Bivalirudin use in an infant with persistent clotting on unfractionated heparin

Perioperative care in an adolescent patient with heparin-induced thrombocytopenia for placement of a cardiac assist device and heart transplantation: case report and literature review

Heparin-induced thrombocytopenia (HIT) can cause life-threatening complications following the administration of heparin. Discontinuation of all sources of heparin exposure and the use of alternative agents for anticoagulation are necessary when HIT is suspected or diagnosed. We present the successful use of bivalirudin anticoagulation in an adolescent patient during cardiopulmonary bypass who underwent both placement of a left ventricular assist device and subsequent heart transplantation within a 36-hour period. The pathophysiology and diagnosis of HIT are reviewed, previous reports of the use of direct thrombin inhibitors for cardiac surgery are presented, and potential dosing regimens for bivalirudin are discussed.

Bivalirudin as an Alternative to Heparin for Anticoagulation in Infants and Children

Bivalirudin, a direct thrombin inhibitor, is a useful alternative to heparin for anticoagulation in infants and children. It has been found to be effective in patients requiring treatment of thrombosis, as well as those needing anticoagulation during cardiopulmonary bypass, extracorporeal life support, or with a ventricular assist device. While it has traditionally been used in patients who were unresponsive to heparin or who developed heparin-induced thrombocytopenia, it has recently been studied as a first-line agent. Bivalirudin, unlike heparin, does not require antithrombin to be effective, and as a result, has the potential to provide a more consistent anticoagulation. The case reports and clinical studies currently available suggest that bivalirudin is as effective as heparin at reaching target activated clotting times or activated partial thromboplastin times, with equivalent or the lower rates of bleeding or thromboembolic complications. It is more expensive than heparin, but the cost may be offset by reductions in the costs associated with heparin use, including anti-factor Xa testing and the need for administration of antithrombin. The most significant disadvantage of bivalirudin remains the lack of larger prospective studies demonstrating its efficacy and safety in the pediatric population.