Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
Department of Anesthesia and Intensive Care, Kerckhoff-Klinik Heart and Lung Center, Bad Nauheim, Germany.
J Cardiothorac Vasc Anesth. 2020 Aug;34(8):2207-2214. doi: 10.1053/j.jvca.2019.08.022. Epub 2019 Aug 21.
Bivalirudin, a direct thrombin inhibitor with a fast onset of action and short half-life, is often referred to as an alternative anticoagulant to a heparin/protamine regimen. Bivalirudin demonstrated promising results as an anticoagulant in cardiac surgery with and without cardiopulmonary bypass, postcardiotomy extracorporeal membrane oxygenation, interventional cardiology and endovascular procedures, and particularly in the treatment of patients with heparin-induced thrombocytopenia undergoing high-risk cardiac surgery. Currently, bivalirudin in cardiac surgery with cardiopulmonary bypass has a limited clinical spectrum, likely because the still obvious advantages of its competitor, heparin, outweigh it in terms of medical costs, established point-of-care monitoring systems, and availability of protamine as a reversal agent. The unique pharmacology of the drug also requires adjustment of surgical and perfusion strategy. In contrast, in off-pump coronary artery surgery, established protocols from interventional cardiology can be easily translated into the operating room. In this setting bivalirudin has the potential for a more important role in the future. Through a triple mechanism of action-inhibition of plasma thrombin, clot bound thrombin, and collagen-induced platelet activation-bivalirudin may perform better than heparin by attenuating the immediate postoperative prothrombotic state and thus positively impacting the early coronary graft patency after off-pump coronary artery bypass grafting. Further studies are necessary to better evaluate this niche field and discover further applications for this unique anticoagulant.
比伐卢定是一种直接凝血酶抑制剂，起效迅速，半衰期短，常被用作肝素/鱼精蛋白方案的替代抗凝剂。比伐卢定在体外循环和非体外循环心脏手术、心脏手术后体外膜肺氧合、介入心脏病学和血管内手术中作为抗凝剂显示出良好的效果，尤其在治疗接受高危心脏手术的肝素诱导血小板减少症患者方面。目前，在体外循环心脏手术中，比伐卢定的临床应用范围有限，可能是因为其竞争对手肝素在医疗成本、已建立的即时检测监测系统以及鱼精蛋白作为逆转剂的可用性方面仍具有明显优势。该药物的独特药理学也需要调整手术和灌注策略。相比之下，在非体外循环冠状动脉手术中，介入心脏病学的既定方案可以很容易地转化到手术室中。在这种情况下，比伐卢定将来可能会发挥更重要的作用。通过抑制血浆凝血酶、结合凝血酶和胶原诱导的血小板激活的三重作用机制，比伐卢定可能比肝素表现更好，通过减轻术后即刻的促血栓形成状态，从而对非体外循环冠状动脉旁路移植术后早期冠状动脉桥通畅产生积极影响。需要进一步的研究来更好地评估这一利基领域，并发现这种独特抗凝剂的进一步应用。
