Bivalirudin anticoagulation during cardiac surgery: a single-center experience in 141 patients

Abstract

The feasibility of bivalirudin for anticoagulation during cardiac surgery has been confirmed in four multicenter clinical trials. Here, we report our single-center experience with bivalirudin anticoagulation in "on-pump" and "off-pump" cardiac surgery in a large number of patients with and without heparin antibodies. Data of patients who underwent cardiac surgery with bivalirudin anticoagulation between 06/2003 and 12/2007 at our institution were reviewed. Assessment included procedural success, blood loss, transfusion requirements, re-exploration rates and drug-related complications during the procedures. There were 141 patients treated with bivalirudin, of whom 40 had heparin antibodies. In 26 patients, "off-pump" coronary artery bypass grafting was performed and the remaining 115 patients had surgery with cardiopulmonary bypass (CPB). The procedural success rate after 7 days and after 30 days was 99.4%. The mean blood loss after "off-pump" surgery was 833 +/- 310 ml, with a transfusion rate of 30%. The mean blood loss after "on-pump" surgery was 750 +/- 494 ml, with a transfusion rate of 56%. Two patients needed re-exploration due to persistent hemorrhage. Overall transfusion rates were increased in patients with heparin antibodies. The current investigation demonstrates that, in experienced hands, bivalirudin anticoagulation can be performed with excellent procedural success and low complication rates during "on-pump" and "off-pump" cardiac surgery. Recent problems associated with the production of heparin have emphasized the urgent need for an alternative for use beyond the limited indication of heparin-induced thrombocytopenia.

Comparison of two pediatric cases requiring the use of bivalirudin during cardiopulmonary bypass

“…There are limited reports describing different ranges of bivalirudin infusion rates during cardiopulmonary bypass, particularly for pediatric patients. 1,2,4,5,7–9,15 In our experience, the bivalirudin rate was increased as high as 5.0 mg/kg/h for the VAD case while it was decreased to 0.5 mg/kg/h for the BLT case. We questioned whether or not there should be maximum and minimum infusion rates for bivalirudin anticoagulation regardless of the point-of-care ACT values.…”

Bivalirudin for Alternative Anticoagulation in Extracorporeal Membrane Oxygenation: A Systematic Review

“…Among the DTIs, bivalirudin has the shortest half-life and potentially the best pharmacological profile for use during ECMO, especially given the broad experience with bivalirudin in patients undergoing cardiac surgery and CPB. 36,39 The short half-life of bivalirudin may also be advantageous compared to other DTIs such as argatroban (39-51 minutes) and lepirudin (78 minutes) for titration of anticoagulation. 40,41 Moreover, argatroban and lepirudin may accumulate in hepatic and renal dysfunction, respectively, potentially leading to derangements of anticoagulation target and thus higher incidence of complications.…”

Bivalirudin as an adjunctive anticoagulant to heparin in the treatment of heparin resistance during cardiopulmonary bypass-assisted cardiac surgery

“…Bivalirudin binds to both exocite 1 and the active site on thrombin, thus, competing with fibrin for access to exocite 1. [36][37][38][39][40][41] Eighty percent of bivalirudin is eliminated by proteolysis, with the remainder eliminated by renal clearance. The drug has a half-life of 25 minutes.…”

“…Prospective studies, such as the randomized controlled EVOLUTION trials in on-pump and off-pump coronary artery bypass grafting (OPCAB) and the CHOOSE trial have established similar safety and efficacy in the use of bivalirudin in comparison to unfractionated heparin. [89][90][91][92] Moreover, , reported that, in "experienced hands", the use of bivalirudin in complex on-pump and off-pump cardiac surgical cases renders good procedural success and minor complications in the areas of perioperative blood loss and transfusion rates. 93 The patient in Case One had a low slope (58 sec/unit/ mL) from the heparin dose response curve.…”