Outcomes With Direct and Indirect Thrombin Inhibition During Extracorporeal Membrane Oxygenation for COVID-19

Area of Science:

• Critical Care Medicine
• Cardiovascular Research
• Infectious Diseases

Background:

• Extracorporeal membrane oxygenation (ECMO) is a life-support measure for severe COVID-19 respiratory failure.
• Anticoagulation is crucial during ECMO but the optimal agent for COVID-19 patients remains debated.
• Direct thrombin inhibitors (DTIs) and unfractionated heparin (UFH) are common anticoagulants used in ECMO.

Purpose of the Study:

• To compare the outcomes of direct thrombin inhibitors (DTIs) versus unfractionated heparin (UFH) for anticoagulation in COVID-19 patients undergoing ECMO.
• To evaluate differences in mortality, thrombosis, stroke, and bleeding events between DTI and UFH groups.

Main Methods:

• Retrospective, multicenter study including adult COVID-19 patients on ECMO from March 2020 to April 2021.
• Patients were stratified into groups receiving either DTIs or UFH for anticoagulation.
• Outcomes including 90-day in-hospital mortality, deep vein thrombosis, stroke, and bleeding requiring transfusion were analyzed.

Main Results:

• Of 411 patients receiving anticoagulation, 160 (39%) received DTIs and 251 (61%) received UFH.
• In-hospital mortality at 90 days was similar between groups (50% DTI vs. 61% UFH).
• Rates of deep vein thrombosis, ischemic stroke, and hemorrhagic stroke were comparable.
• Bleeding events requiring transfusion were significantly lower in the DTI group (aOR: 0.40, 95% CI: 0.18-0.87).

Conclusions:

• Direct thrombin inhibitors are associated with similar mortality, stroke, and thrombosis rates compared to UFH in COVID-19 patients on ECMO.
• DTIs do not increase the risk of clinical bleeding requiring transfusion and may offer a safety advantage.
• These findings support considering DTIs as an alternative to UFH for anticoagulation in ECMO for COVID-19.