Reversal of direct thrombin inhibition after cardiopulmonary bypass in a patient with heparin-induced thrombocytopenia.
We treated persistent hemorrhage after cardiopulmonary bypass in a heart transplant recipient who had received anticoagulation with the direct thrombin inhibitor bivalirudin by a combination therapy aimed at reducing the plasma concentration of the thrombin antagonist (hemodialysis and modified ultrafiltration), increasing the concentration of thrombin at bleeding sites (recombinant factor VIIa), and increasing the plasma concentration of other coagulation factors (fresh frozen plasma and cryoprecipitate). The bleeding was controlled, and there was no thrombotic complication.


CONCLUSIONS
A combination of modified ultrafiltration, hemodialysis, and the administration of recombinant factor VIIa, fresh frozen plasma, and cryoprecipitate may reverse the anticoagulant effect of bivalirudin.
Stratmann
Greg
G
Departments of *Anesthesia and Perioperative Care, †Surgery, and ‡Medicine, University of California at San Francisco; and §Golden Gate Perfusion, Inc., San Francisco, California.
deSilva
Anil M
AM
Tseng
Elaine E
EE
Hambleton
Julie
J
Balea
Michel
M
Romo
Anthony J
AJ
Mann
Michael J
MJ
Achorn
Nancy L
NL
Moskalik
William F
WF
Hoopes
Charles W
CW
D000328:Adult; D000991:Antithrombins / Q000009:adverse effects / Q000494:pharmacology; D002315:Cardiopulmonary Bypass / Q000379:methods*; D006493:Heparin / Q000009:adverse effects* / Q000494:pharmacology; D006629:Hirudins / Q000031:analogs & derivatives* / Q000494:pharmacology; D006801:Humans; D008297:Male; D010446:Peptide Fragments / Q000494:pharmacology / Q000627:therapeutic use; D011994:Recombinant Proteins / Q000494:pharmacology / Q000627:therapeutic use; D013917:Thrombin / Q000037:antagonists & inhibitors*; D013921:Thrombocytopenia / Q000139:chemically induced* / Q000628:therapy
D000991:Antithrombins; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; D006493:Heparin; D013917:Thrombin; C074619:bivalirudin