Is Stopping Heparin Safe in Patients on Extracorporeal Membrane Oxygenation Treatment?

Abstract

Anticoagulation treatment during extracorporeal membrane oxygenation (ECMO) treatment is unavoidable. However, discontinuation of heparin infusion is necessary when challenges associated with the use of heparin, such as bleeding and thrombocytopenia, are encountered. The medical records of 94 adult (age ≥ 18 years) patients treated with ECMO from January 2011 to March 2015, at Chung-Ang University Hospital, Seoul, Korea, were reviewed. Among the 94 patients, 55 patients underwent ECMO treatment for three or more days. In 52.7% of these patients (n = 29, group A), heparin was stopped for three or more days because of thrombocytopenic events (< 50,000 cells/mm), higher than target range (> 230 seconds) activated clotting time (ACT), bleeding complications, or the need for other surgical procedures. In 43.6% of patients (n = 24, group B), heparin was continuously infused during the entire ECMO process. The mean length of ECMO support after the initiation of heparin discontinuation in patients in group A was 10.2 ± 14.7 days. There were no intracardiac, intravascular, or intracircuit thrombotic complications in group A. There was no difference in the ECMO weaning success rate between the two groups (41.4% in group A vs. 54.2% in group B, p = 0.353). Heparin discontinuation can be considered in a select group of patients with coagulation abnormalities or bleeding.

Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock

“…Adding to the controversy, optimal anticoagulant dosing remains unclear and needs to be individualized [prophylactic vs. therapeutic level; ( 159 , 160 )]. There is also emerging evidence that holding anticoagulation while on VA-ECMO may be safe in select patients and may decrease hemorrhagic complications and the requirement for blood transfusions without increasing mortality ( 161 , 162 ). Regardless of the strategy and dosing selected, coagulation status must be monitored meticulously during VA-ECMO support.…”

A Case Report of Venoarterial ECMO as Salvage Therapy for Prolonged Cardiac Arrest Following Post-Reperfusion Intracardiac Thrombosis During Orthotopic Liver Transplantation

“…Studies suggest that it is safe to withdraw anticoagulation for up to 3 days in circumstances of anticoagulation intolerance. 8 Our patient remained coagulopathic and off anticoagulation until POD 3. Coagulopathy was eventually overcome with improved liver function and directed transfusion therapy.…”

ECMO as a bridge to non-transplant cardiac surgery

“…For patients at high risk of bleeding or with ongoing bleeding, withholding anticoagulation during ECMO is a well-recognized practice that can be implemented with relative safety. 22 The duration that VA ECMO can be run off anticoagulation is unknown as no data exist, but extrapolated from the VV ECMO experience, anticoagulation can be withheld while bleeding continues. [23][24][25][26] Persistence of multi-system organ failure may extend the…”

“…However, the need for anticoagulation during VA ECMO under these circumstances can be challenging. For patients at high risk of bleeding or with ongoing bleeding, withholding anticoagulation during ECMO is a well‐recognized practice that can be implemented with relative safety . The duration that VA ECMO can be run off anticoagulation is unknown as no data exist, but extrapolated from the VV ECMO experience, anticoagulation can be withheld while bleeding continues .…”