Original Article

Evaluation of bivalirudin-based anticoagulation for extracorporeal membrane oxygenation, including patients with COVID-19

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

^* Corresponding author: This email address is being protected from spambots. You need JavaScript enabled to view it.

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.