feasibility of bivalirudin for anticoagulation during on-pump coronary artery bypass graft surgery in urgent clinical situations.

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    • "Pharmacokinetically bivalirudin is predominantly eliminated by enzymatic degradation through proteases and thrombin itself (80%) and to a lesser degree by renal clearance (20%) [81]. No reversal for bivalirudin exists, but its elimination can be enhanced by hemodialysis and hemofiltration [81,82]. The theoretical potential of aprotinin to delay bivalirudin elimination and to prolong its anticoagulant effect has not been demonstrated [56]. "
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