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 IV 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, penia, 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. CARDIOVASCULAR