Anticoagulation During Extracorporeal Life Support (ECLS)

• Cardiopulmonary Bypass (CPB) (see Cardiopulmonary Bypass)
  • Especially Useful in the Settings of Heparin-Induced Thrombocytopenia (HIT) or Heparin Resistance (see Heparin-Induced Thrombocytopenia and Heparin)
• Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) (see Venoarterial Extracorporeal Membrane Oxygenation)
  • Especially Useful in the Settings of Heparin-Induced Thrombocytopenia (HIT) or Heparin Resistance (see Heparin-Induced Thrombocytopenia and Heparin)
• Venovenous Extracorporeal Membrane Oxygenation (VV-ECMO) (see Venovenous Extracorporeal Membrane Oxygenation)
  • Especially Useful in the Settings of Heparin-Induced Thrombocytopenia (HIT) or Heparin Resistance (see Heparin-Induced Thrombocytopenia and Heparin)

Anticoagulation During Percutaneous Coronary Intervention (PCI) (see Percutaneous Coronary Intervention)

General Comments

• Use During Percutaneous Coronary Intervention (PCI) was the First FDA-Approved for Bivalirudin (Thromb Haemost, 2008) [MEDLINE]

Clinical Efficacy

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Heparin-Induced Thrombocytopenia (HIT) (see Heparin-Induced Thrombocytopenia)

Clinical Efficacy

• Systematic Review and Meta-Analysis of the Safety/Efficacy of Anticoagulants in the Treatment of Heparin-Induced Thrombocytopenia (Am J Hematol, 2021) [MEDLINE]: n = 4,698 (from 92 studies)
  • The Pooled Rate of Platelet Recovery Ranged from 74% (Bivalirudin) to 99% (Fondaparinux)
  • The Pooled Rate of Thromboembolism Ranged from from 1% (Fondaparinux) to 7% (Danaparoid)
  • The Pooled Rate of Major Bleeding Ranged from 1% (DOAC) to 14% (Bivalirudin)
  • The Pooled Rate of Death Ranged from 7% (Fondaparinux) to 19% (Bivalirudin)
  • Confidence Intervals were Mostly Overlapping, and Results were Not Influenced by Patient Population, Diagnostic Test Used, Study Design, or Type of Article
  • Safety and Efficacy Outcomes were Similar Among the Anticoagulants, and Significant Factors Affecting These Outcomes were Not Identified
  • Findings Support Fondaparinux and DOAC’s as Viable Alternatives to Conventional Anticoagulants for the Treatment of Acute Heparin-Induced Thrombocytopenia

Percutaneous Coronary Intervention (PCI) (see Percutaneous Coronary Intervention)

• Indications
  • Coronary Artery Disease (CAD) (see Coronary Artery Disease)

Bivalirudin is a Thrombin Inhibitor (see Factor IIa Inhibitors)

• Affinity for Thrombin is Intermediate Between that of Lepirudin (Which Has the Highest for Thrombin) and Argatroban (Which Has the Lowest Affinity got Thrombin) (Thromb Haemost, 2008) [MEDLINE]
  • This Explains Why Bivalirudin Interferes with Functional Clotting Assays to an Extent Intermediate Between that Achieved by Lepirudin and Argatroban
    • This effect is best known for the PT (INR)
      • Higher Affinity for Thrombin Corresponds to Lower Molar Direct Thrombin Inhibitor Requirements to Prolong the aPTT
      • In Turn, Lower Concentrations Required for aPTT Prolongation (and, Presumably, In Vivo Effect) Result in Decreased INR Prolongation

Metabolism

• Predominantly Non-Organ Elimination (Proteolysis)
• Half-Life: 25 min

Hemorrhagic Adverse Effects

• Adrenal Hemorrhage (see Adrenal Insufficiency)
• Diffuse Alveolar Hemorrhage (DAH) (see Diffuse Alveolar Hemorrhage)
• Epistaxis (see Epistaxis)
• Gastrointestinal Hemorrhage (see Gastrointestinal Hemorrhage)
• Hematuria (see Hematuria)
• Intracerebral Hemorrhage (Hemorrhagic Cerebrovascular Accident) (see Intracerebral Hemorrhage)
• Intracranial Epidural Hematoma (see Intracranial Epidural Hematoma)
• Retroperitoneal Hemorrhage (see Retroperitoneal Hemorrhage)
• Spinal Epidural Hematoma (see Spinal Epidural Hematoma)
• Subarachnoid Hemorrhage (SAH) (see Subarachnoid Hemorrhage)
• Subdural Hematoma (SDH) (see Subdural Hematoma)

Other Adverse Effects

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