Recombinant hirudin anticoagulation for aortic valve replacement in heparin-induced thrombocytopenia.
OBJECTIVE
To report the case of a patient with HIT that received a prolonged infusion of r-hirudin (lepirudin; Refludan; Hoechst, France) before, during and after cardiopulmonary bypass (CPB) for aortic surgery. Although administration of r-hirudin for CPB anticoagulation has previously been reported, many questions persist concerning the best therapeutic regimen for CPB anticoagulation as well as the time of onset and the doses for postoperative anticoagulation.


METHODS
A 65-yr-old man was admitted for surgery of aortic stenosis after an episode of acute pulmonary edema complicated by deep venous thrombosis in the context of documented HIT. The patient received r-hirudin for 13 dy before surgery at doses (0.4 mg x kg(-1) bolus followed by 0.15 mg x kg(-1) x hr(-1) continuous infusion) that maintained activated partial thromboplastin time (aPTT) ratios between 2 and 2.5. Anticoagulation for CPB was performed with r-hirudin given as 0.1 mg x kg(-1) i.v. bolus and 0.2 mg kg(-1) in the CPB priming volume. Anticoagulation during CPB was monitored with the whole blood activated coagulation time and ecarin clotting time (ECT) performed in the operating room with values corresponding to r-hirudin concentrations >5 microg x ml(-1) during CPB. Anticoagulation during CPB was uneventful. Two bleeding episodes, related to the r-hirudin regimen and necessitating allogeneic blood transfusion, occurred after surgery.


CONCLUSIONS
This case report confirms previous experience of the use of r-hirudin for anticoagulation during CPB and provides additional information in the context of prolonged r-hirudin infusion before and after CPB.
Longrois
D
D
Department of Anesthesia and Intensive Care, CHU Nancy-Brabois, Vandoeuvre-les-Nancy, France. d.longrois@chu-nancy.fr
de Maistre
E
E
Bischoff
N
N
Dopff
C
C
Meistelman
C
C
Angioï
M
M
Lecompte
T
T
D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001021:Aortic Valve / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000601:surgery; D001777:Blood Coagulation / Q000187:drug effects; D001803:Blood Transfusion; D002315:Cardiopulmonary Bypass; D010450:Endopeptidases; D005343:Fibrinolytic Agents; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation; D006493:Heparin / Q000009:adverse effects*; D024764:Hirudin Therapy; D006629:Hirudins / Q000008:administration & dosage / Q000031:analogs & derivatives*; D006801:Humans; D007262:Infusions, Intravenous; D007275:Injections, Intravenous; D008297:Male; D019106:Postoperative Hemorrhage / Q000139:chemically induced / Q000628:therapy; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000627:therapeutic use; D013921:Thrombocytopenia / Q000139:chemically induced*; D020246:Venous Thrombosis / Q000139:chemically induced; D014914:Whole Blood Coagulation Time
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D006629:Hirudins; D011994:Recombinant Proteins; D006493:Heparin; D010450:Endopeptidases; C020097:ecarin; C083544:lepirudin