Difficult management of anticoagulation with argatroban in a patient undergoing on-pump cardiac surgery

EPARIN-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 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 Argatroban seems to be a reasonable option, especially for patients with renal failure because it is metabolized and eliminated primarily via a hepatic route. 3-5 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). 3-5 Although several case reports described the successful management of anticoagulation with argatroban in on-pump cardiac surgery, 6-9 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. A patient presented with renal failure and a history of HIT; the patient underwent on-pump cardiac surgery using argatroban. Initially, the authors could not achieve a target ACT for CPB using an argatroban dosing protocol described previously, 8 and after achieving adequate anticoagulation with a higher dose, prolonged, severe coagulopathy after CPB was encountered.