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Case report
Bivalirudin resistance in a patient on veno-venous extracorporeal membrane oxygenation with a therapeutic response to argatroban
  1. Beric Berlioz1,
  2. Haya S Kaseer2,
  3. Devang K Sanghavi2 and
  4. Pramod K Guru2
  1. 1 Anesthesiology, Mayo Clinic Florida, Jacksonville, Florida, USA
  2. 2 Critical Care, Mayo Clinic Florida, Jacksonville, Florida, USA
  1. Correspondence to Dr Beric Berlioz; berlioz.beric{at}


A 48-year-old male patient requiring extracorporeal membrane oxygenation (ECMO) support for hypoxaemic respiratory failure failed to achieve therapeutic anticoagulation with bivalirudin after continuous dose escalations, and continued to have recurrent fibrin stranding in the circuit over a 6-day course of treatment. Suspecting bivalirudin resistance, the patient was transitioned to argatroban and achieved a therapeutic response in less than 24 hours. The case describes the challenges of anticoagulation in ECMO supported patients. The interplay between bivalirudin metabolism, renal replacement therapy, and immunological effects leading to a heparin-like-effect, inflammatory mediators, and thrombotic burdens may all impact the clinical effect during bivalirudin therapy. The structural biochemistry of thrombin and bivalirudin likely plays a role in the presented patient’s successful response to argatroban. Bivalirudin may fail at achieving therapeutic anticoagulation in patients with genetic thrombin mutations or structural defects that alter the binding pockets at the thrombin exosites.

  • mechanical ventilation
  • venous thromboembolism
  • adult intensive care
  • pharmacology and therapeutics
  • therapeutic indications

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  • Contributors DKS, BB and HSK conceived of the presented idea. BB took the lead in writing the manuscript, acquired the patient’s perspective and conducted the primary literature review. HSK conducted the initial chart review and tabulated the pharmacologic data. HSK contributed to the literature review with respect to pharmacology. DKS supervised the project and conducted a revision of the initial draft. PKG was editor to the final draft, providing valuable information. All authors provided critical feedback and helped.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.