Is anticoagulation with bivalirudin comparable to heparin for pediatric extracorporeal life support? Results from a high‐volume center

Abstract

There is a paucity of data regarding the use of direct thrombin inhibitors such as bivalirudin for children on extracorporeal life support (ECLS). We sought to compare the outcomes of children on ECLS anticoagulated with bivalirudin versus heparin. Patients transitioned from heparin to bivalirudin were treated as a separate group. A single‐institution, retrospective review of all consecutive children (neonate to 18 years) placed on ECLS in the cardiac or pediatric intensive care units was performed (June 2018‐December 2019). Data collected included demographics, anticoagulation strategy, number of circuit interventions, blood product use on ECLS, survival to decannulation, and survival to discharge. Fifty‐four children were placed on ECLS for a total of 56 runs. Demographics and venovenous versus venoarterial ECLS were similar. The bivalirudin group had longer median duration of support compared to the heparin group––11.0 days [IQR 6.2, 23.1] versus 3.3 days [2.1, 6.2], P < .001. Patients switched from heparin to bivalirudin had a similar duration of support (10.3 days [8.3, 18.3]) as those on bilvalirudin alone. However, there was no difference in red blood cell, fresh frozen plasma, or platelet transfusions. There was no difference in the number of circuit interventions, survival to decannulation or discharge. The freedom to first circuit intervention was longer with bivalirudin compared to heparin. Our data suggest that even with longer pediatric ECLS runs on bivalirudin, there were no differences in the outcomes between the heparin and bivalirudin groups, with longer freedom from first circuit intervention with bivalirudin. While this is the largest reported series comparing children on ECLS anticoagulated with heparin versus bivalirudin, larger studies are needed to determine the optimal anticoagulation strategy for this diverse and complicated group of children.

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.…”

“…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]).…”

Highlights of the Sixteenth International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion

“…They observed no difference in neurologic abnormalities, circuit interventions, or survival between groups. 2 Along a similar vein, the group from Le Bonheur Children's Hospital in Tennessee discussed their initial experience with the novel reversible platelet P2Y 12 antagonist Cangrelor. Five patients on VAD support were given the drug for a mean of 42 days.…”

Hemostatic Challenges in Pediatric Critical Care Medicine—Hemostatic Balance in VAD

“…Clinical studies in pediatric showed safety and efficacy of bivalirudin in different settings including procedural anticoagulant, post cardiac surgery ECMO, heart transplant (53,54). In a single institution experience in 54 children placed on ECLS for a total of 56 runs, Bivalirudin use showed no differences in outcomes compared to heparin, however resulted in longer freedom from first circuit intervention (55). Bivalirudin has also been used safely in pediatric in cases of contraindications to heparin (i.e., HIT) (56) or when unreliable heparin monitoring exists (i.e., severe hemolysis and hyperbilirubinemia) (57).…”