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Anticoagulation Practices and the Prevalence of Major Bleeding, Thromboembolic Events, and Mortality in Venoarterial Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis
Sy E, Sklar MC, Lequier L, et al. J Crit Care 2017; 39: 87-96.
Study Question: What is the optimal anticoagulation strategy in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO)?
Study Description: A systematic review and meta-analysis was conducted and identified studies performed between 1977 and 2016 that included patients receiving VA-ECMO and reported on anticoagulation strategies and complications. The primary outcome was a composite of major bleeding, including intracranial hemorrhage, gastrointestinal bleeding, retroperitoneal bleeding, and surgical revision or reoperation.
Results: Twenty-six observational studies were included in the final analysis (1496 patients). Most patients received anticoagulation with heparin, monitored by activated clotting times (ACT) with either a lower target range (< 180 seconds) or a standard range (180-220 seconds) as is currently recommended in guidelines. The prevalence of major bleeding was 27% and occurred in 13% of patients with a lower ACT target, 28% of patients in the standard ACT range, and 43% of patients not receiving anticoagulation.
Conclusion(s): The prevalence of major bleeding varied depending on indication and ACT target for VA-ECMO. The optimal anticoagulation strategy remains uncertain.
Perspective: There was significant heterogeneity between studies and many confounding factors that preclude more definitive conclusions from this analysis. Further areas for research include whether there is even a need for anticoagulation, the best method to monitor anticoagulation during VA-ECMO, and studies that specifically focus on anticoagulation strategies during VA-ECMO.