Heparin vs bivalirudin anticoagulation for extracorporeal membrane oxygenation

Abstract

Background Extracorporeal membrane oxygenation (ECMO) induces hemostatic alterations that may contribute to hematological complications. Unfractionated heparin (UFH) is the mainstay antithrombotic in ECMO and depends on antithrombin III (AT III) to exhibit its actions. However, it bears the risk for heparin‐induced thrombocytopenia. Bivalirudin is a direct thrombin inhibitor and is inherently not dependent on AT III. Aim of the Study To assess the efficacy and safety profiles of UFH compared with bivalirudin during ECMO support. Methods We retrospectively reviewed 52 adult patients who were supported by ECMO from 1 January 2013 to 1 September 2018. Among them, 33 received UFH and 19 received bivalirudin. We analyzed their 7‐day rate of composite thrombotic, bleeding, and mortality episodes while on anticoagulation. Results There were no statistical differences in the 7‐day rate of composite thrombosis (33.3% vs 26.3%; P = 0.60), major bleeding (18.2% vs 5.3%; P = .24), 30‐day mortality, (42.4% vs 26.3%; P = .37), or in‐hospital mortality (45.5% vs 36.8%; P = .58). The percentage of time activated partial thromboplastin time (aPTT) was within the therapeutic range was higher with bivalirudin (50% vs 85.7%; P = .007). Conclusions This study suggests that UFH and bivalirudin are associated with similar rates of thrombosis, major bleeding, and mortality events in patients supported by ECMO. However, it was observed that bivalirudin consistently maintained aPTT within the therapeutic range in comparison to UFH.

Management of Upper Airway Bleeding in COVID‐19 Patients on Extracorporeal Membrane Oxygenation

“…Recent literature suggests that bivalirudin better maintains ECMO anticoagulation within a therapeutic range than UFH, without increasing incidence of bleeding events. 5 Bivalirudin is a direct thrombin inhibitor, as opposed to heparin, which indirectly inhibits thrombin by activating antithrombin. As we highlight in this series, there is still a risk of bleeding events requiring intervention with bivalirudin use.…”

“…Although unfractionated heparin (UFH) is commonly utilized for ECMO anticoagulation, early experiences with ECMO in patients with COVID‐19 at our institution showed maintaining therapeutic anticoagulation at typical doses was challenging. Recent literature suggests that bivalirudin better maintains ECMO anticoagulation within a therapeutic range than UFH, without increasing incidence of bleeding events 5 . Bivalirudin is a direct thrombin inhibitor, as opposed to heparin, which indirectly inhibits thrombin by activating antithrombin.…”

Anticoagulation in Critically Ill Adults during Extracorporeal Circulation

“…Continuous doses range from 0.025 to 0.10 mg/kg/h. [12][13][14][15][16] In patients with active bleeding or those with high risk of major bleeding (e.g., postsurgery, severe thrombocytopenia), an anticoagulation-free strategy may be feasible. A recent systematic review found relatively low rates of circuit and patient thrombosis in anticoagulant-free ECMO in adults, which might also be attributable to the fact that ECMO circuits themself are coated with anticoagulants (e.g., heparin).…”

A Review of Bivalirudin for Pediatric and Adult Mechanical Circulatory Support

“…Despite the widely varied population characteristics, patients remained within their defined therapeutic aPTT target range for the majority of the time (66.3%), demonstrating the efficacy of a standardized protocol for bivalirudin dose adjustment across a diverse population [12]. Similarly, Kaseer et al [13] started bivalirudin at a median dose of 0.1 mg/kg/h and reported a higher time in therapeutic range (aPTT) versus heparin therapy (50% in the heparin group vs. 85.7% in the bivalirudin group; p = 0.007). In another retrospective case report, by Jyoti et al [14], no loading dose was utilized, and bivalirudin was initiated at a rate of 0.6 mg/kg/h then titrated according to ACT and aPTT goals.…”

“…During this time, no major bleeding episodes took place, and no supplemental doses of bivalirudin were necessary to maintain anticoagulation targets [14]. Kaseer et al [13] had a median ECMO duration of 13 days with a range of 3-70 days for their bivalirudin cohort. While there was no specific mention of these patients' outcomes, overall the bivalirudin group had similar safety outcomes as the heparin cohort [13].…”