Cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) are both mechanical circulatory support technologies that augment the native heart and/or lung function. They involve drainage and reinfusion of blood while performing extracorporeal gas exchange. 1 In both devices, contact between patient blood and the non-endothelialized surface of the circuit triggers an inflammatory response and pro-coagulation cascade. 2–5 As a result, prophylactic anticoagulation is integral to prevent catastrophic thrombosis of the circuitry. In rare instances, there exist contraindications to heparin use, necessitating alternative management strategies. 6 In this review, we will examine heparin contraindications in mechanical circulatory support and summarize alternative approaches to anticoagulation in these circumstances.

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Coronary artery spasm constitutes the primary underlying pathology of variant angina. Because provocation of coronary artery spasm may occur with both excess sympathetic and excess parasympathetic stimulation, patients with this disorder have extremely limited options for perioperative pain control. This is especially true for procedures involving extensive abdominal incision/manipulation. Whereas neuraxial analgesia might otherwise be appropriate in these cases, several studies have demonstrated that coronary artery spasm can occur as a result of epidural placement, and therefore, that this may not be an optimal choice for patients with variant angina. This report discusses the case of a patient with a preexisting diagnosis of variant angina who underwent an exploratory laparotomy with large ventral hernia repair and for whom continuous erector spinae plane blocks were successfully used as analgesic adjuncts without triggering coronary artery spasm.