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Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock
Published on: June 12, 2021
'Bail-out' bivalirudin use in patients with thrombotic complications unresponsive to conventional treatment during
Luigi La Vecchia1, Ester Cabianca, Leonardo Varotto
1Catheterization Laboratory, S. Bortolo Hospital, Vicenza, Italy.
Insights
Patients undergoing percutaneous coronary intervention (PCI) with heparin may experience thrombosis due to heparin resistance. Switching to bivalirudin effectively achieved anticoagulation and resolved complications in these cases.
Area of Science:
- Cardiology
- Interventional Cardiology
- Thrombosis Research
Background:
- Percutaneous coronary intervention (PCI) for acute coronary syndromes typically involves clopidogrel and unfractionated heparin.
- Activated clotting time (ACT) monitoring is recommended but often not performed to guide anticoagulation during PCI.
- Heparin resistance can lead to inadequate anticoagulation and periprocedural complications.
Observation:
- Four cases of PCI involving complex bifurcation lesions presented with periprocedural thrombosis and acute ischemia.
- Patients exhibited inadequate ACT measurements despite standard heparin dosing and clopidogrel treatment.
- This suggested a degree of heparin resistance in the context of complicated PCI.
Findings:
- Switching anticoagulation from heparin to bivalirudin rapidly improved ACT measurements.
- Bivalirudin administration, combined with further intervention, successfully resolved the thrombotic events.
- No bleeding complications were observed with the bivalirudin regimen.
Implications:
- Bivalirudin may be a feasible alternative for patients with heparin resistance during complex PCI.
- This strategy can potentially prevent or manage periprocedural thrombosis in challenging cases.
- Highlights the importance of ACT monitoring and tailored anticoagulation strategies in interventional cardiology.
Abstract:
Percutaneous coronary intervention (PCI) is routinely performed in patients with non-ST elevation acute coronary syndromes after pretreatment with clopidogrel and periprocedural administration of unfractionated heparin on a weight-adjusted basis. Although activated clotting time (ACT) monitoring is encouraged to verify the adequacy of anticoagulation during the procedures, this is not a common practice in many laboratories. The authors describe 4 cases of patients with bifurcation lesions involving the left anterior descending coronary artery, who developed periprocedural thrombosis with acute transmural ischemia. All patients had inadequate ACT measurements, despite conventional heparin dosage and ongoing clopidogrel treatment. In order to achieve complete anticoagulation, patients were switched to bivalirudin, which determined a prompt effect on measured ACT. This therapeutic regimen, coupled with further intervention, allowed resolution of the thrombotic complication without bleeding. This report suggests the feasibility of a strategy of bivalirudin use in patients who have some degree of heparin 'resistance' in the setting of complicated PCI.
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