Cost Comparison of Bivalirudin versus Unfractionated Heparin for Children on Left Ventricular Assist Devices

Abstract

Intravenous unfractionated heparin (UFH) has been the traditional immediate post-operative anticoagulant for pediatric ventricular assist device (VAD) recipients. In recent years, bivalirudin has been increasingly used as an alternative agent and may confer advantages over UFH. However, bivalirudin may be cost-prohibitive, due to the price of the drug. The aim of this study was to compare early post-operative costs for patient cohorts receiving UFH versus bivalirudin. Patients supported on the Berlin EXCOR® at Primary Children's Hospital (PCH) and Lucile Packard Children's Hospital (LPCH) from 01/2016 and 12/2018 were included. Patients treated with bivalirudin were matched by underlying diagnosis and implant weight to patients treated with UFH. The cost of heparin therapy included the cost of Heparin Activity Levels (HAL, Anti-Xas), antithrombin activity levels, and antithrombin drug cost. The cost of bivalirudin therapy included drug cost and cost of activated partial thromboplastin times (aPTTs). Drug pricing was based on average wholesale price. Laboratory costs were based on PCH cost. Cost analysis was based on post-operative day 0 - 14, the time frame of greatest anticoagulant lability. Twelve matched patients were included; 5 cardiomyopathy and 1 congenital heart disease per cohort with similar median implant weights (9 kg UFH vs 12 kg bivalirudin, p = 0.58). For the UFH cohort, median cost per patient day of support was $1,025.07/day; labs comprised 69% of total costs, and drug 31%. Bivalirudin median cost per patient day of support was $740.49/day, with 97% drug cost and 3% lab cost. Cost per patient day of support was not significantly different between the groups (p = 0.38). HALs were obtained a median of 2.1 times per patient day for the UFH cohort, while aPTTs were obtained a median of 4.4 times per patient day in the bivalirudin cohort (p=0.006). Bivalirudin and UFH have similar costs during the first 14 days after Berlin EXCOR® implant, when therapeutic drug monitoring is included, thus illustrating noninferiority of bivalirudin from a cost perspective.