Extracorporeal Membrane Oxygenation in 108 Patients with Low Cardiac Output – a Single-Center Experience

Predictive Value of Serial Model of End-Stage Liver Disease Score Determination in Patients with Postcardiotomy Extracorporeal Membrane Oxygenation

(1) Background: The use of extracorporeal membrane oxygenation (ECMO) in low cardiac output states after cardiac surgery may aid in patient recovery. However, in some patients, the clinical state may worsen, resulting in multiple organ failure and high mortality rates. In these circumstances, calculating a model of end-stage liver disease (MELD) score was shown to determine organ dysfunction and predicting mortality. (2) Methods: We evaluated whether serial MELD score determination increases mortality prediction in patients with postcardiotomy ECMO support. (3) Results: Statistically, a cutoff of a 2.5 MELD score increase within 48 h of ECMO initiation revealed an AUC of 0.722. Further, we found a significant association between hospital mortality and 48 h MELD increase (HR: 2.5, 95% CI: 1.33-4.75, p = 0.005) after adjustment for possible confounders. (4) Conclusions: Therefore, serial MELD score determinations on alternate days may be superior to single measurements in this special patient cohort.

Prognosticating Mortality of Primary Cardiogenic Shock Requiring Extracorporeal Life Support: The RESCUE Score

We aimed to identify prognostic laboratory markers during extracorporeal life support (ECLS) in patients with primary refractory cardiogenic shock (RCS) and to create a preliminary specific mortality score. All 208 consecutive subjects admitted for primary RCS and treated with ECLS between January-2009 and December-2018 were retrospectively analyzed. Multivariate regression analysis on laboratory markers during the first nine days of ECLS was used to develop a "Refractory End-stage Shock CUred with Ecls" (RESCUE) score. Serum creatinine (OR = 3.72, 95%CI: 2.01-6.88), direct bilirubin (OR = 1.40, 95%CI: 1.05-1.8), and platelet count (OR = 0.62, 95%CI: 0.42-0.94) were independent predictors of in-hospital mortality and were included in the score. The mean AUC was 0.763 (95%CI: 0.698-0.828) in the development cohort and 0.729 (95%CI: 0.664-0.794) in the bootstrap internal validation cohort. The RESCUE score represents a novel promising instrument to predict early mortality during the first critical days of ECLS and to help in properly guiding the therapeutic decision-making process.

Hemostatic Management in Extracorporeal Membrane Oxygenation

The use of extracorporeal membrane oxygenation (ECMO) for acute cardiac and/or respiratory failure has grown exponentially in the past several decades. Systemic anticoagulation is a fundamental element of caring for ECMO patients. Hemostatic management during ECMO walks a fine line to balance the risk of safe and effective anticoagulant delivery to mitigate thromboembolic complications and minimizing hemorrhagic sequelae. This review discusses the pharmacology, monitoring parameters, and special considerations for anticoagulation in patients requiring ECMO.

Predictors of Survival to Discharge After Successful Weaning From Venoarterial Extracorporeal Membrane Oxygenation in Patients With Cardiogenic Shock

BACKGROUND

This study identified predictors of hospital mortality after successful weaning of patients with cardiogenic shock off venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support.

METHODS AND RESULTS

Adult patients who received peripheral VA ECMO from January 2012 to April 2017 were reviewed retrospectively. After excluding patients who died on ECMO support, predictors for survival to discharge were investigated in patients who were successfully weaned off ECMO. Of 191 patients successfully weaned off ECMO, 143 (74.9%) survived to discharge. The prevalence of a history of stroke and coronary artery disease, as well as ECMO-related complications, including newly developed stroke and sepsis, was a higher in patients who did not survive to discharge than in those who did. On the day of ECMO weaning, Sequential Organ Failure Assessment score and serum lactate were higher in patients who did not survive to discharge, although there was no significant difference in blood pressure and the use of vasoactive drugs between the 2 groups. On multivariable analysis, stroke and sepsis during ECMO support, a lower Glasgow Coma Scale and acute kidney injury requiring continuous renal replacement therapy after weaning were significant predictors for in-hospital mortality.

CONCLUSIONS

Complications that occurred during ECMO and the presence of extracardiac organ dysfunction after weaning were associated with in-hospital mortality in patients with cardiogenic shock who were successfully weaned off ECMO.

