Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysis
Abstract Background The number of patients treated with extracorporeal membrane oxygenation (ECMO) devices is increasing. Anticoagulation therapy is crucial to prevent thrombosis during ECMO therapy. Predominantly, heparin has been used as primary anticoagulant but direct thrombin inhibitors (DTI) h...
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| Format: | Article |
| Language: | English |
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BMC
2022-07-01
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| Series: | Thrombosis Journal |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s12959-022-00401-2 |
| _version_ | 1818018495976177664 |
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| author | René M’Pembele Sebastian Roth Aljoscha Metzger Anthony Nucaro Alexandra Stroda Amin Polzin Markus W. Hollmann Giovanna Lurati Buse Ragnar Huhn |
| author_facet | René M’Pembele Sebastian Roth Aljoscha Metzger Anthony Nucaro Alexandra Stroda Amin Polzin Markus W. Hollmann Giovanna Lurati Buse Ragnar Huhn |
| author_sort | René M’Pembele |
| collection | DOAJ |
| description | Abstract Background The number of patients treated with extracorporeal membrane oxygenation (ECMO) devices is increasing. Anticoagulation therapy is crucial to prevent thrombosis during ECMO therapy. Predominantly, heparin has been used as primary anticoagulant but direct thrombin inhibitors (DTI) have been established as alternatives. The aim of this systematic review and meta-analysis was to evaluate clinical outcomes in patients treated with heparin compared to different DTI during ECMO. Methods A systematic search was conducted. Full scientific articles were sought for inclusion if heparin anticoagulation was compared to DTI (argatroban/bivalirudin) in ECMO patients. Risk of bias was assessed by Newcastle Ottawa scale. Primary endpoint was in-hospital mortality. Bleeding events, thrombotic events, hours of ECMO support, days of hospital stay, percentage of time within therapeutic range and time to therapeutic range were extracted from full texts as secondary endpoints. Results were presented as Forrest-plots. GRADE was used for confidence assessment in outcomes. Results Systematic search identified 4.385 records, thereof 18 retrospective studies for a total of 1942 patients, complied with the predefined eligibility criteria:15 studies investigated bivalirudin and 3 studies investigated argatroban versus heparin. Risk of bias was high for most studies. In-hospital mortality, major bleeding events and pump-related thrombosis were less frequent in DTI group as compared to heparin [mortality—OR 0.69, 95% CI 0.54–0.86; major bleeding—OR 0.48, 95% CI 0.29–0.81; pump thrombosis—OR 0.55, 95% CI 0.40–0.76]. Additionally, percentage of time within therapeutic range was higher for DTI [SMD 0.54, 95% CI 0.14–0.94]. GRADE approach revealed a very low level of certainty for each outcome. Conclusion In this meta-analysis, DTI and especially bivalirudin showed beneficial effects on clinical outcomes in ECMO patients as compared to heparin. However, due to the lack of randomized trials, certainty of evidence is low. Trial Registration This systematic review and meta-analysis was prospectively registered at PROSPERO data base (reference number CRD42021237252 ). Graphical Abstract |
| first_indexed | 2024-04-14T07:40:14Z |
| format | Article |
| id | doaj.art-2e0a78f21ea94137aa3242bcdbf99a0c |
| institution | Directory Open Access Journal |
| issn | 1477-9560 |
| language | English |
| last_indexed | 2024-04-14T07:40:14Z |
| publishDate | 2022-07-01 |
| publisher | BMC |
| record_format | Article |
| series | Thrombosis Journal |
| spelling | doaj.art-2e0a78f21ea94137aa3242bcdbf99a0c2022-12-22T02:05:31ZengBMCThrombosis Journal1477-95602022-07-0120111910.1186/s12959-022-00401-2Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysisRené M’Pembele0Sebastian Roth1Aljoscha Metzger2Anthony Nucaro3Alexandra Stroda4Amin Polzin5Markus W. Hollmann6Giovanna Lurati Buse7Ragnar Huhn8Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-UniversityDepartment of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-UniversityDepartment of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-UniversityDepartment of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-UniversityDepartment of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-UniversityDepartment of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-UniversityDepartment of Anesthesiology, Amsterdam University Medical Center (AUMC)Department of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-UniversityDepartment of Anesthesiology, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-UniversityAbstract Background The number of patients treated with extracorporeal membrane oxygenation (ECMO) devices is increasing. Anticoagulation therapy is crucial to prevent thrombosis during ECMO therapy. Predominantly, heparin has been used as primary anticoagulant but direct thrombin inhibitors (DTI) have been established as alternatives. The aim of this systematic review and meta-analysis was to evaluate clinical outcomes in patients treated with heparin compared to different DTI during ECMO. Methods A systematic search was conducted. Full scientific articles were sought for inclusion if heparin anticoagulation was compared to DTI (argatroban/bivalirudin) in ECMO patients. Risk of bias was assessed by Newcastle Ottawa scale. Primary endpoint was in-hospital mortality. Bleeding events, thrombotic events, hours of ECMO support, days of hospital stay, percentage of time within therapeutic range and time to therapeutic range were extracted from full texts as secondary endpoints. Results were presented as Forrest-plots. GRADE was used for confidence assessment in outcomes. Results Systematic search identified 4.385 records, thereof 18 retrospective studies for a total of 1942 patients, complied with the predefined eligibility criteria:15 studies investigated bivalirudin and 3 studies investigated argatroban versus heparin. Risk of bias was high for most studies. In-hospital mortality, major bleeding events and pump-related thrombosis were less frequent in DTI group as compared to heparin [mortality—OR 0.69, 95% CI 0.54–0.86; major bleeding—OR 0.48, 95% CI 0.29–0.81; pump thrombosis—OR 0.55, 95% CI 0.40–0.76]. Additionally, percentage of time within therapeutic range was higher for DTI [SMD 0.54, 95% CI 0.14–0.94]. GRADE approach revealed a very low level of certainty for each outcome. Conclusion In this meta-analysis, DTI and especially bivalirudin showed beneficial effects on clinical outcomes in ECMO patients as compared to heparin. However, due to the lack of randomized trials, certainty of evidence is low. Trial Registration This systematic review and meta-analysis was prospectively registered at PROSPERO data base (reference number CRD42021237252 ). Graphical Abstracthttps://doi.org/10.1186/s12959-022-00401-2BivalirudinArgatrobanAnticoagulationBleedingThrombosisMechanical circulatory support |
| spellingShingle | René M’Pembele Sebastian Roth Aljoscha Metzger Anthony Nucaro Alexandra Stroda Amin Polzin Markus W. Hollmann Giovanna Lurati Buse Ragnar Huhn Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysis Thrombosis Journal Bivalirudin Argatroban Anticoagulation Bleeding Thrombosis Mechanical circulatory support |
| title | Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysis |
| title_full | Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysis |
| title_fullStr | Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysis |
| title_full_unstemmed | Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysis |
| title_short | Evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation: a systematic review and meta-analysis |
| title_sort | evaluation of clinical outcomes in patients treated with heparin or direct thrombin inhibitors during extracorporeal membrane oxygenation a systematic review and meta analysis |
| topic | Bivalirudin Argatroban Anticoagulation Bleeding Thrombosis Mechanical circulatory support |
| url | https://doi.org/10.1186/s12959-022-00401-2 |
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