Use of argatroban as a heparin alternative in cardiac surgery-a rapid review of case reports and series.

BACKGROUND

Argatroban has been used as an alternative anticoagulant for cardiopulmonary bypass (CPB) in patients with heparin-induced thrombocytopenia (HIT) or heparin allergy. Its mechanism of action differs from heparin, and concerns regarding dosing, monitoring, and circuit thrombosis risk remain insufficiently characterized.

OBJECTIVES

This study systematically reviewed published cases of argatroban anticoagulation during CPB for dosing patterns, activated clotting time (ACT) responses, thrombotic and bleeding events, and transfusions.

METHODS

A rapid review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Rapid Reviews guidance. Searches of MEDLINE, Embase, and other index databases identified clinical reports involving argatroban use during CPB. Two investigators independently screened studies, extracted data, and assessed risk of bias.

RESULTS

Twenty-nine publications describing 30 patients (24 adult and 6 pediatric cases) met inclusion criteria. The median initial argatroban bolus was 0.1 mg/kg, but it was doubled to achieve ACTs of ≥400 seconds. Median infusion rate (25th-75th percentile) was 6.8 (4.6-9.7) μg/kg/min. ACT responses were nonlinear, with fluctuations of >100 seconds occurring in 70% of cases. Despite ACTs of ≥400 seconds, circuit thrombosis occurred in 40% of cases, most commonly in the reservoir or oxygenator. Recovery to ACT of <200 seconds required a median of 7 hours after discontinuing drug infusion. Perioperative transfusion occurred in 80% of cases.

CONCLUSION

Published experience demonstrates major limitations of argatroban as a heparin substitute for CPB, including unpredictable ACT responses and frequently documented circuit thromboses. The reported complication rates should be interpreted as an upper bound given the descriptive nature of case-level evidence and the likelihood of publication bias.