Comparison of Bivalirudin Versus Heparin for Maintenance Systemic Anticoagulation During Adult and Pediatric Extracorporeal Membrane Oxygenation

Abstract

OBJECTIVES: To provide a comparative analysis of conventional heparin-versus bivalirudin-based systemic anticoagulation in adult and pediatric patients supported on extracorporeal membrane oxygenation. DESIGN: Retrospective chart review study of adult and pediatric patients receiving extracorporeal membrane oxygenation from January 1, 2014, to October 1, 2019. SETTING: A large, high-volume tertiary referral adult and pediatric extracorporeal membrane oxygenation center. PATIENTS: Four hundred twenty-four individuals requiring extracorporeal membrane oxygenation support and systemically anticoagulated with either unfractionated heparin (223 adult and 65 pediatric patients) or bivalirudin (110 adult and 24 pediatric patients) were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Digital data abstraction was used to retrospectively collect patient details. The majority of both groups were cannulated centrally (67%), and the extracorporeal membrane oxygenation type was predominantly venoarterial (84%). The adult bivalirudin group had a greater occurrence of heparin-induced thrombocytopenia (12% vs 1%; p < 0.01) and was more likely to require postcardiotomy extracorporeal membrane oxygenation (36% vs 55%; p < 0.01). There were no statistical differences between the groups in regards to age, sex, and extracorporeal membrane oxygenation initiation location. The main finding was a reduced mortality in the adult bivalirudin group (odds ratio, 0.39; p < 0.01), whereas no difference was noted in the pediatric group. A significant reduction in the composite transfusion requirement in the first 24 hours was noted in the pediatric bivaluridin group with an odds ratio of 0.28 (p = 0.02). Groups did not differ in regard to laboratories per day, anticoagulant dose adjustments, or ischemic complications. CONCLUSIONS: When compared with heparin-based systemic anticoagulation, bivalirudin demonstrated feasibility and safety as established by the absence of increases in identifiable adverse outcomes while manifesting substantial improvements in hospital mortality in adult patients. Further studies are necessary to corroborate these findings and further elucidate the role of bivalirudin during extracorporeal membrane oxygenation support.

Is bivalirudin an alternative anticoagulant for extracorporeal membrane oxygenation (ECMO) patients? A systematic review and meta-analysis

“…No articles on the subject were found in CNKI. After screening and evaluation, ten articles [12][13][14][15][16][17][18][19][20][21] were finally included for qualitative synthesis, and nine articles [12][13][14][15][16][17][19][20][21] were included in the meta-analysis because one reference [18] met the inclusion criteria but the data of outcome presented could not be pooled in a meta-analysis. The literature retrieval and screening processes are shown in Fig.…”

“…There was only one study that reported adjusted data based on age, cannulation approach (aortic vs peripheral), ECMO type, and year of ECMO [12]. Others reported unadjusted ORs.…”

“…Similarly, Rivosecchi RM et al [37] conducted a pilot study which included all ECMO patients demonstrated a decrease in time to consecutive therapeutic anticoagulation levels (UFH: 48 h, bivalirudin: 30 h, P = 0.03) and an increase in percentages of anticoagulation levels within goal range (37% vs 56%, P = 0.01). However, Seelhammer TG et al [12] indicated that there was no difference in dose adjustments per day or laboratory monitoring frequency between the UFH and bivalirudin groups in pediatrics; but in adults, the bivalirudin group decreased anticoagulant dose changes per day compared the heparin group (P = 0.03). The methods to evaluate the management of anticoagulation varied, which may result in different conclusions.…”

“…One article only reported in-circuit thrombosis [14]. One article only reported thrombosis from patient [12]. One article only reported thrombotic complication [21].…”

“…All data generated or analyzed during this study are included in this published article (shown in Reference [9][10][11][12][13][14][15][16][17][18]).…”