Use of bivalirudin in patients during veno-venous extracorporeal membrane oxygenation: a case series

Abstract

Objective: This study aimed to evaluate the use of bivalirudin as an alternative to conventional anticoagulant therapy with heparin in patients requiring venovenous extracorporeal membrane oxygenation (V-V ECMO) support for Acute Respiratory Distress Syndrome (ARDS), with a focus on dose titration, therapeutic range monitoring, complications, and clinical outcomes. Materials and Methods: This retrospective case series included six patients who received V-V ECMO support and systemic anticoagulation with bivalirudin between August 2021 and April 2022 at Sakarya University Training and Research Hospital due to a diagnosis of ARDS. Activated clotting time (ACT), activated partial thromboplastin time (aPTT), daily bivalirudin infusion doses, ECMO-related complications, and clinical outcomes were retrospectively analyzed. Results: Bivalirudin infusion doses ranged between 0.01 and 0.2 mg/kg/h across all patients. ACT values were maintained within the target range in all cases, while aPTT values remained below target in four patients. Hemorrhagic complications were observed in two patients, while thrombotic events occurred in another two. In one patient, bivalirudin infusion was discontinued due to the development of acute kidney injury. Of the six patients, two were discharged, while four died during follow-up. Conclusion: Bivalirudin appears to be a safe and effective alternative anticoagulant agent for patients undergoing V-V ECMO. However, individualized and meticulous anticoagulation monitoring is essential, particularly in the context of renal dysfunction, the strengths and limitations of aPTT and ACT monitoring, and the delicate balance between hemorrhagic and thrombotic risks.