Heparin-based versus bivalirudin-based anticoagulation in pediatric extracorporeal membrane oxygenation: A systematic review

Abstract

IntroductionOptimal anticoagulation therapy is essential for the prevention of thrombotic and hemorrhagic complications in pediatric patients supported with extracorporeal membrane oxygenation (ECMO). Recent data have demonstrated bivalirudin has the potential to surpass and replace heparin as the anticoagulant of choice.MethodsWe conducted a systematic review comparing the outcomes of heparin-based versus bivalirudin-based anticoagulation in pediatric patients supported on ECMO to identify the preferred anticoagulant to minimize bleeding events, thrombotic complications, and associated mortality. We referenced the PubMed, Cochrane Library, and Embase databases. These databases were searched from inception through October 2022. Our initial search identified 422 studies. All records were screened by two independent reviewers using the Covidence software for adherence to our inclusion criteria, and seven retrospective cohort studies were identified as appropriate for inclusion.ResultsIn total, 196 pediatric patients were anticoagulated with heparin and 117 were anticoagulated with bivalirudin while on ECMO. Across the included studies, it was found that for patients treated with bivalirudin, trends were noted toward lower rates of bleeding, transfusion requirements, and thrombosis with no difference in mortality. Overall costs associated with bivalirudin therapy were lower. Time to therapeutic anticoagulation varied between studies though institutions had different anticoagulation targets.ConclusionBivalirudin may be a safe, cost-effective alternative to heparin in achieving anticoagulation in pediatric ECMO patients. Prospective multicenter studies and randomized control trials with standard anticoagulation targets are needed to accurately compare outcomes associated with heparin versus bivalirudin in pediatric ECMO patients.

Bivalirudin-hydrogel coatings of polyvinyl chloride on extracorporeal membrane oxygenation for anticoagulation

“…The GelMA hydrogel coating that contains BV was successfully produced, which acts as a direct thrombin inhibitor by binding to the anion-binding exosite of both free and clot-bound catalytic sites of thrombin. Compared with heparin, BV has better safety, reliability, and cost-effectiveness (25). Importantly, the BV-Coating GelMA hydrogel tube did not significantly affect cell growth activity nor elicit hemolysis, complement activation, or coagulation reactions when in contact with blood.…”

Is it time to switch to bivalirudin for ECMO anticoagulation?

“…There are several recent review articles comparing heparin to bivalirudin for ECMO anticoagulation (48)(49)(50)(51)(52)(53)(54)(55), and all of them favor bivalirudin (Table 8). It should be noted, however, that all but one of these studies are meta-analyses and are compromised by the lack of standard definitions for bleeding and thrombosis.…”

What’s new in neonatal and pediatric extracorporeal membrane oxygenation in 2022–2023? Insights from the EuroELSO congress 2023

“…Nevertheless, even though bivalirudin can be considered a good alternative to heparin, its superiority has not been showed so far. Based on these considerations, Valdes CA et al, 29 performed a systematic review to evaluate the outcomes of heparin-based versus bivalirudin-based anticoagulation during neonatal an pediatric ECMO. The authors showed that patients anticoagulated with bivalirudin had a lower rate of bleeding, transfusions and thrombotic complications.…”