A Thrombus in the Venous Reservoir While Using Bivalirudin in a Patient with Heparin-Induced Thrombocytopenia Undergoing Heart Transplantation

Abstract

Direct thrombin inhibitors are heparin alternatives for anticoagulation during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia. We report a case of a large thrombus forming in the venous reservoir while using bivalirudin. We suggest that blood stasis associated with the full venous reservoir maintained in this case led to formation of a large thrombus at the top of the venous canister. Furthermore, activated clotting times may not accurately reflect the magnitude of anticoagulation when using direct thrombin inhibitors.

Thrombosis during off pump LVAD placement in a patient with heparin induced thrombocytopenia using bivalirudin

“…Proteolytic destruction by thrombin plays a major role in bivalirudin elimination, and this places areas of blood stasis at high risk of having subtherapeutic bivalirudin levels. Accordingly, several case reports exist of thrombus associated with bivalirudin in CPB venous reservoirs, in the CPB circuit after or near the termination of the CPB procedure, and post cardiotomy ECMO [9,10]. It is possible that there may have been prolonged stasis of blood between the deairing/washout of the LVAD and the coring of the left ventricle, which may have caused a small volume of blood to become stagnant within the HeartMate II device.…”

Heparin Insensitivity and Thrombotic Risk Associated With Sequential Uses of Prothrombin Complex Concentrate and Andexanet Alfa for Apixaban Reversal During Acute Type A Aortic Dissection Repair: A Case Report

“… 9 Additionally, CPB reservoirs are known to create blood stasis, which predisposes them to thrombus formation as reported in the cases utilizing direct thrombin inhibitors. 10 – 11 Low-flow states such as those that occur during the DHCA used in aortic surgery can exacerbate the risk of thrombosis.…”

Optical Coherence Tomographic Evaluation of Hyperacute Bivalirudin-Induced Coronary Stent Thrombosis

“…1,4,5 Wong and colleagues 6 reported a large thrombus that formed in the venous reservoir during cardiopulmonary bypass in a patient who had been given bivalirudin after an episode of heparin-induced thrombocytopenia. In the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (Horizons-AMI) and Acute Catheterization and Urgent Intervention Triage Strategy (Acuity) trials, patients undergoing primary PCI who were given bivalirudin had higher rates of acute stent thrombosis than did those who were given heparin and a glycoprotein IIb/IIIa inhibitor.…”