Change in Anticoagulant Strategy During IMPELLA Support and Improved Outcomes

Nafamostat mesilate (NM), a synthetic serine protease inhibitor, has been used as an anticoagulant in patients undergoing extracorporeal circulatory support who have bleeding or heparin-related adverse effects. The safety and efficacy of NM-based anticoagulation in patients receiving Impella support who develop bleeding or thrombocytopenia remain uncertain.

Patients who underwent Impella placement without prior cardiopulmonary resuscitation between 2018 and 2026 at our institution were included. In January 2024, the anticoagulation strategy for patients with bleeding or thrombocytopenia was revised to incorporate NM alone or in combination with low-dose heparin, with selective use of a bicarbonate-based purge solution. Differences in 30-day mortality and survival to discharge between the early era (2018-2023) and the late era (2024-2026) were retrospectively evaluated.

A total of 97 patients (median age 70 years; 64% male) were analyzed. The daily amount of transfused red blood cell products during Impella support was significantly lower in the late era (0.8 versus 1.8 units, p = 0.024). 30-day mortality was significantly lower, and survival to discharge was significantly higher in the late era (p < 0.05 for both). Multivariable logistic regression analysis showed that the late era was significantly associated with a higher likelihood of survival to discharge, with an odds ratio of 32.46 (95% confidence interval 4.28-756.14, p < 0.001).

The late era, during which a revised anticoagulation strategy incorporating NM and selective use of a bicarbonate-based purge solution was implemented, was associated with lower daily red blood cell transfusion requirements and higher survival to discharge.