Successful use of Argatroban as a heparin substitute during cardiopulmonary bypass: heparin-induced thrombocytopenia in a high-risk cardiac surgical patient

Whereas heparin is the most widely used intravenous anticoagulant in the US for the treatment of thromboembolic disease and is a seminal adjunct to many clinical procedures, its use can cause serious adverse events. Heparin-induced thrombocytopenia (HIT) has emerged as one of the most frequently seen complications of heparin therapy and can be a life-threatening immunohematological challenge for patients requiring cardiopulmonary bypass (CPB) with obligatory heparin exposure. Unfortunately, lack of convenient monitoring techniques and the presence of HIT and other comorbidities in the complex patient frequently limits or precludes the use of most alternatives to heparin anticoagulation during CPB. This case report describes the successful use of the celite activated clotting time and high-dose thrombin time, while using the direct thrombin inhibitor Argatroban as an alternative to heparin anticoagulation during CPB in a high-risk patient presenting with type II HIT, end-stage renal failure, and ischemic cardiomyopathy with ventricular fibrillatory arrest.     

Successful therapy of severe pneumonia-associated ARDS after pneumonectomy with ECMO and steroids

Pneumonia and acute respiratory distress syndrome are life-threatening complications after pneumonectomy carrying high mortality. Because pulmonary reserve is inadequately low, an effective therapeutic strategy is needed to treat hypoxia. Extracorporeal membrane oxygenation is a highly effective method to reverse hypoxia in patients with acute respiratory distress syndrome, but has only once been described in a patient with postpneumonectomy pulmonary edema. We report a case of successful extracorporeal membrane oxygenation therapy in a patient with pneumonia-associated acute respiratory distress syndrome after pneumonectomy. Methylprednisolone therapy caused a dramatic improvement of pulmonary and systemic organ function.     

Successful use of ECMO in adults with life-threatening infections

Two cases of critically ill patients who received extracorporeal membrane oxygenation (ECMO) using different forms of circuitry and for different indications are presented. Both patients had life-threatening infections with septic shock and were not able to be supported by conventional means. The first patient had staphylococcal septicaemia and received venoarterial ECMO for circulatory failure. The second patient had psittacosis and received venovenous ECMO for respiratory failure. We discuss the expanding indications for this technology and the role it has to play in adult intensive care.     

Novoseven use in a non-cardiac pediatric ECMO patient with uncontrolled bleeding

Despite the presence of normal coagulation values, refractory bleeding during extracorporeal membrane oxygenation (ECMO) is encountered. Occasionally, hemostasis is not achieved through traditional techniques including surgical exploration, anti-fibrinolytics, increasing fibrinogen level, increasing platelet counts, and decreasing activated clotting time (ACT). We report the case of an infant on veno-arterial ECMO for respiratory syncytial virus with severe bleeding and the use of recombinant activated factor VII (rFVIIa; NovoSeven; Novo Nordisk, Copenhagen, Denmark). This was a retrospective review of the patient's medical records, laboratory values, and chest radiographs. rFVIIa was given to this patient on two separate occasions for bleeding unresponsive to traditional bleeding management. On both occasions, the patient's blood loss returned to zero within 20 minutes of administration and remained there for a minimum of 4 days. Continued bleeding on ECMO unresponsive to current medical management may be an indication for rFVIIa. However, rFVIIa should not be administered without first considering the ECMO circuits conditions to include presence of clot, and documentation of circuit pressures, which, after rFVIIa, may be the first indication of intraoxygenator clot formation. Additionally, rFVIIa should not be a first-line treatment until continued studies allow for approved use in this patient population.     

