Key result
Bivalirudin during ECMO shows similar complication rates compared with heparin.
Why the study?
Heparin has traditionally been the anticoagulant of choice during ECMO, but bivalirudin has been suggested as a superior alternative.
Does bivalirudin reduce hemorrhagic and thrombotic complications compared to heparin in adult extracorporeal membrane oxygenation patients?
Cohort (n=144)
No
Does bivalirudin reduce hemorrhagic and thrombotic complications compared to heparin in adult extracorporeal membrane oxygenation patients?
Absolute Event Rate: 0.06% vs 0.13%
p-value: p=0.633
In adult ECMO patients, bivalirudin showed similar rates of hemorrhagic and thrombotic complications compared to heparin but was associated with significantly fewer blood transfusions.
Bivalirudin was associated with similar complication rates but fewer transfusions in ECMO; leaves open net benefit versus heparin pending randomized trials.
Extracorporeal membrane oxygenation is a potentially life-saving intervention in refractory cardiopulmonary failure, but it requires anticoagulation to prevent circuit thromboses, which exposes the patient to hemorrhagic complications. Heparin has traditionally been the anticoagulant of choice, but the direct thrombin inhibitor bivalirudin is routinely used in cases of heparin-induced thrombocytopenia and has been suggested as a superior choice. We sought to examine the timing of hemorrhagic and thrombotic complications after extracorporeal membrane oxygenation cannulation and to compare the rates of such complications between patients anticoagulated with heparin versus bivalirudin. Design Retrospective cohort study. Setting Johns Hopkins Hospital patients between January 2016 and July 2019. Patients Adult (> 18 yr) extracorporeal membrane oxygenation patients. Interventions Patients were anticoagulated either with heparin or bivalirudin. Measurements and main results We compared rates of hemorrhagic and thrombotic complications by time on heparin versus bivalirudin and characterized the average time to each complication. Of 144 extracorporeal membrane oxygenation patients (mean age 55.3 yr; 58% male), 41% were on central venoarterial extracorporeal membrane oxygenation, 40% on peripheral venoarterial extracorporeal membrane oxygenation, and 19% on venovenous extracorporeal membrane oxygenation. Thirteen patients (9%) received bivalirudin during their extracorporeal membrane oxygenation run, due to concern for (n = 8) or diagnosis of (n = 4) heparin-induced thrombocytopenia or for heparin resistance (n = 1). The rate of hemorrhagic or thrombotic complications did not differ between heparin (0.13/d) and bivalirudin (0.06/d; p = 0.633), but patients on bivalirudin received significantly fewer blood transfusions (1.0 U of RBCs/d vs 2.9/d on heparin; p < 0.001). Conclusions Our results confirm the safety and efficacy of bivalirudin as an alternative anticoagulant in extracorporeal membrane oxygenation and suggest a potential benefit in less blood product transfusion, although prospective studies are needed to evaluate the true effect of bivalirudin versus the disease processes that prompted its use in our study population.
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Giuliano et al. (2021) conducted a cohort in Cardiopulmonary failure requiring extracorporeal membrane oxygenation (n=144). Bivalirudin vs. Heparin was evaluated on Rate of hemorrhagic or thrombotic complications (p=0.633). Bivalirudin use during extracorporeal membrane oxygenation was associated with similar rates of hemorrhagic or thrombotic complications compared with heparin (0.06/d vs 0.13/d; p=0.633).
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