Anticoagulation with Bivalirudin in a Case of Mitral Valve Replacement and Coronary Artery Bypass Grafting Requiring Prolonged Extracorporeal Membrane Oxygenation Support: A Case of Emergency Surgery Due to Posterior Papillary Muscle Rupture

Abstract

Extracorporeal membrane oxygenation (ECMO) is an increasingly used support method in cases of refractory cardiopulmonary failure. However, due to the non-biological surfaces of the system and the inflammatory responses it induces, coagulation disorders may develop, necessitating meticulous anticoagulation management. At present, unfractionated heparin (UFH) is used as the standard; however, in complications such as heparin-induced thrombocytopenia (HIT), alternative agents may be required. We present the management of a 59-yearold male who developed acute mitral regurgitation due to posterior papillary muscle rupture and underwent emergency mitral valve replacement and coronary artery bypass grafting. Due to post-operative right ventricular failure, venoarterial ECMO support was initiated. On the 5^th day of ECMO, progressive thrombocytopenia and central catheter thrombosis occurred. With a high 4T score, HIT was suspected. UFH infusion was discontinued, and bivalirudin was initiated as an alternative anticoagulant. The anticoagulation process was monitored with activated clotting time and activated partial thromboplastin time, and therapeutic targets were successfully achieved without major bleeding or thrombotic complications. The patient was weaned off ECMO on day 15 and discharged in stable condition on post-operative day 74. This case demonstrates that bivalirudin is a safe and effective anticoagulant option in ECMO patients who develop HIT. In complex cases with heparin contraindications, bivalirudin plays an important role in individualized anticoagulation strategies.

Cite This Article: Dündar S, Yücel C, Ergin M, Ketenciler S. Anticoagulation with Bivalirudin in a Case of Mitral Valve Replacement and Coronary Artery Bypass Grafting Requiring Prolonged Extracorporeal Membrane Oxygenation Support: A Case of Emergency Surgery Due to Posterior Papillary Muscle Rupture. Koşuyolu Heart J 2026;29(3):228–233.