Anticoagulant monitoring techniques in a heparin-induced thrombocytopenia patient undergoing cardiopulmonary bypass using bivalirudin anticoagulant

Heparin is widely used as the anticoagulant of choice for cardiopulmonary bypass. However, some patients exposed to heparin therapies develop heparin-induced thrombocytopenia (HIT). Severe complications of HIT-induced thrombosis may lead to end-organ dysfunction and death. Bivalirudin, a hirudin analog, is an alternative anticoagulant that may be used in the patient with HIT without inducing thrombotic disorders. This case report provides a look at the successful use of bivalirudin as the sole anticoagulant in a patient diagnosed with HIT undergoing minimally invasive cardiothoracic surgery requiring cardiopulmonary bypass for severe mitral insufficiency. An 80-year-old male presented to the operating room for a minimally invasive mitral valve repair. Past medical history included mitral valve prolapse, atrial fibrillation, hypertension, and congestive heart failure. Preoperative evaluation noted the existence of HIT with heparin exposure 2 months prior. The decision was made to use bivalirudin as the sole anticoagulant for the operative procedure. Anticoagulation evaluation was performed with both high-does thrombin time (HiTT) and Celite activated clotting time tubes for comparison using a Hemochron device. Cardiopulmonary bypass was initiated, and the patient's mitral valve was repaired using a 34-mm annuloplasty ring. The patient was successfully weaned from bypass. No complications or evidence of HIT exacerbation were noted in the postoperative course.     

Use of bivalirudin as an anticoagulant during cardiopulmonary bypass

Bivalirudin is a short-acting direct thrombin inhibitor that has been used in cardiac surgical patients with heparin-induced thrombocytopenia (HIT) or suspected HIT. Although no direct thrombin inhibitor is indicated for anticoagulation during cardiac surgery in patients with heparin-induced thrombocytopenia (HIT) or suspected HIT, use of heparin-alternatives are increasing as the awareness of HIT increases. Reports of anticoagulation with bivalirudin are sporadic, however, with variable dosing and management strategies. In this report, we describe our management techniques for cardiopulmonary bypass with bivalirudin based upon our personal experience. Although the reported clinical experience with bivalirudin in cardiac surgery is reviewed, operative techniques for the perfusionist/surgeon team are discussed in detail. We recognize that the use of bivalirudin during cardiopulmonary bypass is evolving and modifications of technique will undoubtedly occur as further data and experience accumulate.     

Anticoagulation with bivalirudin during cardiopulmonary bypass in cardiac surgery

Heparin is the standard agent used for systemic anticoagulation during cardiopulmonary bypass in cardiac operations. Alternatives are needed when patients with heparin-induced thrombocytopenia type II are encountered. We present a patient with a clinical picture of heparin-induced thrombocytopenia type II who was effectively anticoagulated with bivalirudin, a direct thrombin inhibitor, during cardiopulmonary bypass for a cardiac operation.     

Cardiopulmonary bypass with bivalirudin in type II heparin-induced thrombocytopenia

Cardiopulmonary bypass in patients with type II heparin induced-thrombocytopenia poses significant challenges. Inadequate pharmacokinetic profiles, monitoring, reversibility, and availability often limit alternative anticoagulation strategies. Bivalirudin, a semisynthetic direct thrombin inhibitor, was recently approved for use in patients undergoing percutaneous coronary interventions. Its unique properties, including a relatively short half-life, an anticoagulation effect that closely correlates with activated clotting time, and an alternate metabolic pathway for elimination, make bivalirudin an attractive agent for cardiopulmonary bypass in patients with type II heparin induced-thrombocytopenia. We report our experience using bivalirudin in 2 patients undergoing coronary artery bypass grafting.     

Successful use of extracorporeal membrane oxygenation for acute respiratory failure in a patient with chronic granulomatous disease

A 9-year-old boy presented with pneumonia, bilateral pulmonary lesions, and fulminant respiratory failure requiring support with extracorporeal membrane oxygenation (ECMO). Open lung biopsy and subsequent bronchoscopy identified Nocardia cyriacigeorgica and Burkholderia cepacia pneumonia. Chronic granulomatous disease (CGD) was diagnosed by an abnormal neutrophil oxidative burst assay. An aggressive diagnostic and therapeutic strategy, which included ECMO, allowed for patient survival and return to baseline function. No ECMO survivors with CGD have previously been reported. It is now recognized that several forms of CGD exist, and some forms may be compatible with long-term survival. Therefore, the diagnosis of CGD should not necessarily be considered a contraindication to ECMO. This is the first known survivor of CGD-related acute respiratory failure supported by ECMO.     

