Comparison of Anticoagulation Strategies in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: Heparin Versus Bivalirudin*

Abstract

OBJECTIVES: Extracorporeal membrane oxygenation is a life-sustaining therapy for severe respiratory failure. Extracorporeal membrane oxygenation circuits require systemic anticoagulation that creates a delicate balance between circuit-related thrombosis and bleeding-related complications. Although unfractionated heparin is most widely used anticoagulant, alternative agents such as bivalirudin have been used. We sought to compare extracorporeal membrane oxygenation circuit thrombosis and bleeding-related outcomes in respiratory failure patients receiving either unfractionated heparin or bivalirudin for anticoagulation on venovenous extracorporeal membrane oxygenation support. DESIGN: Retrospective cohort study. SETTING: Single-center, cardiothoracic ICU. PATIENTS: Consecutive patients requiring venovenous extracorporeal membrane oxygenation who were maintained on anticoagulation between 2013 and 2020. INTERNVENTIONS: IV bivalirudin or IV unfractionated heparin. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were the presence of extracorporeal membrane oxygenation in-circuit–related thrombotic complications and volume of blood products administered during extracorporeal membrane oxygenation duration. One hundred sixty-two patients receiving unfractionated heparin were compared with 133 patients receiving bivalirudin for anticoagulation on venovenous extracorporeal membrane oxygenation. In patients receiving bivalirudin, there was an overall decrease in the number of extracorporeal membrane oxygenation circuit thrombotic complications (p < 0.005) and a significant increase in time to circuit thrombosis (p = 0.007). Multivariable Cox regression found that heparin was associated with a significant increase in risk of clots (Exp[B] = 2.31, p = 0.001). Patients who received bivalirudin received significantly less volume of packed RBCs, fresh frozen plasma, and platelet transfusion (p < 0.001 for each). There was a significant decrease in the number major bleeding events in patients receiving bivalirudin, 40.7% versus 11.7%, p < 0.001. CONCLUSIONS: Patients receiving bivalirudin for systemic anticoagulation on venovenous extracorporeal membrane oxygenation experienced a decrease in the number of extracorporeal membrane oxygenation circuit-related thrombotic events as well as a significant decrease in volume of blood products administered.

Eleven Years of Venovenous Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: From H1N1 to SARS-CoV-2. Experience and Perspectives of a National Referral Center

“…Notably, transition from heparin to bivalirudin was accompanied by increase in survival rate (55% vs 31%, p=0.03) and reduced thrombocytopenia incidence in the bivalirudin group (69% vs 35%, p=0.003).Such results are in line with a recently published study on 295 VV ECMO patients, which documented higher 1 year survival rate, less circuit thrombotic events and decreased blood product administration in patients treated with bivalirudin compared to heparin [24]. Furthermore, it is our practice also to administer intravenous short-acting beta-blockers during VV ECMO treatment.…”

“…Baseline PaO 2 /FiO 2 was 64 (52 -77):. Patients had high mortality risk according to risk scores: SOFA was 12 ± 5, SAPS II was 66 ± 25; APACHE II was 28 (22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35), APACHE III was 103 ± 54 and the ECMOnet score 7 ± 4. Variations of pre ECMO respiratory parameters and cause of ARDS over the years under study are shown in supplementary figure 1 and 2, respectively.…”

A comprehensive review of vascular complications in COVID-19

“…ELSO COVID-19 Interim Guidelines support implementing the standard ELSO anticoagulation guidelines in COVID-19 patients [ 62 ]. Systemic anticoagulation with bivalirudin on venovenous ECMO had lower circuit-related thrombotic events [ 63 ]. However, Parzy et al [ 64 ] reported that all their patients with SARS-CoV2 infection and ARDS, who were on venovenous ECMO, suffered from venous thromboembolism despite receiving the anticoagulation.…”

Acute Kidney Injury and Extracorporeal Membrane Oxygenation: Review on Multiple Organ Support Options

“… 49 Its use during ECMO has been successfully reported in the case of HIT. 51 Recently, Rivosecchi et al 52 performed a retrospective cohort study where they compared 162 patients receiving UFH with 133 patients receiving bivalirudin for anticoagulation on VV-ECMO. The bivalirudin group showed a decrease in clot formation in the ECMO circuit as well as a significant decrease in volume of blood product administration (red blood cells, plasma and platelet).…”