{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,5]],"date-time":"2025-11-05T07:27:13Z","timestamp":1762327633075,"version":"build-2065373602"},"reference-count":36,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,11,5]],"date-time":"2025-11-05T00:00:00Z","timestamp":1762300800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:p>Heparin is the standard anticoagulant for structural cardiac procedures, including left atrial appendage occlusion (LAAO). However, alternative agents are needed in patients with contraindications such as heparin-induced thrombocytopenia (HIT). Data on the use of argatroban, a direct thrombin inhibitor, for procedural anticoagulation during LAAO are extremely limited. We describe a 67-year-old man with chronic atrial fibrillation, end-stage renal disease on hemodialysis, and a history of HIT type II who underwent LAAO with a Watchman device under general anesthesia. Due to his renal failure and high risk of recurrent HIT, argatroban was selected for intraoperative anticoagulation. A reduced initial bolus of argatroban achieved supratherapeutic activated clotting time (ACT), and when the infusion was started, ACT levels again exceeded the target range, highlighting the need for close monitoring. The procedure was completed without thromboembolic or hemorrhagic complications. This case demonstrates the effective use of argatroban as an intraoperative anticoagulant in LAAO for patients with HIT and renal impairment. A lower initial bolus and infusion rate may be sufficient with vigilant ACT monitoring to avoid complications of prolonged anticoagulation.<\/jats:p>","DOI":"10.3389\/fmed.2025.1690340","type":"journal-article","created":{"date-parts":[[2025,11,5]],"date-time":"2025-11-05T06:29:06Z","timestamp":1762324146000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Argatroban for intraoperative anticoagulation in a patient with history of heparin-induced thrombocytopenia and end-stage renal disease undergoing left atrial appendage occlusion: a case report"],"prefix":"10.3389","volume":"12","author":[{"given":"Kevin","family":"Eappen","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kendra L.","family":"Walsh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Beverly","family":"Ejiofor","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrew","family":"Maslow","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shyamal","family":"Asher","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2025,11,5]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"1323","DOI":"10.1161\/CIRCULATIONAHA.121.054305","article-title":"Antithrombotic therapy in patients undergoing transcatheter interventions for structural heart disease","volume":"144","author":"Calabr\u00f2","year":"2021","journal-title":"Circulation"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"38A","DOI":"10.1016\/S0002-9149(97)89116-3","article-title":"Atrial fibrillation, anticoagulation, and stroke","volume":"77","author":"Morley","year":"1996","journal-title":"Am J Cardiol"},{"key":"ref3","year":""},{"key":"ref4","doi-asserted-by":"publisher","first-page":"c80","DOI":"10.1159\/000139993","article-title":"Argatroban anticoagulation in renal dysfunction: a literature analysis","volume":"109","author":"Hursting","year":"2008","journal-title":"Nephron Clin Pract"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"318","DOI":"10.1592\/phco.20.4.318.34881","article-title":"The pharmacokinetics and pharmacodynamics of argatroban: effects of age, gender, and hepatic or renal dysfunction","volume":"20","author":"Swan","year":"2000","journal-title":"Pharmacotherapy"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"809","DOI":"10.1056\/NEJMcp052967","article-title":"Heparin-induced thrombocytopenia","volume":"355","author":"Arepally","year":"2006","journal-title":"N Engl J Med"},{"key":"ref7","year":""},{"key":"ref8","article-title":"Bivalirudin","volume-title":"StatPearls [internet]","author":"Berlioz","year":"2025"},{"key":"ref9","year":"2020"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"177","DOI":"10.1002\/ccd.10276","article-title":"Argatroban anticoagulation during percutaneous coronary intervention in patients with heparin-induced thrombocytopenia","volume":"57","author":"Lewis","year":"2002","journal-title":"Catheter Cardiovasc Interv"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"2671","DOI":"10.1161\/CIRCULATIONAHA.104.518563","article-title":"When heparins promote thrombosis","volume":"111","author":"Jang","year":"2005","journal-title":"Circulation"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"e220","DOI":"10.1016\/S2352-3026(18)30046-2","article-title":"Disease burden, complication rates, and health-care costs of heparin-induced thrombocytopenia in the USA: a population-based study","volume":"5","author":"Dhakal","year":"2018","journal-title":"Lancet Haematol"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"2519","DOI":"10.1016\/j.jacc.2016.02.073","article-title":"Heparin-induced thrombocytopenia","volume":"67","author":"Salter","year":"2016","journal-title":"J Am Coll Cardiol"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"1372","DOI":"10.2741\/4462","article-title":"Heparin and anticoagulation","volume":"21","author":"Onishi","year":"2016","journal-title":"Front Biosci (Landmark Ed)"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"515","DOI":"10.1056\/NEJM200008173430718","article-title":"Use of heparin during cardiopulmonary bypass in patients with a history of heparin-induced thrombocytopenia","volume":"343","author":"P\u00f6tzsch","year":"2000","journal-title":"N Engl J Med"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"626","DOI":"10.1177\/1076029615578167","article-title":"Heparin reexposure in patients with a history of heparin-induced thrombocytopenia","volume":"21","author":"Dhakal","year":"2015","journal-title":"Clin Appl Thromb Hemost"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"1229","DOI":"10.1592\/phco.30.12.1229","article-title":"Comparison