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019-Induced Acute Respiratory Distress Syndrome: A Multicenter Descriptive Study

OBJECTIVES

Severe acute respiratory distress syndrome is complicated with coronavirus disease 2019 and extracorporeal membrane oxygenation support may be necessary in severe cases. This study is to summarize the clinical features, extracorporeal membrane oxygenation characteristics, and outcomes of patients with severe acute respiratory syndrome coronavirus 2 pneumonia received extracorporeal membrane oxygenation.

DESIGN

Descriptive study from two hospitals.

SETTING

The ICUs from university hospitals.

PATIENTS

Patients with severe acute respiratory syndrome coronavirus 2 pneumonia received mechanical ventilation, including those underwent extracorporeal membrane oxygenation from Zhongnan Hospital of Wuhan University and Wuhan Pulmonary Hospital from January 8, 2020, to March 31, 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinical records, laboratory results, ventilator parameters, and extracorporeal membrane oxygenation-related data were abstracted from the medical records. One-hundred twenty-nine critically ill patients with severe acute respiratory syndrome coronavirus 2 pneumonia were admitted to ICU of the two referral hospitals. Fifty-nine patients received mechanical ventilation and 21 of them received extracorporeal membrane oxygenation support (fourteen from Zhongnan hospital and seven from Wuhan pulmonary hospital). Compared to mechanical ventilation patients without extracorporeal membrane oxygenation support, there was a tendency of decline in mortality but with no significant difference (no-extracorporeal membrane oxygenation group 24/38 [63.2%] vs extracorporeal membrane oxygenation group 12/21 [57.1%]; p = 0.782). For those patients with extracorporeal membrane oxygenation, 12 patients died and nine survived by April 7, 2020. Among extracorporeal membrane oxygenation patients, the PaCO2 prior to extracorporeal membrane oxygenation was lower (54.40 mm Hg [29.20-57.50 mm Hg] vs 63.20 mm Hg [55.40-72.12 mm Hg]; p = 0.006), and pH prior to extracorporeal membrane oxygenation was higher (7.38 [7.28-7.48] vs 7.23 [7.16-7.33]; p = 0.023) in survivors than nonsurvivors.

CONCLUSIONS

Extracorporeal membrane oxygenation might be an effective salvage treatment for patients with severe acute respiratory syndrome coronavirus 2 pneumonia associated with severe acute respiratory distress syndrome. Severe CO2 retention and acidosis prior to extracorporeal membrane oxygenation indicated a poor prognosis.

Early morbidities following paediatric cardiac surgery: a mixed-methods study

Background

Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.

Objectives

We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.

Design and setting

Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.

Participants

The participants were children aged < 17 years.

Methods

We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.

Results

Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).

Limitations

Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.

Conclusions

Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.

Future work

National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.

What are the important morbidities associated with paediatric cardiac surgery? A mixed methods study

OBJECTIVES

Given the current excellent early mortality rates for paediatric cardiac surgery, stakeholders believe that this important safety outcome should be supplemented by a wider range of measures. Our objectives were to prospectively measure the incidence of morbidities following paediatric cardiac surgery and to evaluate their clinical and health-economic impact over 6 months.

DESIGN

The design was a prospective, multicentre, multidisciplinary mixed methods study.

SETTING

The setting was 5 of the 10 paediatric cardiac surgery centres in the UK with 21 months recruitment.

PARTICIPANTS

Included were 3090 paediatric cardiac surgeries, of which 666 patients were recruited to an impact substudy.

RESULTS

Families and clinicians prioritised:Acute neurological event, unplanned re-intervention, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, postsurgical infection and prolonged pleural effusion or chylothorax.Among 3090 consecutive surgeries, there were 675 (21.8%) with at least one of these morbidities. Independent risk factors for morbidity included neonatal age, complex heart disease and prolonged cardiopulmonary bypass (p<0.001). Among patients with morbidity, 6-month survival was 88.2% (95% CI 85.4 to 90.6) compared with 99.3% (95% CI 98.9 to 99.6) with none of the morbidities (p<0.001). The impact substudy in 340 children with morbidity and 326 control children with no morbidity indicated that morbidity-related impairment in quality of life improved between 6 weeks and 6 months. When compared with children with no morbidities, those with morbidity experienced a median of 13 (95% CI 10.2 to 15.8, p<0.001) fewer days at home by 6 months, and an adjusted incremental cost of £21 292 (95% CI £17 694 to £32 423, p<0.001).

CONCLUSIONS

Evaluation of postoperative morbidity is more complicated than measuring early mortality. However, tracking morbidity after paediatric cardiac surgery over 6 months offers stakeholders important data that are of value to parents and will be useful in driving future quality improvement.

