Off-Pump Coronary Artery Bypass With Bivalirudin for Patients With Heparin-Induced Thrombocytopenia or Antiplatelet Factor Four/Heparin Antibodies

• Published in: The Annals of thoracic surgery Vol. 84; no. 3; pp. 836 - 839
• Main Authors: Dyke, Cornelius M., MD, Aldea, Gabriel, MD, Koster, Andreas, MD, Smedira, Nicholas, MD, Avery, Edwin, MD, Aronson, Solomon, MD, Spiess, Bruce D., MD, Lincoff, A. Michael, MD
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01.09.2007
• Subjects: Aged; Antibodies - blood; Anticoagulants - therapeutic use; Cardiothoracic Surgery; Coronary Artery Bypass, Off-Pump - methods; Female; Heparin - adverse effects; Heparin - immunology; Hirudins; Humans; Male; Middle Aged; Peptide Fragments - therapeutic use; Platelet Factor 4 - immunology; Prospective Studies; Recombinant Proteins - therapeutic use; Surgery; Thrombocytopenia - chemically induced; 16
• ISSN: 0003-4975; 1552-6259
• DOI: 10.1016/j.athoracsur.2007.04.007

Background This study assessed the use of bivalirudin as an alternative anticoagulant in patients with heparin-induced thrombocytopenia-thrombotic syndrome (HIT/TS) or antiplatelet factor four-heparin (anti-PF4/H) antibodies undergoing off-pump coronary artery bypass (OPCAB). Methods In a prospective, open-label, multicenter study, fifty-one patients with documented anti-PF4/H antibodies and (or) HIT/TS underwent OPCAB with bivalirudin anticoagulation (0.75 mg/kg IV bolus, 1.75 mg/kg/hour infusion). Procedural success (absence of death, Q-wave myocardial infarction, repeat revascularization, and stroke), bleeding, and transfusion at day seven/discharge, thirty days, and twelve weeks were assessed. Results Thirty-five patients (67%) were included with positive anti-PF4/H antibodies and no thrombocytopenia or thrombosis, eleven patients (22%) had thrombocytopenia, and five patients had clinical HIT/TS (10%). Procedural success at seven days/discharge was achieved in forty-seven patients (92%), while procedural success at thirty days and twelve weeks was 88%. There were no deaths. Chest tube output over the first twenty-four hours was 936 ± 525 mL and twenty-five patients received a red blood cell transfusion during their hospitalization. Two patients required reexploration for persistent postoperative hemorrhage. Conclusions Bivalirudin was an effective alternative anticoagulant for patients with HIT/TS or circulating anti-PF4/H antibodies undergoing OPCAB, with high rates of procedural success and an acceptable incidence of bleeding or transfusions.