of bivalirudin and argatroban for the management of heparin-induced thrombocytopenia","volume":"30","author":"Skrupky","year":"2010","journal-title":"Pharmacotherapy"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"1601","DOI":"10.1345\/aph.1G033","article-title":"Argatroban anticoagulation in patients with heparin-induced thrombocytopenia requiring renal replacement therapy","volume":"39","author":"Reddy","year":"2005","journal-title":"Ann Pharmacother"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"1185","DOI":"10.1345\/aph.1Q177","article-title":"Bivalirudin dosing adjustments for reduced renal function with or without hemodialysis in the management of heparin-induced thrombocytopenia","volume":"45","author":"Tsu","year":"2011","journal-title":"Ann Pharmacother"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"1115","DOI":"10.1592\/phco.28.9.1115","article-title":"Safety, efficacy, and dosing requirements of bivalirudin in patients with heparin-induced thrombocytopenia","volume":"28","author":"Kiser","year":"2008","journal-title":"Pharmacotherapy"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"178","DOI":"10.1177\/1060028014562949","article-title":"Efficacy and safety of argatroban and bivalirudine in patients with suspected heparin-induced thrombocytopenia","volume":"49","author":"Vo","year":"2015","journal-title":"Ann Pharmacother"},{"key":"ref22","first-page":"60","article-title":"Bivalirudin, a bivalent, thrombin specific anticoagulant as an alternative to heparin in interventional procedures as an alternative to heparin in interventional procedures","volume":"22","author":"Chew","year":"2002","journal-title":"Hamostaseologie"},{"key":"ref23","first-page":"535","article-title":"Use of bivalirudin instead of heparin during a percutaneous coronary intervention in a patient with severe thrombocytopenia","volume":"16","author":"Bejarano","year":"2004","journal-title":"J Invasive Cardiol"},{"key":"ref24","year":"2003"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"1603","DOI":"10.1053\/j.jvca.2018.01.027","article-title":"Assessment of heparin anticoagulation measured using i-STAT and hemochron activated clotting time","volume":"32","author":"Maslow","year":"2018","journal-title":"J Cardiothorac Vasc Anesth"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"4281","DOI":"10.1053\/j.jvca.2022.07.030","article-title":"A pilot study to assess the clinical onset of IV heparin in interventional cardiology and cardiac surgery","volume":"36","author":"Asher","year":"2022","journal-title":"J Cardiothorac Vasc Anesth"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"1318","DOI":"10.1016\/j.amjcard.2004.01.076","article-title":"Validation of the i-STAT handheld activated clotting time for use with bivalirudin","volume":"93","author":"Schussler","year":"2004","journal-title":"Am J Cardiol"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"484","DOI":"10.1016\/j.jacep.2019.12.003","article-title":"Direct thrombin inhibitors as an alternative to heparin during catheter ablation","volume":"6","author":"Voskoboinik","year":"2020","journal-title":"JACC Clin Electrophysiol"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"yty166","DOI":"10.1093\/ehjcr\/yty166","article-title":"A case report of atrial fibrillation in a patient with heparin resistance associated with an antithrombin III deficiency successfully treated by radiofrequency catheter ablation using a direct thrombin inhibitor","volume":"3","author":"Kang","year":"2019","journal-title":"Eur Heart J Case Rep"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"2747","DOI":"10.2169\/internalmedicine.9288-21","article-title":"Atrial fibrillation in a patient with heparin-induced thrombocytopenia successfully treated by radiofrequency catheter ablation using a direct thrombin inhibitor","volume":"61","author":"Sakai","year":"2022","journal-title":"Internal Med (Tokyo, Japan)"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"158","DOI":"10.1213\/XAA.0000000000000373","article-title":"Successful anticoagulation using Argatroban during transcatheter aortic valve implantation in a patient with heparin-induced thrombocytopenia","volume":"7","author":"Naganuma","year":"2016","journal-title":"A & A Case Rep"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"592","DOI":"10.1510\/icvts.2009.215848","article-title":"Argatroban as a substitute of heparin during cardiopulmonary bypass: a safe alternative?","volume":"10","author":"Follis","year":"2010","journal-title":"Interact Cardiovasc Thorac Surg"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"214","DOI":"10.1016\/j.ijcard.2010.02.044","article-title":"Argatroban for elective percutaneous coronary intervention: the ARG-E04 multi-center study","volume":"148","author":"R\u00f6ssig","year":"2011","journal-title":"Int J Cardiol"},{"key":"ref34","article-title":"Active ingredient: heparin sodium","volume-title":"MerativeTM Micromedex\u00ae RED BOOK\u00ae (electronic version)","year":""},{"key":"ref35","article-title":"Active ingredient: argatroban","volume-title":"MerativeTM Micromedex\u00ae RED BOOK\u00ae (electronic version)","year":""},{"key":"ref36","article-title":"Active ingredient: bivalirudin","volume-title":"MerativeTM Micromedex\u00ae RED BOOK\u00ae (electronic version)","year":""}],"container-title":["Frontiers in Medicine"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2025.1690340\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,5]],"date-time":"2025-11-05T06:29:07Z","timestamp":1762324147000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fmed.2025.1690340\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,5]]},"references-count":36,"alternative-id":["10.3389\/fmed.2025.1690340"],"URL":"https:\/\/doi.org\/10.3389\/fmed.2025.1690340","relation":{},"ISSN":["2296-858X"],"issn-type":[{"value":"2296-858X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,5]]},"article-number":"1690340"}}