ID:166 FC-D04-1 Protocol-Based Stepwise Anticoagulation Management for Mechanical Circulatory Support During the Perioperative Period of Noncardiac Surgery

Background: Anticoagulation is an essential management in mechanical circulatory support (MCS) and the optimal balance should be achieved between thrombotic and hemorrhagic events in perioperative MCS. However, no standardized approach has been established and therefore adjustment of medical anticoagulation significantly varies across institutions for patients with a bleeding event. We reported case series to evaluate the safety and effectiveness of an institutional stepwise protocol for anticoagulation during perioperative MCS. Methods: The institutional anticoagulation protocol includes the following four steps. (1) Systemic intravenous unfractionated heparin and a heparin-based purge solution for Impella with a target of activated partial thromboplastin time (aPTT) of 1.5–2.0 times higher than baseline; (2) for a minor hemorrhagic event, aPTT target is decreased to 1.2–1.5 times; (3) for a major hemorrhagic event, intravenous systemic heparin is discontinued, and (4) for a fatal bleeding event, a heparin-based purge solution is also discontinued. We retrospectively reviewed patients treated with perioperative MCS for noncardiac surgery between 2024 and 2025. Result: Three patients requiring perioperative MCS were identified during the study period, with one treated with Impella and two with ECPELLA. The patient with Impella developed septic cardiomyopathy due to non-occlusive mesenteric ischemia, requiring several laparotomies with open abdomen. Standard anticoagulation protocol was maintained during perioperative MCS; no significant hemorrhagic events emerged. The one of patients with ECPELLA developed septic cardiomyopathy following esophagectomy and the other had refractory ventricular fibrillation during the resection of mediastinal carcinoid. Both required temporary fourth step of protocol due to fatal bleeding during approximately one-third of the MCS run time. With multiple ECMO circuit exchanges, both patients were successfully weaned from MCS without major thromboembolic complications. Conclusion: This four-step protocol may be safely adopted in perioperative MCS for noncardiac surgery.