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Meshulami N, Murthy R, Meyer M, Meyer AD, Kaushik S. Bivalirudin anticoagulation for cardiopulmonary bypass during cardiac surgery. Perfusion 2023:2676591231221708. [PMID: 38084653 DOI: 10.1177/02676591231221708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Heparin is the primary anticoagulant for cardiopulmonary bypass (CPB) support during cardiac surgery. While widely used, ∼2% of cardiac surgery patients develop heparin-induced thrombocytopenia (HIT) and 4-26% develop heparin resistance. Bivalirudin is an alternative anticoagulant mainly used for percutaneous coronary interventions. Given the challenges associated with heparin anticoagulation, we conducted a review to explore the use of bivalirudin for CPB surgery. METHODS PubMed and Embase scoping review included 2 randomized controlled trials, a retrospective comparison study, 3 pilot studies, and 30 case reports. To provide a contemporary series, we searched for articles published from 2010 to 2023. Our review included studies from both adult and pediatric populations. RESULTS While data is limited, bivalirudin seems to supply similar effectiveness and safety as heparin for CPB anticoagulation. Across the three comparative studies, the heparin cohorts had a 0-9% mortality rate and 0-27% rate of major bleeding/reoperation compared to a 0-3% mortality and 0-6% major bleeding/reoperation rate for the bivalirudin cohorts. Bivalirudin was successfully used as an anticoagulant in a wide range of CPB surgeries (e.g., heart transplants, ventricular assisted device placements, and valve repairs). Successful patient outcomes were reported with bivalirudin infusion of ∼2 mg/kg/hour, activated clotting time monitoring (target >400 s or 2.5× baseline), use of cardiotomy suctions, minimization of stagnant blood, and post-bypass modified ultrafiltration. CONCLUSION Bivalirudin is a safe and effective anticoagulant for CPB, especially for patients with HIT or heparin resistance. Further comparative research is called for to optimize bivalirudin utilization for CPB during cardiac surgery.
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Affiliation(s)
- Noy Meshulami
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raghav Murthy
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Pediatric Cardiac Surgery, Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maisy Meyer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew D Meyer
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Shubhi Kaushik
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Pediatric Critical Care, Department of Pediatrics, Kravis Children's Hospital at Mount Sinai, Icahn School of Medicine, New York, NY, USA
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Baradaran H, Hashem Zadeh A, Dashti-Khavidaki S, Laki B. Management of drug-induced neutropenia, thrombocytopenia, and anaemia after solid organ transplantation: A comprehensive review. J Clin Pharm Ther 2022; 47:1895-1912. [PMID: 36250775 DOI: 10.1111/jcpt.13775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 12/24/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Advances in the development of more effective immunosuppressive drugs have increased graft survival and drug induced adverse effects. Haematological complications including neutropenia, thrombocytopenia, and anaemia are common side effects that affect the grafts' and patients' outcomes. Several studies have stated the important role of various medications in haematological complications after transplantation. They have reported the incidence and different mechanisms of drug induced cytopenia, as well as an overview of possible treatment modalities. However, there is no comprehensive protocol for the management of these complications following transplantation. This narrative review was performed to develop a comprehensive practical approach for management of drug induced haematological complications following solid organ transplantation. METHOD PubMed, Embase, Cochrane library, Web of Science, and Google scholar databases were searched without time limitations until March, 2021. In addition, some valid drug information data bases (Uptodate and Micromedex) were searched for detailed information until October, 2021. RESULTS AND DISCUSSION Several immunosuppressive and antimicrobial medications may induce neutropenia, thrombocytopenia or anaemia following transplantation. Most of these agents cause dose-related cytopenia, which resolves with dose reduction or drug withdrawal. However, any change in medications may result in negative consequences such as severe infections, bleeding, cardiovascular complications, acute allograft rejection, and graft or patient loss. Thus, cautious evaluation of the patient's condition and the pharmacological properties of the culprit medication are required. WHAT IS NEW AND CONCLUSION Three algorithms are presented to guide healthcare providers in the stepwise management of drug-induced neutropenia, thrombocytopenia, and anaemia after solid organ transplantation.
