Bivalirudin-based versus conventional heparin anticoagulation for postcardiotomy extracorporeal membrane oxygenation

Abstract

IntroductionExtracorporeal membrane oxygenation (ECMO) after cardiac operations (postcardiotomy) is commonly used for the treatment of acute heart failure refractory to drug treatment. Bleeding and thromboembolic events are the most common complications of postcardiotomy ECMO. The present study is a retrospective comparison of the conventional heparin-based anticoagulation protocol with a bivalirudin-based, heparin-free protocol. Endpoints of this study are blood loss, allogeneic blood product use, and costs during the ECMO procedure.MethodsA retrospective study was undertaken in the setting of cardiac surgery, anesthesia, and intensive care departments of a university research hospital. Twenty-one patients (12 adults and nine children) who underwent postcardiotomy ECMO from 2008 through 2011 were retrospectively analyzed. The first consecutive eight patients were treated with heparin-based anticoagulation (H-group) and the next 13 consecutive patients with bivalirudin-based anticoagulation (B-group). The following parameters were analyzed: standard coagulation profile, thromboelastographic parameters, blood loss, allogeneic blood products use, thromboembolic complications, and costs during the ECMO treatment.ResultsPatients in the B-group had significantly longer activated clotting times, activated partial thromboplastin times, and reaction times at thromboelastography. The platelet count and antithrombin activity were not significantly different, but in the H-group a significantly higher amount of platelet concentrates, fresh frozen plasma, and purified antithrombin were administered. Blood loss was significantly lower in the B-group, and the daily cost of ECMO was significantly lower in pediatric patients treated with bivalirudin. Thromboembolic complications did not differ between groups.ConclusionsBivalirudin as the sole anticoagulant can be safely used for postcardiotomy ECMO, with a better coagulation profile, less bleeding, and allogeneic transfusions. No safety issues were raised by this study, and costs are reduced in bivalirudin-treated patients.

Bivalirudin Versus Heparin as an Anticoagulant During Extracorporeal Membrane Oxygenation: A Case-Control Study

“…11,14,15 One recent study 16 systematically analyzed a sample of 21 patients receiving bivalirudin during VA postcardiotomy ECMO. Ranucci et al 16 found that bivalirudin can be used safely and effectively to limit bleeding and allogeneic blood product transfusions in these patients, even if a superiority of bivalirudin versus heparin could not be shown. In this retrospective study, patients in the bivalirudin group had longer activated coagulation times, activated partial thromboplastin clotting times, and reaction times at thromboelastography.…”

Anticoagulation for Extracorporeal Life Support

“…In addition, there is no reliance on AT for its effect and therefore allows for more consistent use across all age groups and populations. 12 Their selective binding to thrombin and not to other circulating plasma proteins makes pharmacokinetics more predictable. In a recent survey of the ELSO database, DTIs were found to be used by up to 50% of respondents when indicated.…”

ECMO Biocompatibility: Surface Coatings, Anticoagulation, and Coagulation Monitoring

“…In the setting of ECMO, small case reports and single-center retrospective reviews have been generated describing the use of bivalirudin over heparin [77][78][79]80]. One such report from Ranucci et al [80] described the reduced use of platelet and plasma donor products in patients receiving bivalirudin for postcardiotomy ECMO compared to patients receiving UFH.…”

“…One such report from Ranucci et al [80] described the reduced use of platelet and plasma donor products in patients receiving bivalirudin for postcardiotomy ECMO compared to patients receiving UFH. Another small case-controlled study from Pieri et al [81] demonstrated less variation in aPTT but no difference in bleeding and thrombotic complications versus UFH.…”