Bivalirudin-based Versus Conventional Heparin Anticoagulation for Postcardiotomy Extracorporeal Membrane Oxygenation

Overview

Journal Crit Care

Specialty Critical Care

Date 2011 Nov 22

PMID 22099212

Citations 62

Authors

Marco Ranucci

Andrea Ballotta

Hassan Kandil

Giuseppe Isgro

Concetta Carlucci

Ekaterina Baryshnikova

Valeria Pistuddi

Affiliations

Soon will be listed here.

Abstract

Introduction: Extracorporeal membrane oxygenation (ECMO) after cardiac operations (postcardiotomy) is commonly used for the treatment of acute heart failure refractory to drug treatment. Bleeding and thromboembolic events are the most common complications of postcardiotomy ECMO. The present study is a retrospective comparison of the conventional heparin-based anticoagulation protocol with a bivalirudin-based, heparin-free protocol. Endpoints of this study are blood loss, allogeneic blood product use, and costs during the ECMO procedure.

Methods: A retrospective study was undertaken in the setting of cardiac surgery, anesthesia, and intensive care departments of a university research hospital. Twenty-one patients (12 adults and nine children) who underwent postcardiotomy ECMO from 2008 through 2011 were retrospectively analyzed. The first consecutive eight patients were treated with heparin-based anticoagulation (H-group) and the next 13 consecutive patients with bivalirudin-based anticoagulation (B-group). The following parameters were analyzed: standard coagulation profile, thromboelastographic parameters, blood loss, allogeneic blood products use, thromboembolic complications, and costs during the ECMO treatment.

Results: Patients in the B-group had significantly longer activated clotting times, activated partial thromboplastin times, and reaction times at thromboelastography. The platelet count and antithrombin activity were not significantly different, but in the H-group a significantly higher amount of platelet concentrates, fresh frozen plasma, and purified antithrombin were administered. Blood loss was significantly lower in the B-group, and the daily cost of ECMO was significantly lower in pediatric patients treated with bivalirudin. Thromboembolic complications did not differ between groups.

Conclusions: Bivalirudin as the sole anticoagulant can be safely used for postcardiotomy ECMO, with a better coagulation profile, less bleeding, and allogeneic transfusions. No safety issues were raised by this study, and costs are reduced in bivalirudin-treated patients.

Citing Articles

The efficacy and safety of bivalirudin and heparin in patients with acute coronary syndrome: a systematic review and meta-analysis.

Zhai Y, Shang H, Li Y, Zhang N, Zhang J, Wu S Syst Rev. 2025; 14(1):39.

PMID: 39930484 PMC: 11808951. DOI: 10.1186/s13643-025-02782-7.

Anticoagulation during extracorporeal membrane oxygenation.

Seelhammer T, Ninan J, Nei S, Nabzdyk C, Wang Z, Gerberi D Cochrane Database Syst Rev. 2025; 6():CD015685.

PMID: 39804113 PMC: 11163473. DOI: 10.1002/14651858.CD015685.

Anticoagulation and associated complications in veno-arterial extracorporeal membrane oxygenation in adult patients: A systematic review and meta-analysis.

Vlok R, Buscher H, Delaney A, Garside T, McDonald G, Chatoor R Crit Care Resusc. 2025; 26(4):332-363.

PMID: 39781486 PMC: 11704180. DOI: 10.1016/j.ccrj.2024.10.003.

Evaluation of Bivalirudin During Adult Extracorporeal Membrane Oxygenation: A Retrospective Characterization of Dosing, Efficacy and Bleeding.

Lopez N, Seto S, Barra M, Roberts R, Rosovsky R, Solomon E Hosp Pharm. 2024; 59(1):77-85.

PMID: 38223854 PMC: 10786057. DOI: 10.1177/00185787231188924.

Comparison of bleeding and thrombotic outcomes in veno-venous extracorporeal membrane oxygenation: Heparin versus bivalirudin.

Kartika T, Mathews R, Migneco G, Bundy T, Kaempf A, Pfeffer M Eur J Haematol. 2023; 112(4):566-576.

PMID: 38088062 PMC: 11034845. DOI: 10.1111/ejh.14146.

References

Warkentin T, Greinacher A, Koster A . Heparin-induced thrombocytopenia in patients with ventricular assist devices: are new prevention strategies required?. Ann Thorac Surg. 2009; 87(5):1633-40. DOI: 10.1016/j.athoracsur.2008.10.060. View

Chen Y, Lin J, Yu H, Ko W, Jerng J, Chang W . Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis. Lancet. 2008; 372(9638):554-61. DOI: 10.1016/S0140-6736(08)60958-7. View

Hirsh J, ODonnell M, Eikelboom J . Beyond unfractionated heparin and warfarin: current and future advances. Circulation. 2007; 116(5):552-60. DOI: 10.1161/CIRCULATIONAHA.106.685974. View

