Heparin-based versus bivalirudin-based anticoagulation in pediatric extracorporeal membrane oxygenation: A systematic review
Valdes CA, Sharaf OM, Bleiweis MS, Jacobs JP, Mumtaz M, Sharaf RM, Jeng EI, Peek GJ (2023) · Frontiers in Medicine · n=313
Study Profile
- Design
- systematic review of seven retrospective cohort studies (PubMed, Cochrane Library, Embase through October 2022)
- Sample size (n)
- 313
- Intervention
- Bivalirudin anticoagulation in pediatric ECMO (n=117 pooled)
- Comparator
- Heparin anticoagulation in pediatric ECMO (n=196 pooled)
- Primary endpoint
- Bleeding events, thrombotic complications, transfusion requirements, mortality
- Primary result
- Bivalirudin trended toward lower bleeding, transfusion requirements, and thrombosis; no mortality difference; bivalirudin associated with lower overall costs; time to therapeutic anticoagulation variable between studies
- Follow-up duration
- ECMO run + hospital course
- PMID
- 36999064
Key Findings
- Pediatric-specific pooled analysis (n=313) of bivalirudin vs heparin
- Trends toward lower bleeding and thrombosis with bivalirudin
- Lower transfusion requirements with bivalirudin
- Lower overall pharmacologic costs with bivalirudin
- No mortality signal in either direction
Limitations
- All 7 included studies retrospective
- Heterogeneous anticoagulation targets across institutions
- Small sample sizes in individual studies
- Cannot adjust for unmeasured confounders
- Not applicable to whole-leech hirudotherapy
Clinical Implications
Valdes 2023 provides a pediatric-specific evidence summary supporting bivalirudin as a feasible heparin alternative in children on ECMO. For ASH, the systematic review confirms the pediatric pharmaceutical pathway operates under retrospective signal-generation distinct from device-leech K040187 US clinical practice. The cost-effectiveness signal supports pharmaceutical pathway scaling under specific clinical scenarios.
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