Catheter-Directed Bivalirudin for Local Anticoagulation and Clot Dissolution in Children Requiring Mechanical Circulatory Support

Abstract

Bivalirudin is a direct thrombin inhibitor that inhibits both circulating thrombin and fibrin-bound thrombin, giving it the ability to not only prevent thrombus extension, but also more directly facilitate clot resolution than heparin. Although still not yet the standard of care, bivalirudin has become more frequently used for anticoagulation in patients on mechanical circulatory support. In patients who develop large or critically localized thrombosis, requiring catheter-directed therapy, alteplase remains the drug of choice. Here we describe three cases of children, all of whom were on mechanical circulatory support, who required catheter-directed thrombolysis. In each case, direct bivalirudin delivery through a lysis catheter was associated with rapid resolution of thrombosis. Although study of more patients is needed to truly assess safety and efficacy, this series demonstrates that bivalirudin may be an effective drug for thrombolysis and should be considered in patients who have experienced bleeding or other complications from catheter-directed alteplase infusion.

Keywords: ECMO; VAD; bivalirudin; catheter-directed lysis; intracardiac thrombosis.