Key result
Adding nafamostat to heparin halts ECMO circuit thrombosis for ~128 hours in an infant case.
Why the study?
Thrombosis in the ECMO circuit can increase mortality and necessitate frequent circuit exchanges, but only a few reports describe nafamostat mesilate for anticoagulation during ECMO.
Does nafamostat mesilate reduce ECMO circuit thrombosis in an infant with congenital heart disease requiring VA-ECMO?
Case Report (n=1)
No
Does nafamostat mesilate reduce ECMO circuit thrombosis in an infant with congenital heart disease requiring VA-ECMO?
Nafamostat mesilate may be an effective adjunctive anticoagulant to reduce ECMO circuit thrombosis without increasing bleeding risk in infants when standard heparin therapy is insufficient.
Answers are grounded in this paper and cite their sources.
Offers a potential alternative anticoagulant for pediatric ECMO; leaves open whether nafamostat.
Background: Thrombosis in the ECMO circuit is a major complication and can increase mortality. Circuit thrombosis may necessitate circuit exchange, and frequent exchanges affect patient prognosis. Nafamostat mesilate (NM) is a serine protease inhibitor widely used for anticoagulation during dialysis in Japan, but only a few reports have described its use for anticoagulation during ECMO. Herein, we report an infant case who received an NM infusion to reduce the frequency of ECMO circuit exchanges due to circuit thrombosis, in addition to standard anticoagulation with unfractionated heparin. Clinical Course: A one-month-old infant weighing 3.5 kg with hypoplastic left heart syndrome status post bilateral pulmonary artery banding underwent Norwood procedure with Sano shunt on the 46th day of life. Postoperatively, the patient gradually deteriorated, leading to the initiation of VA-ECMO with a roller pump due to severe low cardiac output. However, circuit thrombosis occurred 24 hours after ECMO initiation, requiring the first circuit exchange 32 hours later. Then, the second, third, and fourth exchanges were required 80, 118, and 126 hours later, respectively, despite standard anticoagulation with unfractionated heparin. Therefore, NM was added at 0.3 mg/kg/hour into the circuit after the fourth circuit exchange. Thereafter, no obvious formation of circuit thrombosis was observed, and no circuit exchanges were required for 128 hours from the fourth exchange to ECMO weaning. Furthermore, there were no hemorrhagic complications. Discussion: Nafamostat mesilate is a short-acting anticoagulant, so it mainly affects the ECMO circuit when it is given into the circuit. As a result, NM effectively reduced the risk of circuit thrombosis without hemorrhagic complications for this patient. Conclusion: Nafamostat mesilate could be an option to reduce ECMO circuit exchange due to circuit thrombosis when standard anticoagulation is ineffective.
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Nakata et al. (2026) conducted a case report in Hypoplastic left heart syndrome requiring VA-ECMO with circuit thrombosis (n=1). Nafamostat mesilate vs. Standard anticoagulation with unfractionated heparin alone (prior course) was evaluated on ECMO circuit thrombosis requiring circuit exchange. Addition of nafamostat mesilate to standard heparin prevented ECMO circuit thrombosis, requiring no circuit exchanges for 128 hours without hemorrhagic complications in an infant.
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