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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 thrombocytopénie immunitaire à l’héparine (TIH)]

Marcin Wasowicz, MD^*, Annette Vegas, MD FRCPC^*, Michael A. Borger, MD FRCSC and Stephen Harwood, CCP CPC

^* From the Department of Anesthesia and Pain Management,
Division of Cardiac Surgery, and
Cardiovascular Perfusion Services, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.

Address correspondence to: Dr. Annette Vegas, Department of Anesthesia, Toronto General Hospital, 200 Elizabeth St., 3 EN-406, Toronto, Ontario M5G 2C4, Canada. Phone: 416-340-4800, ext. 6443; Fax: 416-340-3698; E-mail: annette.vegas{at}uhn.on.ca

Purpose: To describe the perioperative management in a heparin-induced thrombocytopenia (HIT) positive patient who had prosthetic valve endocarditis and an aortic root abscess. The patient underwent high-risk cardiac re-operation with the use of the alternative anticoagulant, bivalirudin.

Clinical features: A 62-yr-old patient who underwent stentless tissue aortic valve replacement with a Toronto-SPV valve in 1998, was admitted to hospital with symptoms of stroke. A heparin infusion was started and further investigation revealed positive blood cultures. The patient developed HIT which was confirmed by laboratory tests. Echocardiographic examination performed one month later showed vegetations on the aortic tissue valve and a small aortic root abscess. The patient still tested positively for the presence of HIT antibodies and was treated conservatively with antibiotics. A repeat echocardiographic examination showed progression of the aortic root abscess and it was decided to proceed with urgent redo aortic valve surgery. Anticoagulation for cardiopulmonary bypass (CPB) was achieved with the use of a direct thrombin inhibitor (DTI), bivalirudin. Following an uneventful wean from CPB, hemostasis was achieved within 40 min. The postoperative course was uncomplicated and the patient was discharged from hospital on the seventh postoperative day.

Conclusion: Bivalirudin is a DTI, which can be used as an alternative anticoagulant for CPB in HIT positive patients. This case report showed a favourable outcome with bivalirudin for urgent complex redo cardiac surgery requiring CPB.