Bivalirudin and post-cardiotomy ECMO: a word of caution

Anticoagulation with direct thrombin inhibitors during extracorporeal membrane oxygenation

“…This results in the short half-life that has been described. However, instances where blood is stagnant may induce thrombosis due to rapid local cleavage of bivalirudin[47]. Although ECMO is a continuous circuit without any “low-flow” chambers, in cases of cardiac dysfunction the cardiac chambers may act as a source of stagnation.…”

“…This can be particularly problematic in post-cardiotomy ECMO patients with prosthetic heart valves as valve thrombosis may lead to significant morbidity and mortality. It has been suggested that these circumstances may be avoided by minimizing intracardiac blood flow in cases of cardiogenic shock or avoid low-pulsatility states, and by using UFH as alternative anticoagulation in cases where intracardiac spontaneous echo contrast, or “smoke effect,” is noted, or low-flow states are suspected[47]. During EMCO weaning and trial-off period, especially in setting of VA ECMO wean and if the duration of the trial-off is prolonged, preemptive heparin administration is essential to minimize thrombus formation.…”

Ventilatory and Pharmacotherapeutic Strategies for Management of Adult Patients on Extracorporeal Life Support

“…Additionally, bivalirudin elimination depends on proteolysis determined by blood flow and temperature. Diminished activity of bivalirudin may occur in the setting of pericardial blood stagnation during ECLS (stimulating proteases), thereby promoting thrombosis, whereas enhanced anticoagulant activity may be observed in the setting of hypothermia.…”

Bivalirudin for Alternative Anticoagulation in Extracorporeal Membrane Oxygenation: A Systematic Review

“…The 2 largest studies did not use a loading dose and reported lower ranges of bivalirudin infusion, from 0.028 to 0.05 mg/kg/h. 26,31 In 1 case report of a patient with HR, bivalirudin infusion was performed at higher doses (0.1-0.2 mg/ kg/h) without a loading dose, 7 whereas in the other 3 case reports, a loading dose was used (range: 0.4-0.5 mg/kg) and followed by 10-fold variability in infusion range (0.05-0.5 mg/kg/h). 12,28,29 The observed interpatient variability is reinforced comparing the case reported by Jyoti et al 7 (0.1-0.2 mg/kg/h without loading dose) that used less than half the dose than the case presented by Koster et al 12 (0.5 mg/kg/h after a loading dose), aiming at the same ACT target range.…”