Evaluation of Systemic Heparin Versus Bivalirudin in Adult Patients Supported by Extracorporeal Membrane Oxygenation

Systemic anticoagulation is a standard of care in adult patients supported by extracorporeal membrane oxygenation (ECMO) to prevent circuit thrombosis and subsequent thromboembolic events. Unfractionated heparin has long been considered the anticoagulant of choice, but emerging evidence reports successful ECMO runs with direct thrombin inhibitors. This retrospective study sought to determine whether bivalirudin offers distinct clinical benefits as the anticoagulant of choice in ECMO. Primary end points included thrombotic events during the initial 96 hours of anticoagulation, over the course of their entire ECMO run, and at any time during the admission, as well as in-hospital and 30-day mortality. Secondary end points included percent time within therapeutic range for each anticoagulant, neurologic events, vascular complications, and bleeding. Compared with patients receiving heparin, patients receiving bivalirudin show similar rates of thrombotic events across the three time points (17.9% vs. 9.1%; p = 0.47, 21.4% vs. 11.4%; p = 0.41, and 25% vs. 22.7%; p = 1.00, respectively). In-hospital (32.1% vs. 36.4%; p = 0.91) and 30-day mortality (32.1% vs. 36.4%; p = 0.91) were no different. Similarly, no differences were observed in percent time within therapeutic range (83.0% vs. 87.7%, p = 0.34), neurological events (7.1% vs. 11.4%, p = 0.99), vascular complications (57.1% vs. 38.6%, p = 0.20), or major (25.0% vs. 45.5%, p = 0.13) and minor (25.0% vs. 22.7%, p = 1.00) bleeding. These results suggest that bivalirudin is a viable alternative to heparin for anticoagulation in ECMO but may not offer a clinically significant advantage as the anticoagulant of choice.

Right Sided Intracardiac Thrombosis during Veno-Arterial Extracorporeal Membrane Oxygenation: A Case Report and Literature Review

Veno-Arterial Extracorporeal Membrane Oxygenation is a common technology of the modern era used as a bridge in severe refractory cardiac and respiratory failure until definitive management is planned. However, early recognition and management of one of the most challenging complications, intracardiac thrombus, continue to remain a conundrum. The incidence of the clinical scenario is very rare. Therefore, due to the lack of literature, there are no guidelines for risk stratification, prevention, or management of intracardiac thrombus. We describe a case of massive pulmonary embolism, who developed a sudden right sided intra-cardiac thrombosis while being optimally anticoagulated on VA ECMO. We also review the literature to describe the pathophysiology, risk stratification, prevention, and management of this rare entity.

Utilization and Outcomes of Temporary Mechanical Circulatory Support for Graft Dysfunction After Heart Transplantation

Graft dysfunction is the main cause of early mortality after heart transplantation. In cases of severe graft dysfunction, temporary mechanical circulatory support (TMCS) may be necessary. The aim of this systematic review was to examine the utilization and outcomes of TMCS in patients with graft dysfunction after heart transplantation. Electronic search was performed to identify all studies in the English literature assessing the use of TMCS for graft dysfunction. All identified articles were systematically assessed for inclusion and exclusion criteria. Of the 5,462 studies identified, 41 studies were included. Among the 11,555 patients undergoing heart transplantation, 695 (6.0%) required TMCS with patients most often supported using venoarterial extracorporeal membrane oxygenation (79.4%) followed by right ventricular assist devices (11.1%), biventricular assist devices (BiVADs) (7.5%), and left ventricular assist devices (LVADs) (2.0%). Patients supported by LVADs were more likely to be supported longer (p = 0.003), have a higher death by cardiac event (p = 0.013) and retransplantation rate (p = 0.015). In contrast, patients supported with BiVAD and LVAD were more likely to be weaned off support (p = 0.020). Overall, no significant difference was found in pooled 30 day survival (p = 0.31), survival to discharge (p = 0.19), and overall survival (p = 0.51) between the subgroups. Temporary mechanical circulatory support is an effective modality to support patients with graft dysfunction after heart transplantation. Further studies are needed to establish the optimal threshold and strategy for TMCS and to augment cardiac recovery and long-term survival.

Laboratory and clinical predictors of 30-day survival for patients on Extracorporeal Membrane Oxygenation (ECMO): 8-Year experience at Albert Einstein College of Medicine, Montefiore Medical Center

PURPOSE

Survival of patients on ECMO has remained stable in every population. Laboratory values predictors of survival are required to improve patient care.

