title: Antithrombotic strategies in children receiving long-term Berlin Heart EXCOR ventricular assist device therapy.
abstract: BACKGROUND
  Thromboembolic events while receiving ventricular assist device (VAD) support remain a significant cause of morbidity and mortality despite standard anti-coagulation and anti-platelet therapies. The use of bivalirudin and epoprostenol infusions as an alternate anti-thrombotic (AT) regimen in pediatric VAD patients was reviewed.
  
  
  METHODS
  This was a retrospective record review of 6 pediatric patients (aged ≤17 years) at 2 institutions treated with bivalirudin and epoprostenol infusions while being supported with the Berlin Heart EXCOR (Berlin Heart GmbH, Berlin, Germany) VAD.
  
  
  RESULTS
  Six patients (age, 0.8-14 years; weight, 6.7-29.7 kg) were treated. Diagnoses included cardiomyopathy in 2 and congenital heart disease in 4. VAD support was left VAD in 2 and bi-VAD in 4, with duration of support of 21 to 155 days. Three patients required extracorporeal membrane oxygenation before VAD support. Bivalirudin/epoprostenol was used after recurrent thromboses on conventional medication in 3 patients, heparin-induced thrombocytopenia in 2, and in 1 patient considered high risk with a prosthetic mitral valve. The bivalirudin dose was titrated to partial thromboplastin time (PTT) of 1.5- to 2-times baseline (0.1-0.8 mg/kg/hour); the epoprostenol dose was 2 to 10 ng/kg/min. Additional anti-platelet agents included acetylsalicylic acid, dipyridamole, and clopidogrel in 5 patients each. No bleeding complications occurred. One patient sustained a cerebrovascular infarct on therapy, with subsequent complete recovery. No other complications occurred. Five patients underwent successful transplantation, and 1 patient died of multisystem organ failure.
  
  
  CONCLUSIONS
  This report provides data on estimated safety and efficacy of bivalirudin and epoprostenol as an AT strategy in pediatric patients on extended VAD support. The short drug half-life and predictable AT response facilitated conversion to standard AT regimens at the time of transplantation (heparin-induced thrombocytopenia-negative patients). These agents should be considered for management of pediatric VAD patients when standard regimens fail.
authors: Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada. jennifer.rutledge@albertahealthservices.ca
authors: Jennifer M
authors: JM
authors: Rutledge
authors: Sujata
authors: S
authors: Chakravarti
authors: M Patricia
authors: MP
authors: Massicotte
authors: Holger
authors: H
authors: Buchholz
authors: David B
authors: DB
authors: Ross
authors: Umesh
authors: U
authors: Joashi
mesh_terms: D000293:Adolescent; D009202:Cardiomyopathies / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D019468:Disease Management; D004305:Dose-Response Relationship, Drug; D011464:Epoprostenol / Q000009:adverse effects / Q000627:therapeutic use; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006330:Heart Defects, Congenital / Q000628:therapy*; D006353:Heart-Assist Devices / Q000145:classification; D006629:Hirudins / Q000009:adverse effects; D006801:Humans; D007223:Infant; D010446:Peptide Fragments / Q000009:adverse effects / Q000627:therapeutic use; D011994:Recombinant Proteins / Q000009:adverse effects / Q000627:therapeutic use; D012189:Retrospective Studies; D013923:Thromboembolism / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; D011464:Epoprostenol; C074619:bivalirudin