American Society of Hirudotherapy

Extracorporeal Membrane Oxygenation Complications in Heparin- and Bivalirudin-Treated Patients

Research article published in Critical care explorations (2021)

Last Updated: June 18, 2026Reviewed by: ASH Editorial Board
Research article — evidence reviewArticle reference
Evidence: Research reportClinical LiteratureDrug DevelopmentGiuliano et al. · Critical care explorations, 2021

Abstract

UNLABELLED: Extracorporeal membrane oxygenation is a potentially life-saving intervention in refractory cardiopulmonary failure, but it requires anticoagulation to prevent circuit thromboses, which exposes the patient to hemorrhagic complications. Heparin has traditionally been the anticoagulant of choice, but the direct thrombin inhibitor bivalirudin is routinely used in cases of heparin-induced thrombocytopenia and has been suggested as a superior choice. We sought to examine the timing of hemorrhagic and thrombotic complications after extracorporeal membrane oxygenation cannulation and to compare the rates of such complications between patients anticoagulated with heparin versus bivalirudin. DESIGN: Retrospective cohort study. SETTING: Johns Hopkins Hospital patients between January 2016 and July 2019. PATIENTS: Adult (> 18 yr) extracorporeal membrane oxygenation patients. INTERVENTIONS: Patients were anticoagulated either with heparin or bivalirudin. MEASUREMENTS AND MAIN RESULTS: We compared rates of hemorrhagic and thrombotic complications by time on heparin versus bivalirudin and characterized the average time to each complication. Of 144 extracorporeal membrane oxygenation patients (mean age 55.3 yr; 58% male), 41% were on central venoarterial extracorporeal membrane oxygenation, 40% on peripheral venoarterial extracorporeal membrane oxygenation, and 19% on venovenous extracorporeal membrane oxygenation. Thirteen patients (9%) received bivalirudin during their extracorporeal membrane oxygenation run, due to concern for (n = 8) or diagnosis of (n = 4) heparin-induced thrombocytopenia or for heparin resistance (n = 1). The rate of hemorrhagic or thrombotic complications did not differ between heparin (0.13/d) and bivalirudin (0.06/d; p = 0.633), but patients on bivalirudin received significantly fewer blood transfusions (1.0 U of RBCs/d vs 2.9/d on heparin; p < 0.001). CONCLUSIONS: Our results confirm the safety and efficacy of bivalirudin as an alternative anticoagulant in extracorporeal membrane oxygenation and suggest a potential benefit in less blood product transfusion, although prospective studies are needed to evaluate the true effect of bivalirudin versus the disease processes that prompted its use in our study population.

Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.

Publication typeJournal Article

Summary

In this retrospective cohort, complication rates for 144 adult ECMO patients did not differ between heparin (0.13/d) and bivalirudin (0.06/d; p = 0.633), but those on bivalirudin received significantly fewer red blood cell transfusions (1.0 vs 2.9 U/d; p < 0.001).

Why This Matters for Hirudotherapy

This retrospective cohort study examined timing and rates of hemorrhagic and thrombotic complications in 144 adult ECMO patients anticoagulated with either heparin or bivalirudin at Johns Hopkins Hospital (January 2016–July 2019). No significant difference in daily complication rates was observed between heparin (0.13/d) and bivalirudin (0.06/d; p=0.633), though patients on bivalirudin received significantly fewer red blood cell transfusions (1.0 U/d vs. 2.9/d; p<0.001). Caveat: The small bivalirudin subgroup (n=13) limits comparative strength, and the authors call for prospective studies. Bivalirudin (formerly Hirulog) is a synthetic peptide anticoagulant designed partly on the C-terminal sequence of hirudin, the anticoagulant of the medicinal leech (Maraganore et al., 1990); this paper studies the drug, not leech therapy.

Citation

Reference (Vancouver style)

Giuliano K, Bigelow BF, Etchill EW, Velez AK, Ong CS, Choi CW, et al. Extracorporeal Membrane Oxygenation Complications in Heparin- and Bivalirudin-Treated Patients. Crit Care Explor. 2021;3(7):e0485. doi:10.1097/CCE.0000000000000485. PMID: 34278315

Bibliographic details (authors, volume, pages, DOI) are taken from the PubMed record.

DOIPubMed

Added to ASH library: May 28, 2026 · Site last updated: June 18, 2026

This website provides educational information and does not constitute medical advice, diagnosis, or treatment recommendations. Medicinal leech therapy carries clinically meaningful risks and should be performed only by qualified clinicians under institutionally approved protocols. FDA 510(k) clearance for medicinal leeches is limited to specific indications; investigational and off-label discussions are labeled accordingly. For patient-specific guidance, consult a qualified healthcare provider.