Bivalirudin as systemic anticoagulant and flush solution additive for sequential mitral and tricuspid valve percutaneous edge to edge repair in a patient with heparin induced thrombocytopenia

Abstract We present a patient with a prior history of heparin induced thrombocytopenia who underwent percutaneous mitral valve edge-to-edge repair followed two months later by tricuspid edge-to-edge repair. Recommendations exist for systemic anticoagulant alternatives for percutaneous mitral valve edge-to-edge repair with the MitraClip device, but minimal guidance and experience is present regarding alternative systemic anticoagulation during the performance of right-sided interventions including tricuspid edge-to-edge repair (TriClip). Notably, there is no clear consensus regarding the use of an alternative anticoagulant in the catheter flush solution for the delivery systems used during these procedures, particularly for right-sided interventions. We present two sequential procedures in the same patient where we elected to use bivalirudin for both systemic anticoagulation and as an additive to the utilized flush solutions and provide a brief discussion of options for managing these situations.