Anticoagulation strategies during peripheral ultrafiltration in diuretic-resistant congestive heart failure

Introduction and objectives Peripheral ultrafiltration (UF) is an effective strategy for the management of diuretic-resistant congestion in patients with decompensated heart failure. However, extracorporeal circuit clotting remains one of the main technical limitations of the procedure, and the optimal anticoagulation strategy during UF has not been clearly established. The primary aim of this study was to evaluate the efficacy and safety of different anticoagulation strategies during UF. Methods This prospective, nonrandomized, single-center study included 87 consecutive patients who underwent UF between January 2021 and November 2025. The anticoagulation strategy was tailored according to the patients' baseline anticoagulant therapy: unfractionated heparin (UFH), n = 8; low-molecular-weight heparin (LMWH), n = 41; vitamin K antagonists (VKAs), n = 12; and direct oral anticoagulants (DOACs), n = 26. Procedural efficacy was defined as successful completion of the UF session without premature interruption due to extracorporeal circuit dysfunction or clinical complications. Results Baseline characteristics and UF technical parameters were comparable among groups (P > .1). Procedural efficacy was highest with intravenous heparin (UFH = 100%, LMWH = 48.7%, VKAs = 66.6%, and DOACs = 65.4%; P = .048). Extracorporeal circuit clotting was more frequent with subcutaneous heparin (UFH = 0%, LMWH = 31.7%, VKAs = 25%, and DOACs = 27%; P = .018). Conclusions UFH was associated with a lower rate of extracorporeal circuit clotting and a higher rate of successful UF completion. Complications were infrequent. Given the observational design and the small sample size, these findings warrant confirmation in larger prospective studies. Full English text available from: www.revespcardiol.org/en.