hirudin and Mitral-Valve-Insufficiency

Herein the case of a patient with a prior history of heparin-induced thrombocytopenia who underwent percutaneous mitral valve edge-to-edge repair that was followed by a tricuspid edge-to-edge repair two months later is presented. Recommendations exist for systemic anticoagulant alternatives for percutaneous mitral valve edge-to-edge repair with the MitraClip device (Abbott, Chicago, IL), but minimal guidance and experience are present regarding alternative systemic anticoagulation during the performance of right-sided interventions, including tricuspid edge-to-edge repair (TriClip; Abbott). Notably, there is no clear consensus regarding the use of an alternative anticoagulant in the catheter flush solution for the delivery systems used during these procedures, particularly for right-sided interventions.

Topics: Anticoagulants; Cardiac Catheterization; Heart Valve Prosthesis Implantation; Hirudins; Humans; Mitral Valve Insufficiency; Peptide Fragments; Recombinant Proteins; Thrombocytopenia; Treatment Outcome; Tricuspid Valve

Hypersensitivity to heparin and heparin-like compounds is a rare condition that represents therapeutic challenges for patients requiring a cardiopulmonary bypass (CPB). We here report the case of a woman with a combined allergy to heparins (fractionated and unfractionated), danaparoid and fondaparinux. She underwent a mitral valve replacement under CBP using lepirudin for systemic anticoagulation. The use of lepirudin instead of unfractionated heparin (UFH) in this setting has many important implications. Lepirudin therapeutic index is narrow and so, overdosing can lead to catastrophic bleeding, whereas underdosing can result in clotting in the CPB tubing. Monitoring of lepirudin activity is essential. The usual activated clotting time monitoring is not a reliable method to monitor anticoagulation with lepirudin in the operating theater. Our experience suggests that the diluted thrombin time provides a valuable alternative during CPB.

Topics: Adult; Anticoagulants; Blood Coagulation; Cardiopulmonary Bypass; Drug Hypersensitivity; Drug Monitoring; Female; Heparin; Hirudins; Humans; Mitral Valve; Mitral Valve Insufficiency; Recombinant Proteins; Thrombin Time; Thrombosis

Heparin-induced thrombocytopenia (HIT) is a serious, antibody-mediated complication of heparin which significantly confers risks of thrombosis and devastating outcomes. Once diagnosed, it requires immediate cessation of heparin and therapy with an alternative anticoagulant. No data are available in the literature on the pathophysiology and clinical implications of performing prolonged extracorporeal membrane oxygenation with a heparin-coated system in a patient with acute HIT treated with bivalirudin.

Topics: Acute Disease; Aged; Antibodies; Anticoagulants; Extracorporeal Membrane Oxygenation; Female; Heparin; Hirudins; Humans; Mitral Valve Insufficiency; Peptide Fragments; Platelet Count; Recombinant Proteins; Thrombocytopenia

Unfractionated heparin has been a near universal anticoagulant for cardiac surgery; however it is contraindicated in heparin-induced thrombocytopenia type II. Alternative anticoagulants such as bivalirudin (a direct thrombin inhibitor) are being utilized. Bivalirudin was successfully used in an immunologically complex patient (diagnoses of heparin-induced thrombocytopenia type II, systemic lupus erythematosus, antiphospholipid syndrome, and dialysis-dependent renal failure) requiring cardiopulmonary bypass. Thrombotic events are common in antiphospholipid syndrome patients undergoing cardiac surgery utilizing high-dose heparin. This may represent unrecognized heparin-induced thrombocytopenia type II. Our patient did not experience perioperative thrombotic or bleeding complications. The possible cross-reactivity between heparin induced thrombocytopenia type II and antiphospholipid syndrome has not been investigated.

Topics: Adult; Antibody Specificity; Anticoagulants; Antiphospholipid Syndrome; Autoantibodies; Cross Reactions; Drug Evaluation; Drug Therapy, Combination; Female; Heart Failure; Heparin; Hirudins; Humans; Hypertension, Pulmonary; Kidney Failure, Chronic; Lupus Erythematosus, Systemic; Mitral Valve Insufficiency; Peptide Fragments; Platelet Count; Platelet Factor 4; Recombinant Proteins; Renal Dialysis; Thrombocytopenia; Thrombophilia; Warfarin

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.

Topics: Aged; Aged, 80 and over; Anticoagulants; Cardiopulmonary Bypass; Contraindications; Drug Monitoring; Heparin; Hirudins; Humans; Male; Minimally Invasive Surgical Procedures; Mitral Valve Insufficiency; Peptide Fragments; Recombinant Proteins; Thrombin Time; Thrombocytopenia