Antithrombotic Management during Percutaneous Mitral Valve Repair with the Mitraclip System in a Patient with Heparin-Induced Thrombocytopenia

Abstract

Interventional cardiology procedures require full anticoagulation to prevent thrombus formation on catheters and devices with potential development of embolic complications. Bivalirudin, a short half-life direct thrombin inhibitor, has been largely used during percutaneous coronary interventions and represents the preferred alternative to heparin in patients with heparin-induced thrombocytopenia (HIT). However, few data are available about intraprocedural use of bivalirudin during transcatheter structural heart disease interventions. Activated clotting time (ACT) monitoring during bivalirudin infusion presents some limitations and it is not mandatory. We report a case of bivalirudin use in a patient with type-2 HIT during percutaneous mitral valve repair with the Mitraclip system (Abbott, Abbott Park, Illinois, United States). Despite use of standard bivalirudin dose (0.75 mg/kg bolus and 1.4 mg/kg/min infusion—reduced infusion rate was motivated by a glomerular filtration rate of 37 mL/min), the patient developed a large thrombus on the second clip during its orientation toward the mitral orifice. ACT was measured at that time and was suboptimal (240 seconds). The case was successfully managed with clip and thrombus retrieval, adjunctive 0.3 mg/kg bivalirudin bolus and increased infusion rate, and clip repositioning with ACT monitoring. This report makes the case for mandatory ACT checking and drug titration during high-risk catheter–based structural heart disease interventions, even when thromboprophylaxis is performed with bivalirudin. Additional coagulation tests may be useful to monitor bivalirudin response in similar cases.

Keywords

Thrombosis - heart - antithrombin

• References

• 1 Berardini A, Biagini E, Saia F. , et al. Percutaneous mitral valve repair: the last chance for symptoms improvement in advanced refractory chronic heart failure?. Int J Cardiol 2017; 228: 191-197
• 2 Arepally GM. Heparin-induced thrombocytopenia. Blood 2017; 129 (21) 2864-2872
• 3 Dangas GD, Lefèvre T, Kupatt C. , et al; BRAVO-3 Investigators. Bivalirudin versus heparin anticoagulation in transcatheter aortic valve replacement: the randomized BRAVO-3 trial. J Am Coll Cardiol 2015; 66 (25) 2860-2868
• 4 Bellmann B, Nagel P, Muntean BG. Successful intraprocedural anticoagulation with bivalirudin during pulmonary vein isolation in a patient with known heparin-induced thrombocytopenia type II. J Arrhythm 2016; 32 (02) 154-155
• 5 Ellis ER. Successful use of bivalirudin in place of heparin infusion for pulmonary vein isolation using a cryoballoon catheter in a patient with heparin allergy. HeartRhythm Case Rep 2017; 3 (01) 10-12
• 6 Carroll RC, Chavez JJ, Simmons JW. , et al. Measurement of patients' bivalirudin plasma levels by a thrombelastograph Ecarin clotting time assay: a comparison to a standard activated clotting time. Anesth Analg 2006; 102 (05) 1316-1319
• 7 Cardinale M, Ha M, Liu MH, Reardon DP. Direct thrombin inhibitor resistance and possible mechanisms. Hosp Pharm 2016; 51 (11) 922-927
• 8 Weeks PA, Alkhateeb HM, Michaud SE, Diez JG. Evaluation of bivalirudin hyper- and hypo-ACT responses in the setting of percutaneous coronary intervention. J Invasive Cardiol 2013; 25 (05) 250-253