Objective:

To report a case of suspected refractory heparin resistance and recurrent intra-stent thrombosis during complex PCI, and to evaluate the effectiveness of bivalirudin as an alternative anticoagulant in this context.

Approach:

• Case Presentation: A 67-year-old male with a history of exertional chest tightness and palpitations underwent PCI for severe coronary artery stenoses. He experienced recurrent stent thrombosis despite high doses of unfractionated heparin, indicating potential heparin resistance.

Key Findings:

• The patient had a cumulative dose of 11,000 U of unfractionated heparin with an activated clotting time (ACT) of 132 s.
• Switching to bivalirudin resulted in a rapid increase in ACT to 320 s within 10 minutes.
• Post-dilation after bivalirudin administration led to thrombus resolution.

Interpretation:

The results suggest that bivalirudin was effective in managing heparin resistance and preventing thrombosis progression during complex PCI.

Limitations:

• Antithrombin III activity and anti-Xa levels were not measured during the procedure, which could provide additional insights into anticoagulation efficacy.
• The patient experienced acute epigastric pain and vomiting, which may indicate potential gastrointestinal complications related to the procedure.

Conclusion:

Bivalirudin may be considered as an alternative for managing heparin resistance in high-risk PCI scenarios, but further studies are needed to confirm its efficacy.