Bivalirudin

Children assisted with mechanical circulatory support experience bleeding and thrombotic complications that may depend upon anticoagulation strategies. The primary aim of this study was to compare the incidence of thrombotic events in pediatric heart failure patients assisted with mechanical circulatory support with the use of bivalirudin versus heparin anticoagulation. A secondary aim was to compare the percentage of out-of-range partial thromboplastin time values between these anticoagulants.

Retrospective cohort study.

Tertiary pediatric cardiac intensive care unit.

Pediatric patients undergoing mechanical circulatory support for cardiac failure.

None.

A total of 36 pediatric patients on mechanical support treated with either heparin (n.18) or bivalirudin (n.18) during the first 30 days of intensive care unit admission were compared. Bivalirudin group data were retrieved from February 2018 to August 2020 while data on the heparin group were extrapolated from 2015 to 2017. A comparison of anticoagulation was conducted specifically in EXCOR Berlin Heart and extracorporeal membrane oxygenation patients. Berlin Heart patients showed 1 (12.5%) versus 8 (80%) thrombotic episodes in the bivalirudin and heparin groups, respectively (p = 0.005), 0 and 3 (30%) cerebrovascular events, and 0 versus 3 (30%) death episodes, respectively (p = 0.054). In extracorporeal membrane oxygenation patients, the bivalirudin and heparin groups showed 0 versus 1 (8.3%) patient with a thrombosis episode (p = 0.40), 0 and 0 cerebrovascular events, and 5 (50%) versus 3 (25%) death episodes, respectively (p = 0.169). The number of out-of-range partial thromboplastin time values was higher in the heparin group both in Berlin Heart and extracorporeal membrane oxygenation patients (p < 0.0001).

In a cohort of children with heart failure, bivalirudin use was associated with a reduction in thrombotic events in Berlin Heart patients compared with heparin over a period of 30 days.

Extracorporeal membrane oxygenation (ECMO) is a critical intervention for patients with severe respiratory or cardiac failure, requiring careful management of anticoagulation to prevent thromboembolic complications. This review examines current practices and challenges in ECMO anticoagulation, focusing on strategies, agents, and emerging insights. Unfractionated heparin (UFH) remains the most commonly used anticoagulant, monitored via activated partial thromboplastin time (aPTT) or activated clotting time (ACT). Increasing attention is given to alternative tools like anti-Xa and viscoelastic assays (VEA), which offer potentially more reliable results. Supplementation with antithrombin should be considered if levels fall below 50%-70% to optimize heparin efficacy. Low molecular weight heparin (LMWH) is occasionally used due to its predictable pharmacokinetics, though challenges in dosing and reversal limit its application. Direct thrombin inhibitors, such as bivalirudin, are valuable alternatives, particularly for patients with heparin-induced thrombocytopenia (HIT), though their cost and availability remain barriers. Anticoagulation in ECMO patients is complex, balancing the risks of thrombosis and bleeding. Factors such as patient age, underlying conditions, and ECMO-induced coagulopathies complicate management. Personalized anticoagulation protocols and point-of-care VEA are emerging as effective tools for improving therapy. Routine no-anticoagulation strategies are not recommended unless there are significant bleeding complications. Ongoing research into novel anticoagulants and the long-term impact of anticoagulation on ECMO outcomes is critical. Anticoagulation management in ECMO continues to evolve, focusing on individualized approaches, improved monitoring, and better outcomes. Standardized protocols and further research are essential for optimizing care in this high-risk population.