Management of refractory bleeding post-cardiopulmonary bypass in an acute heparin-induced thrombocytopenia type II renal failure patient who underwent urgent cardiac surgery with bivalirudin (Angiox^®) anticoagulation

Abstract

Acute heparin-induced thrombocytopenia (HIT) patients present a myriad of anticoagulation management challenges, in clinical settings where unfractionated heparin (UFH) is the traditional drug of choice. UFH use in cardiac surgery is a known entity that has been subject to rigorous research. Research has, thus, led to its unparalleled use and the development of well-established protocols for cardiac surgery. In comparison to UFH, bivalirudin use for acute HIT patients requiring urgent cardiac surgery with cardiopulmonary bypass (CPB) is still in its infancy. We describe the tailored post-CPB management of refractory bleeding in a 65-year-old infective endocarditis, acute HIT patient with renal failure who underwent urgent aortic valve replacement and mitral valve repair with bivalirudin anticoagulation. A management approach that entailed a combination of continuous venovenous haemofiltration (CVVH), 4-Factor prothrombin complex concentrate (PCC) (Beriplex), recombinant factor VIIa (rFactor VIIa) and desmopressin (DDAVP) were consecutively used post-operatively in theatre. Based on this case study experience, two modifications to institutional protocols are recommended. The first is the use of CVVH in theatre to eliminate bivalirudin in renal failure patients or in patients where bivalirudin elimination is prolonged. Secondly, a 'rescue therapy/intervention' algorithm for the swift identification of refractory bleeding post-CPB is also recommended. Rescue therapy agents, such as a 4-Factor PCCs and rFactor VIIa, should be incorporated into the protocol after a robust evidence-based search and agreement with the haematologist. The aim of these recommendations is to reduce the risk of bleeding associated with bivalirudin use for inexperienced institutions and experienced institutions alike, until larger randomized, controlled studies provide more in-depth knowledge to expand our clinical practice.

Use of prothrombin complex concentrate containing heparin for emergency reversal of bivalirudin anticoagulation: a word of caution

“…We read with great interest the case reported by Dr. Hassen and colleagues describing the management of severe bleeding associated with bivalirudin in a patient with acute heparin-induced thrombocytopenia (HIT) undergoing emergent complex cardiac surgery. 1 Acute renal failure serves as an explanation for the persisting anticoagulant effect observed in this case as, in dialysis patients, the half-life of bivalirudin can be prolonged up to 3.5 hours. 2 Uncontrollable diffuse bleeding is a challenging scenario for cardiac surgical teams.…”

“…We read with great interest the case reported by Dr. Hassen and colleagues describing the management of severe bleeding associated with bivalirudin in a patient with acute heparin-induced thrombocytopenia (HIT) undergoing emergent complex cardiac surgery. 1…”

Novel Applications of Anticoagulation with Bivalirudin in Cardiac Surgery

“…Bivalirudin dosing in the CHOOSE-ON and EVOLUTION-ON trials included a loading dose of 1.0 mg/kg, infusion of 2.5 mg kg h, and pump prime of 50 mg. The adequacy of anticoagulation was monitored using 2.5 times the baseline ACT [10,11] for use in patients with HIT [12,13]. We would like to add that use off pump (beating heart technique) and of BIMA -of fully skeletonized internal mammary arteries bilaterally and radial arteries avoids the need for antiplatelet agents in the postoperative period [7] and use of Bivalirudin in these patients is safe and is extremely useful in the subset of patient awaiting liver transplant or those with HIT.…”

GTH 2021 State of the Art—Cardiac Surgery: The Perioperative Management of Heparin-Induced Thrombocytopenia in Cardiac Surgery

“…10 However, the results show that some patients required transfusion of very large quantities of blood products. Several case reports confirm the risk of bleeding when bivalirudin is used during CPB, [11][12][13] particularly in situations where the team lacks experience with this drug. The peculiar pharmacokinetic properties of bivalirudin require adaptations to the CPB circuit and surgical techniques.…”