Feasibility and Safety of Systemic Anticoagulation-Free Veno-Venous Extracorporeal Membrane Oxygenation in Adults Respiratory Failure Patients

Abstract

Purpose Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is increasingly used as a bridge to lung transplant. Bleeding diasthesis resulting from standard anticoagulation is the predominant cause of morbidity associated with VV-ECMO during waiting lung transplant. Given the improvements in ECMO components reducing their thrombogenicity, we explored whether VV-ECMO can be utilized without therapeutic levels of anticoagulation. Methods Single center analysis of patients undergoing VV-ECMO between January 2016 and December 2017. Overall, 41 patients (mean age, 47.4 ± 15.2 year) with respiratory failure underwent VV-ECMO implantation: 18 anticoagulation free (AC-), 23 systemic anticoagulation (AC+). Anticoagulation levels were targeted to maintain activated clotting time (ACTs) of 160-180 seconds in the AC+. No ACTs were checked in AC- groups and they received standard venous thromboprophylaxis. Results One patient in AC- group (5.6%) and seven in AC+ group (26.0%) had GI bleeding requiring endoscopy (p=0.04). The events per patient-day (EPPD) of GI bleeding was 0.010 in anticoagulation free patients and 0.012 in systemic anticoagulation patients (p=0.04). Planned oxygenator change were 1 time (5.5%, 0.01 EPPD) in AC- group and 8 time (34.7%, 0.01 EPPD) in AC+ group (p=0.02). AC+ group received more blood transfusion during VV ECMO supports (pRBC; 10 AC- (66.7%), 22 AC+ (95.6%); p=0.01, FFP; 3 AC- (20.0%), 17 AC+ (73.9%); p=0.001, Plt; 7 AC- (46.7%), 21 AC+ (91.3%); p=0.002). Overall survival was not significantly different between the groups (p=0.41). No circuit thrombosis or heparin-induced thrombocytopenia were observed in any groups. No differences were found in the incidence of new pulmonary embolism or venous thrombosis in the two groups after initiation of ECMO. Conclusion VV-ECMO can be used without continuous systemic anticoagulation. Our approach can achieve less complication rate and less blood transfusion rate, which could be huge benefit for bridge to lung transplant patients.