Recombinant hirudin for cardiopulmonary bypass anticoagulation: A randomized, prospective, and heparin-controlled pilot study

Background: Lepirudin, a recombinant hirudin, is a direct acting thrombin inhibitor that has been used as a heparin alternative in patients with heparin-induced thrombocytopenia requiring onpump cardiac surgery. To evaluate the efficacy, safety, and clinical utility of lepirudin as a cardiopulmonary bypass (CPB) anticoagulant, we compared lepirudin with heparin in a routine CPB setting. Methods: Twenty patients were randomly assigned to receive lepirudin (0.25 mg/kg b.w. bolus and 0.2 mg/kg b.w. added to the CPB priming) or heparin (400 U/kg b.w. bolus) with protamine reversal. Lepirudin and heparin anticoagulation during CPB was monitored using the ecarin clotting time or ACT, respectively and additional lepirudin (5mg) or heparin (5000 U) boluses were administered. Results: The CPB circuit was performed in both groups without thromboembolic complications. Median blood loss during the first 36 hours was statistically higher (p = 0.007) in the lepirudin group (1.226 ± 316 ml) compared to the heparin group (869 ± 189 ml). One patient of the lepirudin group developed pulmonary embolism 24 hours after surgery. This patient was tested homozygous for the FV-Leiden mutation. Conclusion: Lepirudin provides effective CPB anticoagulation but induces a higher postoperative blood loss than heparin. Lepirudin should be restricted to patients undergoing CPB who cannot be exposed to heparin.