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Bivalirudin fails to prevent atrial thrombus development in heparin-induced thrombocytopaenia and thrombosis syndrome
  1. Alexandru Topliceanu1,
  2. Thomas Breen1,
  3. Hiren Patel1,
  4. Neil Yager1,
  5. Erica Maceira2,
  6. Mikhail Torosoff1
  1. 1Division of Cardiology, Albany Medical College, Albany Medical Center, Albany, New York, USA
  2. 2Clinical Pharmacy Specialist, Albany Medical Center, Albany, New York, USA
  1. Correspondence to Dr. Thomas Breen, thomasbreen01{at}


An 81-year-old woman presented with acute decompensated heart failure due to new-onset atrial fibrillation and a flail myxomatous mitral valve which necessitated surgical mitral valve repair. No atrial thrombi were noted on transoesophageal echocardiograms performed prior to surgery and intraoperatively. Immediately postoperatively, while treated with unfractionated heparin, the patient developed thrombocytopaenia with positive platelet factor 4 antibodies and an abnormal serotonin functional platelet assay, consistent with heparin-induced thrombocytopaenia. The anticoagulation therapy was changed to the direct thrombin inhibitor bivalirudin with an improvement in the platelet count. Despite bivalirudin therapy, a left atrial layering thrombus was revealed on transoesophageal echocardiogram performed in preparation for cardioversion of the symptomatic atrial fibrillation. Anticoagulation was changed to warfarin, and the patient was discharged without thromboembolic complications neither during her hospital stay nor the 3-year outpatient follow-up.

  • cardiovascular medicine
  • cardiovascular system
  • haematology (drugs and medicines)
  • unwanted effects / adverse reactions

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  • Contributors AT: collected the patient information, performed a thorough literature search and drafted the original paper. TB: also searched through patient records, performed a literature search and revised the paper. HP: provided further interpretation of patient data. NY provided further expertise on the topic. EM: helped with the pharmacology associated with the paper and provided further information regarding institutional policies at AMC. MT: oversaw all efforts associated with the paper and was involved with the original case. All authors helped with revisions to create the final draft; agreed to be accountable for the article and agree with the final draft that has been submitted.

  • 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 Obtained.

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