The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology

Clinical Practice Guidelines—Anticoagulation During Cardiopulmonary Bypass

Linda Shore-Lesserson, MD; Robert A. Baker, PhD, CCP; Victor A. Ferraris, MD, PhD; Philip E. Greilich, MD; David Fitzgerald, MPH, CCP; Philip Roman, MD, MPH; John W. Hammon, MD


Anesth Analg. 2018;126(2):413-424. 

In This Article


The ideal anticoagulation strategy for cardiac surgery with CPB in patients who cannot take heparin does not exist. Heparin and protamine remain the gold standard for anticoagulation therapy. A small subset of patients requires heparin alternatives for the conduct of CPB. Bivalirudin seems to offer the safest heparin alternative in this setting. This drug has a short half-life of approximately 25 minutes. Nonetheless, coagulopathy occurs in bivalirudin-treated patients. There is no well-defined reversal agent for bivalirudin, and patients with coagulopathy and excessive bleeding require unusual interventions for hemorrhage control. Only anecdotal experience is available to address coagulopathy in cases of bivalirudin-related hemorrhage.[68,71] Consensus suggests that a multifaceted approach offers the best chance of successful hemorrhage control for these patients. Recombinant activated factor VII may be an important part of hemorrhage control but other interventions including modified ultrafiltration, hemodialysis, and clotting factor replacement are also advocated.[71]