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.1-4 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.5,6 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.