Bivalirudin burst dosing in children supported with paracorporeal ventricular assist devices: A single-center experience.

Children supported with paracorporeal ventricular assist devices (VADs) are at increased risk of thrombotic complications despite anticoagulation advances. Bivalirudin, a direct thrombin inhibitor, has emerged as an alternative to heparin through initiatives led by ACTION. At our institution, a burst dosing protocol was implemented, consisting of a 20% to 50% dose increase per hour for 2 hours, to manage fibrin or pin-point thrombus deposition. In this case series, 9 patients received a total of 132 bivalirudin bursts across the duration of support. No bleeding events occurred within 12 hours of a burst, and no thromboembolic events occurred within 48 hours. These preliminary findings suggest that bivalirudin burst dosing is feasible and not temporally related to adverse events in our pediatric population requiring paracorporeal support. Further prospective investigation is necessary to validate safety, establish optimal dosing parameters, and develop standardized burst initiation criteria.