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CARDIOVASCULAR ANESTHESIA

Reversal of Direct Thrombin Inhibition After Cardiopulmonary Bypass in a Patient with Heparin-Induced Thrombocytopenia

Greg Stratmann, MD, PhD^*, Anil M. deSilva, MD^*, Elaine E. Tseng, MD, Julie Hambleton, MD, Michel Balea^*, Anthony J. Romo, MD^*, Michael J. Mann, MD, Nancy L. Achorn, CCP, William F. Moskalik, CCP, and Charles W. Hoopes, MD

Departments of *Anesthesia and Perioperative Care, Surgery, and Medicine, University of California at San Francisco; and Golden Gate Perfusion, Inc., San Francisco, California

Address correspondence and reprint requests to Greg Stratmann, MD, Department of Anesthesia and Perioperative Care, Mailbox 0464, Room U 368 P, Moffitt Hospital, 513 Parnassus Ave., San Francisco, CA 94143. Address e-mail to gstratmann{at}anesthesia.ucsf.edu

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.

IMPLICATIONS: 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.

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