title: Thrombosis during off pump LVAD placement in a patient with heparin induced thrombocytopenia using bivalirudin.
abstract: Here we present our attempt at off pump HeartMate II left ventricular assist device (LVAD) implantation using the anticoagulant bivalirudin in a patient with heparin induced thrombocytopenia, which resulted in thrombosis within the LVAD device. This required that our procedure be converted to on pump, and a new HeartMate II LVAD device to be implanted. In our view, this thrombotic event may have been caused by a number of factors that include bivalirudin's (1) short half-life of about 20 minutes, (2) decreased activity with blood stasis, (3) inability to prevent clot propagation, and (4) uncertainty with real-time monitoring of therapeutic levels. To prevent future thrombotic events, it may be beneficial to immediately deair the LVAD device prior to the coring of the left ventricle during off pump LVAD placement. In addition, a solution other than blood may be used for priming. If blood is used for priming of the LVAD device, the duration of blood stasis should not exceed 20 minutes when bivalirudin is being used for anticoagulation. Furthermore, this case emphasizes the importance of having a backup LVAD device available and ready to use during surgical procedures.
authors.forename: Hamdy
authors.initials: H
authors.lastname: Awad
authors.forename: Richard
authors.initials: R
authors.lastname: Bryant
authors.forename: Obaid
authors.initials: O
authors.lastname: Malik
authors.forename: Galina
authors.initials: G
authors.lastname: Dimitrova
authors.forename: Chittoor Bhaskar
authors.initials: CB
authors.lastname: Sai-Sudhakar
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects* / Q000627:therapeutic use; D000991:Antithrombins / Q000627:therapeutic use*; D001777:Blood Coagulation; D005260:Female; D006352:Heart Ventricles; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006493:Heparin / Q000009:adverse effects*; D006629:Hirudins; D006801:Humans; D010446:Peptide Fragments / Q000627:therapeutic use*; D011994:Recombinant Proteins / Q000627:therapeutic use; D019616:Thoracic Surgical Procedures; D013921:Thrombocytopenia / Q000139:chemically induced* / Q000150:complications; D013927:Thrombosis / Q000188:drug therapy / Q000209:etiology*
chemical_list: D000925:Anticoagulants; D000991:Antithrombins; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; D006493:Heparin; C074619:bivalirudin