Left Ventricular Assist Device Implantation Under Argatroban Anticoagulation in Heparin-Induced Thrombocytopenia: A Literature Review and Clinical Case Presentation

Abstract

This review provides an in-depth analysis of argatroban as an alternative anticoagulant in cardiac surgery, with a focus on its use in patients with heparin-induced thrombocytopenia (HIT). We examine argatroban's pharmacokinetics and dosing regimens and the challenges associated with cosnventional monitoring methods-such as activated clotting time (ACT) and activated partial thromboplastin time (aPTT)-to evaluate its safety and effectiveness in high-risk surgical settings. Drawing on data from multiple case reports and series, our review highlights both the potential benefits and limitations of argatroban, including complications such as clot formation in extracorporeal circulation systems and prolonged postoperative coagulopathy. In addition to the literature review, we present a detailed clinical case of urgent HeartMate 3 left ventricular assist device implantation in a patient with advanced heart failure and active HIT. In this case, despite targeting an ACT above 400 s, intraoperative complications such as clot formation in the heart-lung machine and difficulty achieving hemostasis highlight the need for improved monitoring and dosing protocols. Our findings call for refined anticoagulation strategies and advanced monitoring techniques to optimize argatroban use in cardiac surgery, offering valuable insights for clinicians managing complex scenarios where conventional heparin therapy is contraindicated.

Keywords: anticoagulation; argatroban; cardiac surgery; heart failure; heart transplantation; heparin-induced thrombocytopenia; left ventricular assist device.

Figure 1

ACT values and argatroban administration on the day of surgery.

Figure 2

Heart–lung machine blood reservoir with blood clots.

Figure 3

Rotational thromboelastometry (ROTEM) post-surgery.

Figure 4

aPTT values on the day of surgery (1st day) and in the following days and argatroban continuous infusion (administration of argatroban on the day of surgery is omitted and is presented in Figure 1).