Beiras-Fernandez A, Deutsch M, Kainzinger S, Kaczmarek I, Sodian R, Ueberfuhr P . Extracorporeal membrane oxygenation in 108 patients with low cardiac output – a single-center experience. Int J Artif Organs. 2011; 34(4):365-73. DOI: 10.5301/IJAO.2011.7727. View

Hirsh J, ODonnell M, Weitz J . New anticoagulants. Blood. 2004; 105(2):453-63. DOI: 10.1182/blood-2003-12-4195. View

Peek G, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany M . Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009; 374(9698):1351-63. DOI: 10.1016/S0140-6736(09)61069-2. View

Pollak U, Yacobobich J, Tamary H, Dagan O, Manor-Shulman O . Heparin-induced thrombocytopenia and extracorporeal membrane oxygenation: a case report and review of the literature. J Extra Corpor Technol. 2011; 43(1):5-12. PMC: 4680089. View

Polimenakos A, Wojtyla P, Smith P, Rizzo V, Nater M, El Zein C . Post-cardiotomy extracorporeal cardiopulmonary resuscitation in neonates with complex single ventricle: analysis of outcomes. Eur J Cardiothorac Surg. 2011; 40(6):1396-405. DOI: 10.1016/j.ejcts.2011.01.087. View

Oliver W . Anticoagulation and coagulation management for ECMO. Semin Cardiothorac Vasc Anesth. 2009; 13(3):154-75. DOI: 10.1177/1089253209347384. View

10.

Weitz J, Hudoba M, Massel D, Maraganore J, Hirsh J . Clot-bound thrombin is protected from inhibition by heparin-antithrombin III but is susceptible to inactivation by antithrombin III-independent inhibitors. J Clin Invest. 1990; 86(2):385-91. PMC: 296739. DOI: 10.1172/JCI114723. View

11.

Leprince P, Combes A, Bonnet N, Ouattara A, Luyt C, Theodore P . Circulatory support for fulminant myocarditis: consideration for implantation, weaning and explantation. Eur J Cardiothorac Surg. 2003; 24(3):399-403. DOI: 10.1016/s1010-7940(03)00382-8. View

12.

Combes A, Leprince P, Luyt C, Bonnet N, Trouillet J, Leger P . Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Crit Care Med. 2008; 36(5):1404-11. DOI: 10.1097/CCM.0b013e31816f7cf7. View

13.

Koster A, Huebler S, Potapov E, Meyer O, Jurmann M, Weng Y . Impact of heparin-induced thrombocytopenia on outcome in patients with ventricular assist device support: single-institution experience in 358 consecutive patients. Ann Thorac Surg. 2006; 83(1):72-6. DOI: 10.1016/j.athoracsur.2006.05.077. View

14.

Smedira N, Moazami N, Golding C, McCarthy P, Apperson-Hansen C, Blackstone E . Clinical experience with 202 adults receiving extracorporeal membrane oxygenation for cardiac failure: survival at five years. J Thorac Cardiovasc Surg. 2001; 122(1):92-102. DOI: 10.1067/mtc.2001.114351. View

15.

Koster A, Weng Y, Bottcher W, Gromann T, Kuppe H, Hetzer R . Successful use of bivalirudin as anticoagulant for ECMO in a patient with acute HIT. Ann Thorac Surg. 2007; 83(5):1865-7. DOI: 10.1016/j.athoracsur.2006.11.051. View

16.

Ranucci M, Isgro G, Cazzaniga A, Soro G, Menicanti L, Frigiola A . Predictors for heparin resistance in patients undergoing coronary artery bypass grafting. Perfusion. 1999; 14(6):437-42. DOI: 10.1177/026765919901400606. View

17.

Barzaghi N, Locatelli A, Ranucci M . Ventricular assist device implantation and the risk for heparin-induced thrombocytopenia. Ann Thorac Surg. 2007; 85(1):360-1. DOI: 10.1016/j.athoracsur.2007.06.010. View

18.

Dyke C, Smedira N, Koster A, Aronson S, McCarthy 2nd H, Kirshner R . A comparison of bivalirudin to heparin with protamine reversal in patients undergoing cardiac surgery with cardiopulmonary bypass: the EVOLUTION-ON study. J Thorac Cardiovasc Surg. 2006; 131(3):533-9. DOI: 10.1016/j.jtcvs.2005.09.057. View

19.

Bartlett R, Gattinoni L . Current status of extracorporeal life support (ECMO) for cardiopulmonary failure. Minerva Anestesiol. 2010; 76(7):534-40. View

20.

Pappalardo F, Maj G, Scandroglio A, Sampietro F, Zangrillo A, Koster A . Bioline heparin-coated ECMO with bivalirudin anticoagulation in a patient with acute heparin-induced thrombocytopenia: the immune reaction appeared to continue unabated. Perfusion. 2009; 24(2):135-7. DOI: 10.1177/0267659109106773. View