Lepirudin is an alternative
anticoagulant therapy in
heparin-induced
thrombocytopenia (HIT) during
cardiopulmonary bypass (CPB). We report a case of a female patient with HIT referred for
aortocoronary bypass graft despite persistence of
antibodies to platelet factor 4-heparin complexes. Anticoagulation management is described. Whole blood
hirudin concentration attempted during CPB was above 4 microg ml(-1). To obtain this concentration,
lepirudin administration was managed as follows: 0.1 mg kg(-1) h(-1)
lepirudin during preoperative course, 0.2 mg kg(-1) bolus just before CPB and 0.2 mg kg(-1) in the priming
solution, complementary boluses of 5 and 10 mg during procedure (according to whole blood
ecarin clotting time).
Aprotinin was administered simultaneously according to Royston protocol. Anticoagulation was monitored with whole blood
ecarin time performed in the operation room (patient's whole blood was diluted one half and one third with normal whole blood; in vitro calibration curve was constructed using normal whole blood spiked with
lepirudin). CPB duration was 73 min. When measured, whole blood
hirudin concentration was 3.8-5.8 microg ml(-1). Total
lepirudin administration was 44 mg. No haemorrhagic or thrombotic events were observed during
surgical procedure and postoperative course. Despite
lepirudin administration is not yet clearly precise for CPB procedure, its use seems adapted and safe in subjects without
renal insufficiency but requiring precise coordination for anaesthesiological, surgical and
biological teams.