Successful use of videolaryngoscopy in an adult patient with acute epiglottitis: a case report

Acute epiglottitis is a potentially life-threatening infection of the supraglottic structures, which can lead to sudden, fatal airway obstruction. Different techniques have been described to facilitate tracheal intubation in acute epiglottitis. We describe the successful intubation, with the help of the videolaryngoscope, of a 60-year-old female with acute epiglottitis. On admission the patient was ill and severely distressed, sitting in the upright position, drooling saliva, showing severe inspiratory stridor, hyperventilation, but no trismus. Intubation was performed in OR conditions with difficult intubation equipment including fiberoptic bronchoscope, videolaryngscope, laryngeal mask airway and surgical tracheostomy ready for use. After pre-oxygenation for three minutes with 100% oxygen with the patient still in the sitting position, induction was performed with 250 mg propofol i.v. The patient was subsequently positioned supine. Face mask ventilation was successful with capnographic tracing and 100 mg succinylcholine was administered. Videolaryngoscopy was performed and a red, swollen epiglottitis with pin point lumen was seen. Intubation with a 5 mm microlarynx tube was successful at the first attempt. This is the first case describing intubation using videolaryngoscopy in an adult patient with acute epiglottitis. Videolaryngoscopy has already proven to be an excellent intubation device in normal and difficult airways. Direct laryngoscopy in patients with epiglottitis may be difficult due to the swelling and distortion of the airway. This case report shows that videolaryngoscopy is a good alternative intubation device option in adults with acute epiglottitis. Nevertheless, all other precautions (difficult airway trolley, surgical tracheostomy) need to be ready for immediate use.     

Successful use of levosimendan in a patient with peripartum cardiomyopathy

This case represents the first reported use of levosimendan, a calcium-sensitizing drug with additional vasodilation properties, for treatment of a woman with peripartum cardiomyopathy. Levosimendan induced a steady decline of increased pulmonary capillary wedge pressure, followed by a definitive increase in cardiac stroke volume. The patient recovered from this serious episode of heart failure, and she ultimately regained left ventricular function. IMPLICATIONS: Acute heart failure is a life-threatening event that only rarely occurs during childbirth. We report a case of a woman who experienced cardiovascular collapse during vaginal delivery. We determined that she met current diagnostic criteria for peripartum cardiomyopathy, and we successfully treated her with levosimendan, a calcium-sensitizing drug with additional vasodilation properties.     

Successful use of VV ECMO in managing negative pressure pulmonary edema

The indications for extracorporeal membrane oxygenation (ECMO) are expanding. Postobstructive pulmonary edema, also known as negative pressure pulmonary edema, can result in severe respiratory compromise and acute respiratory distress syndrome. We present a case of a 26-year-old female with laryngeal papillomatosis and laryngospasm after direct laryngoscopy, who developed severe NPPE refractory to mechanical ventilator support, which was successfully treated with veno-venous ECMO.     

Preoperative ECMO in transposition of the great arteries with persistent pulmonary hypertension

Persistent fetal circulation in transposition of the great arteries results in severe persistent pulmonary hypertension, which increases the risk of early mortality. We report the case of a newborn with transposition of the great arteries and intact ventricular septum associated with pulmonary hypertension. After the failure of immediate balloon atrial septostomy and supportive therapy including inhaled nitric oxide, preoperative extracorporeal membrane oxygenation reversed pulmonary hypertension and ventricular insufficiency and preceded a safe, delayed, cardiac surgical procedure. Unlike the authors of the other few case reports on this subject, we recommend a preoperative stabilization period after discontinuation of extracorporeal membrane oxygenation to avoid left ventricular "deconditioning" and postoperative deterioration related to recurrent persistent pulmonary hypertension.     

