Anticoagulation of Impella with a Bivalirudin Purge Solution

The use of percutaneous ventricular assist devices (VADs) in the acute management of cardiogenic shock is becoming increasingly common. The Impella is a percutaneous VAD, which requires a heparin-containing purge solution to prevent thrombosis and maintain proper pump functionality. In this report, we describe two patients with heparin-induced thrombocytopenia (HIT) supported with an Impella using a bivalirudin-containing purge solution. Case 1 involved a 39-year-old man with cardiogenic shock, initially implanted with an intraaortic balloon pump, who developed HIT early in his hospital course. His worsening hemodynamics necessitated the placement of an Impella and later venoarterial extracorporeal membrane oxygenation until he eventually underwent durable left VAD implantation. Case 2 involved a 69-year-old man who had an Impella implanted for worsening cardiogenic shock. HIT was suspected shortly after device insertion, necessitating switching his anticoagulation to bivalirudin. He was successfully bridged directly to heart transplantation. Both patients' courses resulted in therapeutic anticoagulation without major bleeding or thrombotic events. These cases demonstrate the safe and effective use of bivalirudin-containing purge solutions for patients with confirmed HIT requiring temporary mechanical circulatory support with Impella.