Cardiopulmonary bypass for complex cardiac surgery using bivalirudin anticoagulation in a patient with heparin antibodies

BACKGROUND: The presence of antibodies directed against heparin necessitates the use of an alternative anticoagulant in patients undergoing cardiac surgery. Bivalirudin is a short-acting direct thrombin inhibitor that has been used successfully in routine cardiac surgical cases. Experience in complicated cases requiring extended cardiopulmonary bypass is limited, however. We report the successful use of bivalirudin in a patient who underwent complex cardiac surgery. METHOD: A 42-year-old patient with aortic regurgitation due to endocarditis who had heparin antibodies underwent a Ross procedure for aortic valve replacement using bivalirudin as anticoagulant during cardiopulmonary bypass (CPB). Bivalirudin was given with a bolus of 1 mg/kg and a continuous infusion of 2.5 mg/kg/hours during CPB. Monitoring of bivalirudin was performed using the ecarin clotting time (ECT). RESULTS: After 128 minutes of extracorporeal circulation, the patient was weaned from CPB without problems. After termination of CPB, modified ultrafiltration (MUF) was commenced. Perioperatively, six units of fresh frozen plasma were transfused. The 12-hour postoperative blood loss was 550 mL. The postoperative course was uneventful and the patient was discharged from hospital after 5 days. CONCLUSION: Bivalirudin can be safely used for anticoagulation during CPB even in complex cardiac surgery.