Successful preemptive renal retransplantation in a patient with previous acute graft loss secondary to HIT type II: a case report and review of literature

Type II heparin-induced thrombocytopenia (HIT II) is an immune-mediated reaction to heparin administration associated with thrombocytopenia and thrombotic complication with potentially serious outcome. We report a case of a 50-year-old man with history of autosomal dominant polycystic kidney disease (ADPKD), homocystinemia, and history of deep vein thrombosis (DVT), who was switched to intravenous heparin from oral coumadin preoperatively in preparation for preemptive living related renal transplant. Following the operation heparin-induced thrombocytopenia type II lead to graft renal artery thrombosis and subsequent graft loss. One year after first transplant patient underwent successful second living unrelated kidney transplantation with no complications with continued anticoagulation with coumadin and with no reexposure to heparin. Two years after the second transplant and 1?year after stopping anticoagulation, patient was readmitted with bilateral lower extremity DVT and high probability of pulmonary embolism. He was given argatroban on admission as a bridge to anticoagulation with lifelong coumadin therapy and is doing well with excellent graft function. To our knowledge, this is the third reported case of HIT in renal transplantation, second reported case associated with graft loss secondary to HIT and the first reported case of successful retransplantation after initial HIT with graft loss. Heparin-induced thrombocytopenia in transplantation can lead to catastrophic consequences in organ recipients. Successful management of this condition emphasizes promptness of diagnosis and treatment and complete cessation of heparin exposure.     

Successful use of the TandemHeart percutaneous ventricular assist device as a bridge to recovery for acute cellular rejection in a cardiac transplant patient

In this report, we presented a patient who benefited from hemodynamic support with the TandemHeart Percutaneous Ventricular Assist Device (pVAD; Cardiac Assist, Inc) implantation in the setting of early acute graft rejection 2 months after orthotopic heart transplant. The TandemHeart initially had been used for temporary hemodynamic assistance during postcardiotomy heart failure and high-risk coronary interventions. More recently, its use in patients with cardiogenic shock from acute myocardial infarction, fulminant myocarditis, and critical aortic stenosis has been reported. To our knowledge, this is one of the first reported cases in which the TandemHeart pVAD served as a successful device for support during acute cardiac transplant rejection.     

Deep hypothermic circulatory arrest and bivalirudin use in a patient with heparin-induced thrombocytopenia and antiphospholipid syndrome

BACKGROUND: Patients with heparin-induced thrombocytopenia II (HIT II) need an alternative nonheparin-based method of anticoagulation for cardiopulmonary bypass (CPB) to prevent thrombosis and thrombosis related complications. METHODS: Bivalirudin was used during CPB and deep hypothermic circulatory arrest (DHCA) for resection of multiple right atrial masses in a patient with HIT II and antiphospholipid antibodies syndrome (APS). Anticoagulation was monitored with the activated clotting time (ACT) and a target ACT of 450 seconds or greater was maintained. RESULTS: Surgical removal of multiple right atrial masses was successful and there was no evidence of thromboembolic events. Clot was noticed in the cardiotomy and venous reservoir after CPB was discontinued and the system flushed. The postoperative course was uneventful. CONCLUSIONS: Anticoagulation was successfully managed with bivalirudin, a new short-acting, and direct thrombin inhibitor. Further studies are necessary to evaluate the safety of bivalirudin during DHCA.     

Successful management of life-threatening hemorrhage in a patient with synchronous lupus anticoagulant and factor VIII inhibitor

Acquired factor VIII inhibitor is increasingly recognized as a cause of major soft tissue hemorrhage. The laboratory diagnosis can be obscured by the synchronous presence of the lupus anticoagulant, an extremely rare occurrence that has been reported outside the vascular surgery literature. Vascular surgeons should be knowledgeable of factor VIII inhibitor and aware that it can present with other blood disorders, making the diagnosis more difficult and management more complex. This case report describes such a patient and reviews the current literature on this topic.