Anticoagulation with Argatroban in Patients Undergoing Extracorporal Life Support System Therapy

Objectives: Anticoagulation for extracorporeal life support (ECLS) is routinely achieved using heparin, which can be difficult in patients suspected of having heparin-induced thrombocytopenia. In ECLS anticoagulation is mandatory, and direct thrombin inhibitors (DTIs) have been reported in these cases. However, the use of DTIs in ECLS patients is not well described.

Methods: We performed a retrospective study of patients treated with ECLS therapy for severe heart failure after major cardiac surgery. Standard anticoagulation was achieved by intravenous application of heparin. When HIT II was suspected anticoagulation was changed to argatroban. A PTT from 60 to 80 seconds was conducted as the target in all patients. Incidences of bleeding and thromboembolic complications were recorded under each anticoagulation regime. Risk factors for bleeding and thromboembolic complications were identified.

Results: A total of 277 patients with 298 ECLS runs were included into the study. The total supporting time was 34.894 hours ECLS time. The mean supporting time per patient was 267.7 ± 171.9 hours. In 230 ECLS runs anticoagulation was achieved by heparin (I), in 16 runs argatroban (II) was the only anticoagulant and in 52 runs anticoagulation was switched from heparin to argatroban (III). Further demographic details are displayed in [Table 1]. The length of heparin use seemed to be an independent risk factor for thromboembolic complications. Most thrombolic complications were seen in group III. The lowest incidence of thromboembolic complications was seen in group II. Bleeding complications were less in group II. Relevant risk factor for bleeding complications was the length of anticoagulation use. Furthermore the use of clopidogrel before surgery and the length of ECLS support seemed to be a risk factor for bleeding.

Conclusion: In conclusion, we illustrate that argatroban is a reasonable alternative to heparin anticoagulation for patients requiring ECLS.

Table 1

		All	Heparin (I)	Argatra (II)	Both (III)	p
Type of surgery (%)	CABG	100 (40.2)	82 (41.2)	1 (12.5)	17 (40.5)	0.429
	Valve surgery	39 (15.7)	33 (16.6)	0 (0.0)	6 (14.3)	0.429
	Combination	40 (16.1)	30 (15.1)	3 (37.5)	7 (16.7)	0.429
Reoperation (%)		71 (23.8)	54 (23.5)	4 (25.0)	13 (25.0)	0.430
Duration (min)		360.0 ± 239.42	356.5 ± 254.68	465.5 ± 219.41	359.0 ± 151.62	0.498
Closs-clamp (min)		99.7 ± 55.77	98.4 ± 56.12	135.4 ± 84.37	98.8 ± 46.66	0.228
Open chest (%)		145 (48.7)	126 (54.8)	5 (31.3)	14 (26.9)	0.001 I vs. III
ECMO prior to surgery (%)		4 (1.3)	2 (0.9)	2 (12.5)	0 (0.0)	0.017 I vs. II;
Low output (%)		39 (13.1)	29 (12.6)	5 (31.3)	5 (9.6)	0.094