Hemostasis, coagulation and thrombin in venoarterial and venovenous extracorporeal membrane oxygenation: the HECTIC study

Abstract

Extracorporeal membrane oxygenation (ECMO) support has a high incidence of both bleeding and thrombotic complications. Despite clear differences in patient characteristics and pathologies between veno-venous (VV) and veno-arterial (VA) ECMO support, anticoagulation practices are often the same across modalities. Moreover, there is very little data on their respective coagulation profiles and comparisons of thrombin generation in these patients. This study compares the coagulation profile and thrombin generation between patients supported with either VV and VA ECMO. A prospective cohort study of patients undergoing VA and VV ECMO at an Intensive care department of a university hospital and ECMO referral centre. In addition to routine coagulation testing and heparin monitoring per unit protocol, thromboelastography (TEG), multiplate aggregometry (MEA), calibrated automated thrombinography (CAT) and von-Willebrand’s activity (antigen and activity ratio) were sampled second-daily for 1 week, then weekly thereafter. VA patients had significantly lower platelets counts, fibrinogen, anti-thrombin and clot strength with higher d-dimer levels than VV patients, consistent with a more pronounced consumptive coagulopathy. Thrombin generation was higher in VA than VV patients, and the heparin dose required to suppress thrombin generation was lower in VA patients. There were no significant differences in total bleeding or thrombotic event rates between VV and VA patients when adjusted for days on extracorporeal support. VA patients received a lower median daily heparin dose 8500 IU [IQR 2500–24000] versus VV 28,800 IU [IQR 17,300–40,800.00]; < 0.001. Twenty-eight patients (72%) survived to hospital discharge; comprising 53% of VA patients and 77% of VV patients. Significant differences between the coagulation profiles of VA and VV patients exist, and anticoagulation strategies for patients of these modalities should be different. Further research into the development of tailored anticoagulation strategies that include the mode of ECMO support need to be completed.

Longitudinal multiparametric characterization of platelet dysfunction in COVID-19: Effects of disease severity, anticoagulation therapy and inflammatory status

“…To test how enhanced platelet consumption affects observed COVID-19 patient platelet phenotype, we have studied platelets of the COVID-19 patients on ECMO therapy [52] . In COVID-19 patients receiving ECMO, platelet count and platelet responsiveness dropped in the first 2–3 days after the start of the ECMO therapy ( Fig.…”

Multiple Surgical Treatments for Recurrent Retroperitoneal Hemorrhage in a COVID-19 Patient with Respiratory Failure on Extracorporeal Membrane Oxygenation

“…The use of systemic procoagulants was also considered, but thrombus-induced-malfunction of ECMO in the situation has been reported to result in the patient still being very dependent on ECMO [17], and the end organ damage from microthrombus and fibrin deposition caused by systemic pro-coagulation was of concern [18,19].…”

Anticoagulation Strategies during Extracorporeal Membrane Oxygenation: A Narrative Review

“…Furthermore, different configurations of ECMO may also alter hemostasis. In the prospective HECTIC trial, the rate of thrombosis in va-ECMO was around 40%, with rates twice as high in vv-ECMO [ 47 ]. Moreover, in an ex vivo model, ECMO flow rates below 1.5 L/min were shown to decrease platelet aggregation, weaken clot firmness, and surprisingly increase hemolysis (despite the lower pump speed) [ 48 ].…”