Bivalirudin for Cardiac Surgery in HIT

Bivalirudin has been used off-label for cardiac surgery in a number of patients with acute or previous history of HIT, with both "on-pump" and "off-pump" experience reported. Except for several case reports (Spiess et al., 2002; Vasquez et al., 2002; Davis et al., 2003; Koster et al., 2003a; Bott et al., 2003; Gordon et al., 2003; Jabr et al., 2004; Baker et al., 2004; Clayton et al., 2004; Dyke et al., 2005; Veale et al., 2005; Wasowicz et al., 2005)—including two instances in which bivalirudin was used during heart transplantation (Almond et al., 2006; Mann et al., 2005)— experience had been anecdotal in HIT until recent completion of the CHOOSE trials. These employed bivalirudin for anticoagulation in HIT patients undergoing either CPB (CHOOSE-ON) or OPCAB surgery (CHOOSE-OFF). Results of these studies have revealed comparable safety and efficacy endpoints (Koster et al., 2007; Dyke et al., 2007) (see Chapter 19). The rationale for using bivalirudin in these settings included its direct thrombin inhibition without the requirement of a cofactor, its rapid, dose-dependent prolongation of the ACT, its short half-life, lack of structural similarity to heparin (thus, no cross-reactivity with anti-PF4/heparin antibodies), avoidance of protamine use (and its potentially severe adverse reactions), no need for dose reduction in mild renal impairment, and an ability to "reverse" its anticoagulant effect through hemofiltration. Further, there is the potential to avoid HIT antibody formation and, consequently, postoperative HIT.

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