Extracorporeal Membrane Oxygenation, Circuits, and Coatings “Pro and Cons” During Anticoagulation

We read with great interest the article “Feasibility of venovenous extracorporeal membrane oxygenation without systemic anticoagulation.”1Kurihara C. Walter J.M. Karim A. et al.Feasibility of venovenous extracorporeal membrane oxygenation without systemic anticoagulation.Ann Thorac Surg. 2020; 110: 1209-1215Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar However the coating circuits and anticoagulants relationship was not thoroughly treated, so we take advantage here to report the theme. After initiation of venovenous extracorporeal membrane oxygenation (ECMO), systemic anticoagulation therapy is traditionally administered and can cause bleeding diathesis.1Kurihara C. Walter J.M. Karim A. et al.Feasibility of venovenous extracorporeal membrane oxygenation without systemic anticoagulation.Ann Thorac Surg. 2020; 110: 1209-1215Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Anticoagulation is complicated because of the complexities of the hemostatic system, variable effects of the etiology of critical illness on hemostasis, and blood–circuit interaction. In this circumstance the choice of the circuit could be crucial. One technique used to reduce the contact of blood with “non-self” surfaces is the “coating” of the internal surfaces of the ECMO. This can be done with phospholipidic, electrically neutral, and heparin derivates with anticoagulant activity.2Condello I. Santarpino G. Nasso G. et al.Air, inflammation and biocompatibility of the extracorporeal circuits.Perfusion. 2021; 36: 781-785Crossref Scopus (5) Google Scholar Here we report the pros and cons from the literature for ECMO circuit coating: active or passive. The pro of active coating is the control of bleeding from severe trauma or in patients with high bleeding risk (lung transplantation, postcardiotomy procedures) with higher flow and heparin-free setting for flows between 3.5 and 4.0 L/min without increasing the risk of thromboembolism.3Ogawa F. Sakai T. Takahashi K. et al.A case report: veno-venous extracorporeal membrane oxygenation for severe blunt thoracic trauma.J Cardiothorac Surg. 2019; 14: 88Crossref Scopus (11) Google Scholar,4Bharat A. DeCamp M.M. Veno-arterial extracorporeal membrane oxygenation without therapeutic anticoagulation for intra-operative cardiopulmonary support during lung transplantation.J Thorac Dis. 2017; 9: E629-E631Crossref PubMed Scopus (17) Google Scholar Guidelines suggest a continuous infusion of unfractionated heparin to achieve anticoagulation. Therefore the con of active coating is the major risk of anticoagulation with heparin infusions and heparin-coated circuits for heparin-induced thrombocytopenia (HIT), and in this context active coating is contraindicated.5Natt B. Hypes C. Basken R. Malo J. Kazui T. Mosier J. Suspected heparin-induced thrombocytopenia in patients receiving extracorporeal membrane oxygenation.J Extracorp Technol. 2017; 49: 54-58PubMed Google Scholar The pro of biopassive coating is that its use during ECMO with argatroban or bivaluridin prevents HIT in patients already exposed to unfractionated heparin and therefore is the first recommended choice in patients with HIT.5Natt B. Hypes C. Basken R. Malo J. Kazui T. Mosier J. Suspected heparin-induced thrombocytopenia in patients receiving extracorporeal membrane oxygenation.J Extracorp Technol. 2017; 49: 54-58PubMed Google Scholar The con of biopasssive coating is the difficult anticoagulation management for the control of bleeding from severe trauma or in patients with high risk of bleeding.3Ogawa F. Sakai T. Takahashi K. et al.A case report: veno-venous extracorporeal membrane oxygenation for severe blunt thoracic trauma.J Cardiothorac Surg. 2019; 14: 88Crossref Scopus (11) Google Scholar Feasibility of Venovenous Extracorporeal Membrane Oxygenation Without Systemic AnticoagulationThe Annals of Thoracic SurgeryVol. 110Issue 4PreviewVenovenous extracorporeal membrane oxygenation (ECMO) is increasingly being used for acute respiratory distress syndrome and as a bridge to lung transplantation. After initiation of venovenous ECMO, systemic anticoagulation therapy is traditionally administered and can cause bleeding diathesis. Here, we investigated whether venovenous ECMO can be administered without continuous systemic anticoagulation administration for patients with acute respiratory distress syndrome. Full-Text PDF Modern Extracorporeal Membrane Oxygenation Circuitry May Obviate the Need for Continuous Systemic AnticoagulationThe Annals of Thoracic SurgeryVol. 113Issue 1PreviewWe thank Dr Condello for his letter.1 We recently demonstrated the feasibility of venovenous extracorporeal membrane oxygenation (ECMO) without systemic anticoagulation.2 This strategy can reduce bleeding complications and the need for blood transfusions during venovenous ECMO. Interestingly we found that avoiding continuous systemic anticoagulation can also decrease the number of oxygenator and circuit exchanges. We speculate that this is because of an induced hypercoagulable state resulting from cessation and reinitiation of anticoagulation drips due to varying anticoagulation levels with the use of heparin drip. Full-Text PDF