Difficult Management of Anticoagulation With Argatroban in a Patient Undergoing On-Pump Cardiac Surgery

Abstract

HEPARIN-INDUCED THROMBOCYTOPENIA (HIT), presenting as severe thrombocytopenia and possible vascular thrombosis resulting from platelet activation secondary to immune response to heparin-platelet factor 4 (PF4) complexes, is a critical concern in patients with this disorder and at risk of exposure to heparin. 1 Hassell K. Heparin-induced thrombocytopenia: Diagnosis and management. Thromb Res. 2008; 123: S16-S21 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Patients with HIT requiring cardiopulmonary bypass (CPB) present complex issues regarding the choice of an alternative agent to heparin for anticoagulation during CPB. Alternative anticoagulants include lepirudin, bivalirudin, danaparoid, and argatroban. 2 Murphy G.S. Marymont J.H. Alternative anticoagulation management strategies for the patient with heparin-induced thrombocytopenia undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2007; 21: 113-126 Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar Argatroban seems to be a reasonable option, especially for patients with renal failure because it is metabolized and eliminated primarily via a hepatic route. 3 Kathiresan S. Shiomura J. Jang I.K. Argatroban. J Thromb Thrombolysis. 2002; 13: 41-47 Crossref PubMed Scopus (44) Google Scholar , 4 Cleveland K.W. Argatroban, a new treatment option for heparin-induced thrombocytopenia. Crit Care Nurse. 2003; 23: 61-66 PubMed Google Scholar , 5 Swan S.K. Hursting M.J. The pharmacokinetics and pharmacodynamics of argatroban: Effects of age, gender, and hepatic or renal dysfunction. Pharmacotherapy. 2000; 20: 318-329 Crossref PubMed Scopus (346) Google Scholar Furthermore, its anticoagulant effect is spontaneously reversed within 2 to 4 hours because of its short elimination half-life (39-53 minutes), and its anticoagulant effect can be conveniently monitored with the activated coagulation time (ACT). 3 Kathiresan S. Shiomura J. Jang I.K. Argatroban. J Thromb Thrombolysis. 2002; 13: 41-47 Crossref PubMed Scopus (44) Google Scholar , 4 Cleveland K.W. Argatroban, a new treatment option for heparin-induced thrombocytopenia. Crit Care Nurse. 2003; 23: 61-66 PubMed Google Scholar , 5 Swan S.K. Hursting M.J. The pharmacokinetics and pharmacodynamics of argatroban: Effects of age, gender, and hepatic or renal dysfunction. Pharmacotherapy. 2000; 20: 318-329 Crossref PubMed Scopus (346) Google Scholar Although several case reports described the successful management of anticoagulation with argatroban in on-pump cardiac surgery, 6 Furukawa K. Ohteki H. Hirahara K. et al. The use of argatroban as an anticoagulant for cardiopulmonary bypass in cardiac operations. J Thorac Cardiovasc Surg. 2001; 122: 1255-1256 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar , 7 Edwards J.T. Hamby J.K. Worrall N.K. Successful use of argatroban as a heparin substitute during cardiopulmonary bypass: Heparin-induced thrombocytopenia in a high-risk cardiac surgical patient. Ann Thorac Surg. 2003; 75: 1622-1624 Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar , 8 Martin M.E. Kloecker G.H. Laber D.A. Argatroban for anticoagulation during cardiac surgery. Eur J Haematol. 2007; 78: 161-166 PubMed Google Scholar , 9 Smith A.I. Stroud R. Damiani P. et al. Use of argatroban for anticoagulation during cardiopulmonary bypass in a patient with heparin allergy. Eur J Cardiothorac Surg. 2008; 34: 1113-1114 Crossref PubMed Scopus (17) Google Scholar the lack of an effective antidote may pose a significant problem. At present, reports describing the use of argatroban for adult on-pump cardiac surgery are quite limited in number. Therefore, there is no consensus regarding precautions necessary with the use of argatroban for CPB.