Anti-Xa versus time-guided anticoagulation strategies in extracorporeal membrane oxygenation: a systematic review and meta-analysis

Abstract

The purpose was to compare time-based vs anti-Xa-based anticoagulation strategies in patients on ECMO. We conducted a systematic review and meta-analysis using multiple electronic databases and included studies from inception to July 19, 2019. The proportion of bleeding, thrombosis, and mortality were evaluated. Twenty-six studies (2,086 patients) were included. Bleeding occurred in 34.2% (95%CI 25.1;43.9) of the patients with anti-Xa-based versus 41.6% (95%CI 24.9;59.4) of the patients with time-based anticoagulation strategies. Thrombosis occurred in 32.6% (95%CI 19.1;47.7) of the patients with anti-Xa-based versus 38.4% (95%CI 22.2;56.1) of the patients with time-based anticoagulation strategies. And mortality rate was 35.4% (95%CI 28.9;42.1) of the patients with anti-Xa-based versus 42.9% (95%CI 36.9;48.9) of the patients with time-based anticoagulation strategies. Among the seven studies providing results from both anticoagulation strategies, significantly fewer bleeding events occurred in the anti-Xa-based anticoagulation strategy (adjusted OR 0.49 (95%CI 0.32;0.74), p < 0.001) and a significantly lower mortality rate (adjusted OR 0.61 (95%CI 0.40;0.95), p = 0.03). There was no significant difference in thrombotic events (adjusted OR 0.91 (95%CI 0.56;1.49), p = 0.71). In these seven observational studies, only a small fraction of the patients were adults, and data were insufficient to analyze the effect of the type of ECMO. In this meta-analysis of observational studies of patients on ECMO, an anti-Xa-based anticoagulation strategy, when compared to a time-based strategy, was associated with fewer bleeding events and mortality rate, without an increase in thrombotic events.

Assessing Anticoagulation in Neonates With Congenital Diaphragmatic Hernia During Extracorporeal Membrane Oxygenation: Does Anti-Factor Xa or Thromboelastometry Provide Additional Benefit?

“…In a systematic review, Willems et al ( 24) compared time-guided vs. anti-factor Xaguided anticoagulation strategies for UNFH titration in patients on ECMO. This meta-analysis showed that an anti-factor Xa-based anticoagulation strategy was associated with fewer hemorrhagic complications without an increase in thrombotic events, when compared to a time-based anticoagulation strategy (24). In contrast to these findings, we found no differences regarding anti-factor Xa values, when comparing the groups with and without bleeding events.…”

“…However, we did not compare two different anticoagulation strategies. Nevertheless, the results shown in the study by Willems et al (24) could suggest that an anti-factor Xa-based UNFH titration strategy could also reduce bleeding complications in neonatal patients on ECMO.…”

The role of rotational thromboelastometry during the COVID-19 pandemic: a narrative review

“…Accordingly, close monitoring of all hematologic parameters, including VET and personalized antithrombotic therapy, is recommended in patients with severe COVID-19, particularly during ECMO support [29]. The degree of anticoagulation can be assessed based on the anti-Xa activity or INTEM/HEPTEM CT-ratio for UFH, anti-Xa activity or NATEM/NAHEPTEM CT-ratio for LMWH, and anti-IIa activity, EXTEM CT, or ECATEM/ECA-test CT for IV direct thrombin inhibitors such as argatroban and bivalirudin [65,73,74,[85][86][87][88][89][90].…”

In vitro and in vivo safety studies indicate that R15, a synthetic polyarginine peptide, could safely reverse the effects of unfractionated heparin

“…1A,B). Considering the limitation of APTT in monitoring UFH [33], and the recommendation of anti‐FXa assays in the application of UFH determination [34,35], the anti‐FXa assays and turbidity assays were chosen to determine the potency of PS and R15, followed by verification in rats in vivo .…”