Antithrombotic Management during Percutaneous Mitral Valve Repair with the Mitraclip System in a Patient with Heparin-Induced Thrombocytopenia

Abstract

Interventional cardiology procedures require full anticoagulation to prevent thrombus formation on catheters and devices with potential development of embolic complications. Bivalirudin, a short half-life direct thrombin inhibitor, has been largely used during percutaneous coronary interventions and represents the preferred alternative to heparin in patients with heparin-induced thrombocytopenia (HIT). However, few data are available about intraprocedural use of bivalirudin during transcatheter structural heart disease interventions. Activated clotting time (ACT) monitoring during bivalirudin infusion presents some limitations and it is not mandatory. We report a case of bivalirudin use in a patient with type-2 HIT during percutaneous mitral valve repair with the Mitraclip system (Abbott, Abbott Park, Illinois, United States). Despite use of standard bivalirudin dose (0.75 mg/kg bolus and 1.4 mg/kg/min infusion—reduced infusion rate was motivated by a glomerular filtration rate of 37 mL/min), the patient developed a large thrombus on the second clip during its orientation toward the mitral orifice. ACT was measured at that time and was suboptimal (240 seconds). The case was successfully managed with clip and thrombus retrieval, adjunctive 0.3 mg/kg bivalirudin bolus and increased infusion rate, and clip repositioning with ACT monitoring. This report makes the case for mandatory ACT checking and drug titration during high-risk catheter–based structural heart disease interventions, even when thromboprophylaxis is performed with bivalirudin. Additional coagulation tests may be useful to monitor bivalirudin response in similar cases.

Acute Device-Related Thrombus Elimination During Transcatheter Edge-to-Edge Repair Via Vacuum Catheter Aspiration

“…There are a few reports of thrombus formation during TEER procedures, both during heparin and bivalirudin use, and sometimes even with ACT >250 seconds. 5 , 6 Predeployment device thrombus in the sheath or around the clip is typically treated with aspiration and removal of the catheter. However, management of device-related thrombus postdeployment is challenging.…”

“…There have been reports of continued use of the current anticoagulant, supplementation with additional anticoagulation, or low-dose thrombolysis in this setting. 6 , 7 , 8 There are also reports of planned use of the AngioVac (Angiodynamics) for aspiration of a left atrial thrombus. 9 , 10 However, to our knowledge, this is the first reported use of this specific catheter for aspiration of a thrombus adherent to a TEER device.…”

Neck Hematoma after Central Venous Catheterization and Awake Intubation as Rescue Airway Management Technique: A Case Report

“…Along with multiple attempts to central line placement, another factor directly contributing to hematoma development is heparin administration and non-reversal with protamine. Interventional cardiology procedures require full anticoagulation to prevent thrombus formation on catheters and devices with potential development of embolic complications ( 11 ). For MitraClip procedure, an initial bolus of heparin is given after transseptal puncture ( 12 ).…”