J Extra Corpor Technol 2026, 58, 57--64 Ó The Author( s), published by EDP Sciences, 2026 https:// doi. org / 10.1051 / ject / 2025045
Available online at: ject. edpsciences. org
ORIGINAL ARTICLE
Evaluation of bivalirudin-based anticoagulation for extracorporeal membrane oxygenation, including patients with COVID-19
Miranda Raguindin( PharmD, BCCCP) 1, 2,*, Casey Bardsley( PharmD, BCCCP) 1, 3, Chelsea Bast( PharmD, BCCCP) 1, 4, David Sugrue( PharmD, BCCCP) 1, 5, Hasan Kazmi( PharmD, BCPS, BCCP) 1, and Ashley Milkovits( PharmD, BCCCP) 1
1 Carilion Roanoke Memorial Hospital, Roanoke, VA 24014, USA 2 Hartford Hospital, Hartford, CT 06106, USA 3 North Florida Regional Medical Center, Gainesville, FL 32605, USA 4 Sentara Virginia Beach General Hospital, Virginia Beach, VA 23454, USA 5 Duke Raleigh Hospital, Raleigh, NC 27609, USA
Received 11 May 2025, Accepted 1 August 2025
Abstract – Background: Although unfractionated heparin( UFH) has traditionally been used for anticoagulation during extracorporeal membrane oxygenation( ECMO), bivalirudin may be preferred due to fewer complications. A prior medication use evaluation of ECMO patients who received bivalirudin resulted in dosing updates for our pharmacist-directed bivalirudin protocol. This study intended to evaluate the efficacy and safety of bivalirudin for anticoagulation during ECMO support post-protocol initiation. Methods: This was a retrospective, single-center, pre-post study. Adult patients requiring ECMO support for at least 24 h and who received bivalirudin between January 1, 2015 to July 31, 2018( pre-group) and May 1, 2019 to June 30, 2021( post-group) were included. Results: There were 38 patients in the pre- and 35 patients in the post-group. The primary outcome, median time to two consecutive activated partial thromboplastin times( aPTTs) within therapeutic range for the initial goal range, was 8.9 h in the pre- and 14.2 h in the post-group( p = 0.517). In a subgroup analysis of the post-group, the primary outcome was higher in patients with COVID-19( 26.5 vs. 8.6 h, p = 0.018). The median number of dose adjustments to achieve goal aPTT was higher in COVID-19 patients( 4 vs. 2, p = 0.017). Conclusion: These results suggest that a standardized pharmacist-directed protocol for bivalirudin in ECMO achieves timely therapeutic anticoagulation levels. Patients with COVID-19 trended toward longer times to two consecutive therapeutic aPTTs. Further studies are needed to evaluate dosing strategies in patients with and without COVID-19.
Key words: ECMO( extracorporeal membrane oxygenation), Bivalirudin, Pharmacology, Acute respiratory distress syndrome( ARDS), COVID-19.
Introduction
Extracorporeal membrane oxygenation( ECMO) is a therapeutic modality that allows for temporary support in pulmonary and / or cardiac failure refractory to conventional clinical treatment [ 1--3 ]. Systemic anticoagulation is necessary due to continuous contact between the patient’ s blood and the foreign surfaces of the ECMO circuit components. This interaction can trigger the coagulation cascade and lead to pump thrombi, oxygenator thrombi, or fibrin stranding, resulting in thromboembolic events [ 4 ]. Hemorrhage is the most frequent and serious complication associated with ECMO support and can
* Corresponding author: mirandacthomas22 @ gmail. com stem from supratherapeutic anticoagulation, thrombocytopenia, platelet dysfunction, coagulopathy, acquired von Willebrand syndrome, or hyperfibrinolysis [ 2 ]. The balance between bleeding and thrombosis in the setting of ECMO is delicate and requires close monitoring of systemic anticoagulation.
The Extracorporeal Life Support Organization( ELSO) Anticoagulation Guideline does not recommend a preferred anticoagulant [ 5 ]. Although heparin was historically the systemic anticoagulant of choice as a rapidly reversible agent with wide availability and favorable cost, there are known complications such as heparin-induced thrombocytopenia( HIT), heparin resistance, and variable clinical responses [ 6 ]. Bivalirudin is a short-acting anticoagulant that demonstrates more predictable pharmacokinetics and greater reduction of thrombin generation
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