MATERIALS AND METHODS

Clinical Looking Glass software was used to assess Electronic Medical Records (EMRs) of patients at Albert Einstein College of Medicine, Montefiore Medical Center (2007-2014).

RESULTS

Our population comprises of 166 adults and was divided in survivors and non-survivors, within 30days. Indications for ECMO were cardiac (65%), respiratory (25%) and infectious diseases (<10%). Eighty six patients (51.8%) survived the procedure. Gender, body weight, ejection fraction, diastolic blood pressure, and socio-economic status did not differ among survivors and non-survivors. In contrast, younger patients (45yo vs 55yo, p=0.0001) and higher systolic blood pressure (115mmHg vs 103mmHg, p=0.025) have favorable outcome. Univariate analysis shows that pre-cannulation values for creatinine (p=0.0003), chloride (p=0.009), bicarbonate (p=0.015) and pH (p=0.03) have prognostic value. Post-cannulation aPTT, pH, platelet and lymphocyte counts also have discriminative power. Notably, multiple logistic regressions for Multivariate Analysis identified chloride (OR 1.07; 95% CI 1.02-1.13; p=0.004), pH (OR 3.35; 95% CI 1.89-5.9; p<0.0001) and aPTT (OR 0.98; 95% CI 0.976-0.998; p=0.024) as independent risk factors for 30-day mortality. These results imply that pre-existing renal conditions and hemostatic dysregulation contribute to poor outcome. Finally, patients on VV-ECMO have increase odds of survival (OR 1.88; 95% CI 1.06-3.34; p=0.029).

CONCLUSIONS

Laboratory markers identified herein may guide the management of patients on ECMO.

Post-cardiotomy ECMO in pediatric and congenital heart surgery: impact of team training and equipment in the results

Introduction

Post-cardiotomy myocardial dysfunction requiring mechanical circulatory support occurs in about 0.5% of cases. In our environment, the use of extracorporeal membrane oxygenation has been increasing in recent years.

Objective

To evaluate the impact of investment in professional training and improvement of equipment in the rate of weaning from extracorporeal membrane oxygenation and survival.

Methods

A retrospective study. Fifty-six pediatric and/or congenital heart patients underwent post-cardiotomy extracorporeal membrane oxygenation at our institution between November 1999 and July 2014. We divided this period into two phases: phase I, 36 cases (before the structuring of the extracorporeal membrane oxygenation program) and phase II, 20 cases (after the extracorporeal membrane oxygenation program implementation) with investment in training and equipment). Were considered as primary outcomes: extracorporeal membrane oxygenation weaning and survival to hospital discharge. The results in both phases were compared using Chi-square test. To identify the impact of the different variables we used binary logistic regression analysis.

Results

Groups were comparable. In phase I, 9 patients (25%) were weaned from extracorporeal membrane oxygenation, but only 2 (5.5%) were discharged. In phase II, extracorporeal membrane oxygenation was used in 20 patients, weaning was possible in 17 (85%), with 9 (45%) hospital discharges (P<0.01). When the impact of several variables on discharge and weaning of extracorporeal membrane oxygenation was analyzed, we observe that phase II was an independent predictor of better results (P<0.001) and need for left cavities drainage was associated with worse survival (P=0.045).

Conclusion

The investment in professional training and improvement of equipment significantly increased extracorporeal membrane oxygenation results.

Comparative Review of Outcomes in Patients With Congenital Heart Disease Requiring Cardiopulmonary Support for Failure to Wean From Cardiopulmonary Bypass or for Refractory Sudden Cardiac Arrest

Background:

We reviewed the outcomes of patients who underwent cardiopulmonary support (CPS) for either refractory sudden cardiac arrest or failure to wean from cardiopulmonary bypass (CPB).

Methods:

Between January 2005 and July 2013, 37 patients with congenital heart disease (CHD) underwent 39 instances of CPS for sudden cardiac arrest as extracorporeal cardiopulmonary resuscitation (E-CPR; group I, n = 19) or for failure to wean from CPB (group II, n = 20). Univariate analyses determined which variables differed among the groups and which had significant association with hospital survival. Binary logistic regression determined the significant associations in a multivariable model.

