Prolonged elevation of plasma argatroban in a cardiac transplant patient with a suspected history of heparin-induced thrombocytopenia with thrombosis
Case report published in Transfusion (2009)
Abstract
BACKGROUND: Direct thrombin inhibitors (DTIs) provide an alternative method of anticoagulation for patients with a history of heparin-induced thrombocytopenia (HIT) or HIT with thrombosis (HITT) undergoing cardiopulmonary bypass (CPB). In the following report, a 65-year-old critically ill patient with a suspected history of HITT was administered argatroban for anticoagulation on bypass during heart transplantation. The patient required massive transfusion support (55 units of red blood cells, 42 units of fresh-frozen plasma, 40 units of cryoprecipitate, 40 units of platelets, and three doses of recombinant Factor VIIa) for severe intraoperative and postoperative bleeding. STUDY DESIGN AND METHODS: Plasma samples from before and after CPB were analyzed postoperatively for argatroban concentration using a modified ecarin clotting time (ECT) assay. RESULTS: Unexpectedly high concentrations of argatroban were measured in these samples (range, 0-32 microg/mL), and a prolonged plasma argatroban half life (t(1/2)) of 514 minutes was observed (published elimination t(1/2) is 39-51 minutes [< or = 181 minutes with hepatic impairment]). CONCLUSIONS: Correlation of plasma argatroban concentration versus the patient's coagulation variables and clinical course suggest that prolonged elevated levels of plasma argatroban may have contributed to the patient's extended coagulopathy. Because DTIs do not have reversal agents, surgical teams and transfusion services should remain aware of the possibility of massive transfusion events during anticoagulation with these agents. This is the first report to measure plasma argatroban concentration in the context of CPB and extended coagulopathy.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
Direct thrombin inhibitors (DTIs) provide an alternative method of anticoagulation for patients with a history of heparin-induced thrombocytopenia (HIT) or HIT with thrombosis (HITT) undergoing cardiopulmonary bypass (CPB).
Why This Matters for Hirudotherapy
This case report describes a 65-year-old cardiac transplant patient with suspected heparin-induced thrombocytopenia with thrombosis who received argatroban for anticoagulation during cardiopulmonary bypass, resulting in unexpectedly high plasma argatroban concentrations (up to 32 µg/mL) and a prolonged half-life of 514 minutes, accompanied by severe bleeding requiring massive transfusion support. The abstract classifies argatroban among direct thrombin inhibitors and notes that these agents lack reversal agents, highlighting the risk of prolonged anticoagulation in surgical settings. However, the abstract makes no mention of hirudin, leeches, or any leech-derived compounds. This case concerns a pharmaceutical anticoagulant in cardiac surgery, and no defensible connection to hirudotherapy or the leech secretome is evident from the abstract.
Citation
Prolonged elevation of plasma argatroban in a cardiac transplant patient with a suspected history of heparin-induced thrombocytopenia with thrombosis
Genzen JR et al. · Transfusion, 2009
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