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Affiliation(s)
- Hananeh Baradaran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Simin Dashti-Khavidaki
- Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahareh Laki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Neethling E, Moreno Garijo J, Mangalam TK, Badiwala MV, Billia P, Wasowicz M, Van Rensburg A, Slinger P. Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications. J Cardiothorac Vasc Anesth 2020; 34:2189-2206. [DOI: 10.1053/j.jvca.2019.09.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/07/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
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Taguchi K, Ishiyama K, Ide K, Ohira M, Tahara H, Ohdan H. Simultaneous Liver-Kidney Transplantation in Patient with a History of Heparin-Induced Thrombocytopenia: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:980-987. [PMID: 31285416 PMCID: PMC6640169 DOI: 10.12659/ajcr.916717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patient: Male, 58 Final Diagnosis: Heparin-induced thrombocytopenia Symptoms: Liver and kidney failure Medication: — Clinical Procedure: Simultaneous liver-kidney transplantation Specialty: Transplantology
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Affiliation(s)
- Kazuhiro Taguchi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan.,Institute for Clinical Research, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Hiroshima, Japan
| | - Kohei Ishiyama
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan.,Department of Surgery, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Hiroshima, Japan
| | - Kentaro Ide
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
| | - Hiroyuki Tahara
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima City, Hiroshima, Japan
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Bryant ME, Regan WL, Fynn-Thompson F, Hoganson D, Nasr VG, Zaleski K, Faella K, Matte GS. Comparison of two pediatric cases requiring the use of bivalirudin during cardiopulmonary bypass. Perfusion 2018; 33:525-532. [DOI: 10.1177/0267659118767374] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction: Comparison of two pediatric cases at our institution that utilized bivalirudin for anticoagulation on cardiopulmonary bypass (CPB); a bilateral lung transplant (BLT) and a ventricular assist device (VAD) implantation. Methods: The same bivalirudin protocol was utilized in both cases with an initial bolus of 1 mg/kg administered by the anesthesia team, a 50 mg bolus in the pump prime at the time of the initial patient bolus and an initial infusion rate of 2.5 mg/kg/h, with titration as needed during CPB to maintain kaolin-activated clotting time (K-ACT) values >400 s. Results: The BLT experienced high K-ACT levels (>720 s) for the majority of the case despite decreasing the bivalirudin infusion rate to 0.5 mg/kg/h. The VAD implantation case required the bivalirudin infusion rate to be increased to 5.0 mg/kg/h throughout the case due to low K-ACTs. Conclusion: The literature strongly supports a specific infusion rate1–7 (2.5 mg/kg/h) for bivalirudin anticoagulation during extracorporeal circulation. Clinicians must consider the loss of clotting factors and the administration of blood products while adjusting the bivalirudin infusion during bypass. We have now elected to maintain an infusion rate of ≥0.5 mg/kg/h for bivalirudin anticoagulation at our center, based on institutional experience, though consideration for a higher infusion rate for an added margin of safety should be considered. It is imperative to have a well-developed protocol for the management of these cardiopulmonary bypass patients and we offer our one-page timeline of events to help guide other pediatric centers looking to use bivalirudin anticoagulation.
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Affiliation(s)
- Molly E. Bryant
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - William L. Regan
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Hoganson
- Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Viviane G. Nasr
- Division of Cardiac Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine Zaleski
- Division of Cardiac Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Katie Faella
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Gregory S. Matte
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts, USA
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Chen E, Clarke N, Huffman L, Peltz M. Transplantation in a patient on extracorporeal membrane oxygenation with infective endocarditis, pericarditis and heparin-induced thrombocytopenia. Interact Cardiovasc Thorac Surg 2017; 24:462-463. [PMID: 28040771 DOI: 10.1093/icvts/ivw359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 10/10/2016] [Indexed: 11/14/2022] Open
Abstract
Heart failure patients with pacemaker or defibrillator-associated endocarditis in cardiogenic shock have few treatment options. We present a case of an INTERMACS I patient who developed device infection, sepsis, bacterial pericarditis and heparin-induced thrombocytopenia. The patient was stabilized with extracorporeal membrane oxygenation and successfully transplanted.
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Affiliation(s)
- Eunise Chen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nicholas Clarke
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lynn Huffman
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Duggal N, Haft J, Engoren M, Peters W. Pulmonary Endarterectomy Under Hypothermic Circulatory Arrest in a Patient With Heparin-Induced Thrombocytopenia. J Cardiothorac Vasc Anesth 2016; 30:741-5. [DOI: 10.1053/j.jvca.2015.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Indexed: 11/11/2022]
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Pazhenkottil AP, Rudiger A, Flammer A, Enseleit F, Jacobs S, Falk V, Ruschitzka F, Bettex D. Left Main Artery Thrombus Complicating Heart Transplantation in a Patient With Heparin-Induced Thrombocytopenia. J Cardiothorac Vasc Anesth 2015; 30:1334-6. [PMID: 27431594 DOI: 10.1053/j.jvca.2015.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Indexed: 01/19/2023]
Affiliation(s)
| | | | | | | | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany, University Heart Center, University Hospital Zurich, Zurich, Switzerland
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Van De Car DA, Rao SV, Ohman EM. Bivalirudin: a review of the pharmacology and clinical application. Expert Rev Cardiovasc Ther 2014; 8:1673-81. [DOI: 10.1586/erc.10.158] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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