Bivalirudin Resistance During Percutaneous Coronary Intervention in a Patient With ESRD

First Author(s)

• 

  Hassan Hashm

  Pulmonary Disease Fellow
  Rosalind Franklin University of Medicine and Science
  Wadsworth, Illinois

  Disclosure information not submitted.

  Slides and Audio

Co-Author(s)

• LS

  Lavanya Srinivasan, MD, FCCP

  Pulmonary and Critical Care Medicine Physician
  Rosalind Franklin University of Medicine and Science, United States

  Disclosure information not submitted.
• KP

  Kunal Patel, MD

  Pulmonary and Critical Care Medicine Physician
  Rosalind Franklin University of Medicine and Science, United States

  Disclosure information not submitted.

Title: Bivalirudin Resistance During Percutaneous Coronary Intervention in a Patient with ESRD

Case Report Body:

Introduction:

Bivalirudin is a synthetic direct thrombin inhibitor that is used for anticoagulation during percutaneous coronary interventions (PCI). The activated clotting time (ACT) is widely used to guide anticoagulation during PCI and cardiothoracic procedures. To the best of our knowledge, only a few cases of bivalirudin resistance have been published.

Description:

A 61-year-old female with a history of ESRD requiring HD presented to the ED due to worsening shortness of breath and chest pain over the past two days. Her chest x-ray findings were consistent with pulmonary edema. The patient’s PT/INR, PTT, platelets, liver function testing, serial troponin levels, and ECG were unremarkable. Due to a recent normal cardiac stress test, the patient underwent coronary catheterization. A thrombus was discovered in the mid RCA. Bivalirudin was given as a 0.75 mg/kg bolus and subsequent infusion of 0.25 mg/kg/hour. After six minutes, the ACT was 150 seconds, below the target of 300 seconds. An additional 0.3 mg/kg bolus was given and a repeat ACT five minutes later was still below 300 seconds. The patient was then given a 25 mcg/kg bolus of tirofiban with a subsequent 0.075 mcg/kg/minute infusion. A repeat ACT remained below 300 seconds. The bivalirudin infusion was increased to 0.5 mg/kg/hr and ultimately 1 mg/kg/hr, with ACT checks every five minutes, but to no avail. To account for the possibility of device malfunction, three ACT machines were used near simultaneously. All three devices read below 300 seconds. To pursue adequate anticoagulation, the decision was made to administer 3000 units of unfractionated heparin. Repeat ACT testing was over 400 seconds on all three devices. Thrombectomy via an aspiration catheter and drug-eluting stent placement were successfully performed. The patient's symptoms improved and she was later discharged on clopidogrel and aspirin.

Discussion:

Resistance to bivalirudin is an extremely rare phenomenon with a pathophysiology that is not well understood at this time. Current theories suggest a possible genetic mutation that alters thrombin binding sites. Despite the increased doses, an adequate ACT in our patient was not achieved until the utilization of unfractionated heparin. This case demonstrates the importance of recognizing bivalirudin resistance in patients with ESRD.