Off-pump coronary artery bypass with bivalirudin for patients with heparin-induced thrombocytopenia or antiplatelet factor four/heparin antibodies.
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 i.v. 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.
Dyke
Cornelius M
CM
Department of Cardiovascular and Thoracic Surgery, Gaston Memorial Hospital, Gastonia, North Carolina 28054, USA. dykec@gmh.org
Aldea
Gabriel
G
Koster
Andreas
A
Smedira
Nicholas
N
Avery
Edwin
E
Aronson
Solomon
S
Spiess
Bruce D
BD
Lincoff
A Michael
AM
D000368:Aged; D000906:Antibodies / Q000097:blood*; D000925:Anticoagulants / Q000627:therapeutic use*; D047549:Coronary Artery Bypass, Off-Pump / Q000379:methods*; D005260:Female; D006493:Heparin / Q000009:adverse effects* / Q000276:immunology; D006629:Hirudins; D006801:Humans; D008297:Male; D008875:Middle Aged; D010446:Peptide Fragments / Q000627:therapeutic use*; D010978:Platelet Factor 4 / Q000276:immunology*; D011446:Prospective Studies; D011994:Recombinant Proteins / Q000627:therapeutic use; D013921:Thrombocytopenia / Q000139:chemically induced*
D000906:Antibodies; D000925:Anticoagulants; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; D010978:Platelet Factor 4; D006493:Heparin; C074619:bivalirudin