Bivalirudin-Guided Cardiopulmonary Bypass in Redo Tricuspid Valve Replacement for Heparin-Induced Thrombocytopenia: Anaesthetic and Perfusion Challenges in a Paediatric Patient

AbstractBackground: Heparin-induced thrombocytopenia (HIT) presents a significant challenge in paediatric cardiac surgery requiring cardiopulmonary bypass (CPB). Redo right-sided valve surgery further increases perioperative risk due to adhesions, bleeding, and difficulty in separation from CPB. Evidence guiding alternative anticoagulation strategies in children remains limited.Case presentation: We report a 9-year-old boy with repaired Tetralogy of Fallot, severe tricuspid regurgitation, mild tricuspid stenosis, hepatic congestion, eosinophilia, and a documented history of HIT, scheduled for redo tricuspid valve replacement. Preoperative assessment suggested an anticipated difficult airway, and video laryngoscopy was used for tracheal intubation. Bivalirudin was employed as the sole anticoagulant for CPB, with activated clotting time (ACT)-guided titration.Management and Outcome: The intraoperative course was complicated by prior HIT influencing anticoagulation strategy, significant adhesiolysis-related bleeding and difficulty in separation from CPB due to right ventricular dysfunction. Adequate anticoagulation was maintained without thrombotic or catastrophic bleeding complications. The patient was successfully weaned from CPB and had an uneventful postoperative recovery.Conclusion: This case highlights the importance of meticulous anaesthetic, surgical, and perfusion coordination in perioperative planning and demonstrates that bivalirudin is a safe and effective alternative anticoagulant for CPB in paediatric patients with HIT undergoing complex redo right-sided valve surgery.