Current use and limitations of direct thrombin inhibitors in pediatric ECMO: A European survey
Research article published in Perfusion (2026)
Abstract
IntroductionDirect thrombin inhibitors (DTIs) are an alternative to unfractionated heparin during pediatric ECMO. We aimed to describe their use and limitations across Europe.MethodsFifty-two pediatric EuroELSO centers were surveyed from July to December 2025. Thirty-seven respondents were analyzed across 11 countries.ResultsMost centers (n = 30, 81.1%) were referral sites for pediatric cardiothoracic surgery and 20 (54.1%) also provided non-ECMO mechanical support (i.e., ventricular assist devices [VADs]). Seventeen (45.9%) centers reported having used DTIs for the maintenance of systemic anticoagulation during ECMO at least once over the last years. Of these 17 centers, only 3 (17.6%) use DTIs as a first-line anticoagulant for pediatric ECMO. Most centers (n = 11/17, 64.7%) reserve DTIs for specific situations, such as VAD patients or suspected heparin-induced thrombocytopenia. Among the 17 respondents who reported using DTIs, bivalirudin (BIV) was identified as the preferred agent by 16 (94.1%). Dedicated protocols for DTIs management are implemented in 12 (70.6%) out of these 17 centers. Activated partial prothrombin time is the primary assay for monitoring BIV anticoagulation. From the 16 centers using BIV, only 4 (25.0%) reported having specific assays available. The main reported barrier for DTIs implementation was the lack of guidelines and published protocols (n = 14/20, 70.0%).ConclusionAlthough recent studies have discussed the interest in DTIs, their adoption as first-line anticoagulant during pediatric ECMO remains limited. Findings from this survey indicate the need for more evidence of DTIs clinical benefit, as well as robust guidelines regarding their protocolized use during pediatric ECMO.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
Current use and limitations of direct thrombin inhibitors in pediatric ECMO: A European survey.
Why This Matters for Hirudotherapy
This European survey of 37 pediatric ECMO centers across 11 countries examined current use and limitations of direct thrombin inhibitors (DTIs) as alternatives to unfractionated heparin, finding that among the 17 centers reporting DTI use, bivalirudin was the preferred agent in 94.1% (16/17), though only 3 centers used DTIs as first-line anticoagulants and the main barrier to broader adoption was the lack of guidelines and published protocols. For ASH and hirudotherapy, this study is directly relevant because bivalirudin is a synthetic hirudin analog derived from the medicinal leech anticoagulant hirudin, illustrating how a leech-secretome-inspired therapeutic is being selectively adopted in critical cardiopulmonary care. However, as a survey of self-reported practice patterns rather than a clinical trial, it captures usage trends and perceived barriers—not comparative efficacy or safety outcomes—and the authors themselves note the need for more evidence of DTIs' clinical benefit.
Citation
Current use and limitations of direct thrombin inhibitors in pediatric ECMO: A European survey
Gardeton T et al. · Perfusion, 2026
Added to ASH library: May 27, 2026 · Site last updated: June 18, 2026