Results:

Overall 30-day and hospital survival were 76.9% (30) and 69.2% (27), respectively. For groups I and II, hospital survival was 68.4% (13) and 70.0% (14), respectively. Variables associated with mortality in the univariate analysis included hours on CPS ( P = .045), initial aspartate aminotransferase (AST) level on CPS ( P = .007), and bicarbonate 24 hours on CPS ( P = .004). Logistic regression showed single-ventricle physiology ( P = .05), initial AST level on CPS ( P = .03), and lower bicarbonate 24 hours on CPS ( P = .026) to be significantly associated with mortality.

Conclusions:

Comparable rates of survival to discharge can be obtained when CPS is initiated for E-CPR or for failure to wean from CPB in resuscitating patients with CHD. Hepatic and renal factors indicative of inadequate early tissue perfusion, single-ventricle physiology, and lower bicarbonate level are factors associated with poor outcome.

Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies

Background

Following the 2009 H1N1 Influenza pandemic, extracorporeal membrane oxygenation (ECMO) emerged as a viable alternative in selected, severe cases of ARDS. Acute Respiratory Distress Syndrome (ARDS) is a major public health problem. Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual. Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently “rescue” a significant proportion of those affected.

Discussion

Here we present a synopsis of the challenges, considerations, and potential controversies regarding veno-venous ECMO that will be of benefit to anesthesiologists, surgeons, and intensivists, especially those newly confronted with care of the ECMO patient. We outline a number of points related to ECMO, particularly regarding cannulation, pump/oxygenator design, anticoagulation, and intravascular fluid management of patients. We then address these challenges/considerations/controversies in the context of their potential future implications on clinical approaches to ECMO patients, focusing on the development and advancement of standardized ECMO clinical practices.

Summary

Since the 2009 H1N1 pandemic ECMO has gained a wider acceptance. There are challenges that still must be overcome. Further investigations of the benefits and effects of ECMO need to be undertaken in order to facilitate the implementation of this technology on a larger scale.

Pediatric postoperative cardiac care

Postoperative care of cardiac patients requires a comprehensive and multidisciplinary approach to critically ill patients with cardiac disease whose care requires a clear understanding of cardiovascular physiology. When a patient fails to progress along the projected course or decompensates acutely, prompt evaluation with bedside assessment, laboratory evaluation, and echocardiography is essential. When things do not add up, cardiac catheterization must be seriously considered. With continued advancements in the field of neonatal and pediatric postoperative cardiac care, continued improvements in overall outcomes for this specialized population are anticipated.

Image guided placement of extracorporeal life support through bi-caval dual lumen venovenous membrane oxygenation in an interventional radiology setting--initial experience

PURPOSE

To report our initial results of venovenous ECMO placement of a novel bicaval dual lumen catheter in six consecutive patients with severe respiratory failure.

METHODS

[corrected] The dual lumen catheters (Avalon elite, Avalon Laboratories, Rancho Dominguez, CA, USA; available in 13, 16, 19, 20, 23, 27, and 31 French) were inserted with ultrasound-guided puncture via the right internal jugular vein. The devices were placed with the proximal drainage inlet in the SVC, with the distal drainage inlet tip in the IVC, and with the return outlet in the right atrium under fluoroscopy.

RESULTS

All catheter placements (1 x 19, 1 x 23, 1 x 27 and 3 x 31 French) were performed successfully: after insertion, adequate flows and gas exchange were obtained in all patients. Median support time was 9.5 days (range 3-41). We did not observe any cannulation-related events, especially no cannula displacement, no cannula thrombosis, no necessary repositioning, and no device failure. Decannulation and extubation was attained in 4/6 (66.7%) patients. 2/6 (33.3%) patients died (on day 3 and on day 10) while still under ECMO because of disease progression not controllable by medical means undertaken. The overall survival and hospital discharge rate in our small sample volume was 66.7% (4/6 patients).

CONCLUSIONS

Our initial results suggest that single cannulation dual lumen venovenous ECMO catheter placement can be performed successfully and safely in an Interventional Radiology setting. The technique reported is feasible, easy to use, and the outcome seems to be comparable to other performing implanting specialties.

Recurrent thrombosis after mechanical circulatory support

The immediate complication after implantation of mechanical circulatory support (MCS) is more often bleeding than thromboembolic events. We report an unusual case of massive thrombus formation following systemic thrombolytic therapy which happened twice after implantation of MCS. Various mechanisms may contribute to this severe complication, but attention should be paid to patients who receive MCS after systemic thrombolysis because of the secondary hypercoagulability induced by this therapy.

Bivalirudin-based versus conventional heparin anticoagulation for postcardiotomy extracorporeal membrane oxygenation

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.