Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines

As the use of mechanical circulatory support has increased in volume and complexity, anticoagulation remains an intricate component of a patient’s pharmacotherapy plan. Traditionally, heparin has been the primary anticoagulant utilized because of its ease of titration and  familiarity of use. More recently, bivalirudin, a direct thrombin inhibitor, has attracted attention as a potential alternative to traditional therapy. While labeled for use in percutaneous coronary interventions, it is utilized off-label for heparin-induced thrombocytopenia and mechanical circulatory support. A literature search identified ten studies in which bivalirudin was used in extracorporeal membrane oxygenation and five studies in which it was used in ventricular assist devices. The purpose of this review was to summarize the currently available literature for bivalirudin use for mechanical circulatory support in both adult and pediatric patients.

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A Review of Bivalirudin for Pediatric and Adult Mechanical Circulatory Support

The Use of Bivalirudin in Pediatric Cardiac Surgery and in the Interventional Cardiology Suite

Ventricular assist devices (VAD) are used more in children. Safe and effective anticoagulation is required for successful management of children supported with ventricular assist devices. Developmental hemostasis, device hemocompatibility, plastic to body ratio, surgical variable techniques, lack of knowledge on pharmacokinetics of anticoagulants, and wide variability in anticoagulation protocols have all contributed to increased incidence of bleeding and thromboembolic complications. New collaborative learning networks, such as the ACTION network, provide opportunities to define best practices, optimize, and reduce anticoagulation related adverse events. ACTION was established Dec 2017. It consists of expert clinicians in heart failure, as well as researchers, parents, and patients, with goals to improve outcomes, share data, improve education and standard practice for children with heart failure (, n.d). Changes in pediatric VAD anticoagulation strategy from using mainly heparin to DTI such as bivalirudin have helped reduce bleeding and clotting complications.

/pdf/hemostatic-challenges-in-pediatric-critical-care-medicine-19f2lfivu9.pdf

Hemostatic Challenges in Pediatric Critical Care Medicine-Hemostatic Balance in VAD

We describe our experience of bivalirudin use, a newer direct thrombin inhibitor, in an infant who was supported with Berlin Heart EXCOR VAD (Berlin VAD) as bridge to transplant for 122 days withou...

N. Siva Krishna

Papers

Randomized Controlled Trial of Heparin Versus Bivalirudin Anticoagulation in Acyanotic Children Undergoing Open Heart Surgery.