Bentall Surgery in a Patient with Cold Agglutinin and Antiphospholipid Antibody: Double Trouble.

Cold agglutinin disease is an uncommon disease with potential to cause hemolysis and thrombosis during hypothermic cardiac surgery. Antiphospholipid syndrome is also rare disease with hypercoagulation tendacy. Perioperative management of both these diseases is challenging. We present successful perioperative management of high risk Bentall surgery in patient with both these dreadful diseases.

Bivalirudin in venovenous extracorporeal membrane oxygenation.

Optimal anticoagulation plays a pivotal role in successful outcome of extracorporeal membrane oxygenation (ECMO). Heparin has been the anticoagulant of choice owing to its advantages like easy monitoring and reversibility. However, if heparin resistance is encountered, one has to decide whether to treat heparin resistance with fresh-frozen plasma or antithrombin concentrates or to choose one of the heparin alternatives for anticoagulation. We report a case of heparin resistance resulting from antithrombin III deficiency in a patient on venovenous ECMO, in which anticoagulation was managed with bivalirudin. The dose of bivalirudin for anticoagulation in ECMO has not been standardized and different authors have reported different doses. We found a bivalirudin dose of .1-.2 mg/kg/h to be adequate to maintain a target activated clotting time of 200-220 seconds. Platelet counts were stable throughout and no major bleeding or thrombotic complications took place. We found bivalirudin to be a feasible and effective anticoagulant and safe to use for long durations in ECMO without any major complications.