Education  |   February 2018
Argatroban and Bivalirudin for Perioperative Anticoagulation in Cardiac Surgery
Author Notes
  • From the Institute of Anesthesiology, Heart and Diabetes Center NRW, Bad Oeynhausen, Ruhr-University Bochum, Germany (A.K.); Department of Anesthesiology and Pain Medicine, Hospital for Sick Children, University of Toronto, Toronto, Canada (D.F.); and Department of Anesthesiology, Cardiac Anesthesiology and Intensive Care, Duke University School of Medicine, Durham, North Carolina (J.H.L.).
  • This article is featured in “This Month in Anesthesiology,” page 1A.
    This article is featured in “This Month in Anesthesiology,” page 1A.×
  • Charles D. Collard, M.D., served as Handling Editor for this article.
    Charles D. Collard, M.D., served as Handling Editor for this article.×
  • Submitted for publication May 21, 2017. Accepted for publication September 26, 2017.
    Submitted for publication May 21, 2017. Accepted for publication September 26, 2017.×
  • Address correspondence to Dr. Koster: Institute of Anesthesiology, Heart and Diabetes Center NRW, D-32545 Bad Oeynhausen, Georgstr. 11, Germany. akoster@hdz-nrw.de. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Education / Cardiovascular Anesthesia / Coagulation and Transfusion / Clinical Focus Review
Education   |   February 2018
Argatroban and Bivalirudin for Perioperative Anticoagulation in Cardiac Surgery
Anesthesiology 2 2018, Vol.128, 390-400. doi:10.1097/ALN.0000000000001976
Anesthesiology 2 2018, Vol.128, 390-400. doi:10.1097/ALN.0000000000001976
UNFRACTIONATED heparin (UFH) is the mainstay of anticoagulation for cardiovascular surgery, for patients requiring extracorporeal membrane oxygenation (ECMO), initially for ventricular assist devices (VADs), and for postoperative thrombosis prophylaxis. The elimination half-life of heparin is dose dependent and increases from approximately 30 min after a bolus of 25 U/kg, to 60 min with a bolus of 100 U/kg and 150 min with a bolus of 400 U/kg.1  UFH has many advantages in this setting, including the ability to monitor using standard coagulation assays or point of care tests, including activated clotting time (ACT), the ability for safe usage in patients with renal failure, and complete and rapid reversal with protamine. Heparin, unlike other anticoagulants, requires a cofactor antithrombin to inhibit thrombin and factor Xa. One of the potential unique aspects of heparin is that alterations in the heparin dose response can occur. In case of “heparin resistance,” very high or increasing dosages of heparin are required to achieve the targeted anticoagulant effect.1  The most important factors contributing to this condition are critically decreased concentrations of antithrombin, high fibrinogen levels and thrombocytosis.1 
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