Restricted accessResearch articleFirst published online 2025-9
Anticoagulation in the setting of concomitant temporary mechanical circulatory support: Experience from a quaternary care center in the Middle East and review of the literature
The combination of VA-ECMO and Impella®, known as “ECpella” offers an alternative to the method of left ventricle unloading with intra-aortic balloon pump (IABP). Limited information is available to inform anticoagulation management in cases of concomitant use of Mechanical Circulatory Support (MCS) devices.
Methods:
This retrospective study included 34 patients receiving hemodynamic support through concomitant MCS for cardiogenic shock for a duration exceeding 24 h. Data collection included patients’ demographics, comorbidities, transfusion requirements, anticoagulation protocol, time within therapeutic anticoagulation range, and incidence of bleeding or ischemic events.
Results:
Survival to discharge was 32.4% (11 out of 34). Of the 34 patients, 28 patients were treated with a combination of VA-ECMO and IABP (82.4%), while 6 patients (17.6%) were supported with the ECpella. Patients in the VA-ECMO with IABP group had a longer hospital stay (median = 30 days, IQR = 20–43.5) when compared to the ECpella group (median = 21.5 days, IQR = 6–63). Bleeding was documented in a similar proportion in both arms of the investigation (89% in the VA-ECMO with IABP group and 83% in the ECpella group). Thrombosis was more common in the VA-ECMO with IABP group (17.9%) as compared to the ECpella group (16.7%).
Conclusion:
Cardiogenic shock requiring concomitant MCS which includes VA-ECMO presents a challenging clinical scenario where the risks of bleeding and thrombosis have to be balanced. Our experience, and review of the literature, highlight the need for further investigation via large retrospective registry analysis as well as randomized controlled trials.
Lo CocoVLorussoRRaffaGM, et al. Clinical complications during veno-arterial extracorporeal membrane oxygenation in post-cardiotomy and non post-cardiotomy shock: still the Achille’s heel. J Thorac Dis2018; 10(12): 6993–7004.
3.
McMichaelABVRyersonLMRatanoD, et al. 2021 ELSO adult and pediatric anticoagulation guidelines. ASAIO J2022; 68(3): 303.
4.
VyasABishopMA.Extracorporeal membrane oxygenation in adults. Treasure Island, FL: StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK576426/ (2023, accessed 15 November 2023).
5.
BelohlavekJHunzikerPDonkerDW.Left ventricular unloading and the role of ECpella. Eur Heart J Suppl J Eur Soc Cardiol2021; 23(Suppl A): A27–A34.
TrubyLKTakedaKMauroC, et al. Incidence and implications of left ventricular distention during venoarterial extracorporeal membrane oxygenation support. ASAIO J2017; 63(3): 257–265.
8.
DonkerDWBrodieDHenriquesJPS, et al. Left ventricular unloading during veno-arterial ECMO: a review of percutaneous and surgical unloading interventions. Perfusion2019; 34(2): 98–105.
9.
HishamMGhalibHHKakarV, et al. Anticoagulation practices and complications associated with Impella® support at an advanced cardiac center in the Middle East gulf region. J Thromb Thrombolysis2023; 56(1): 164–174.
BeaversCJDunnSPDiDomenicoRJJr, et al. Bicarbonate-based purge solution during Impella support: a growing alternative. J Am Coll Cardiol2022; 79(9_Supplement): 633.
13.
EzadSMRyanMDonkerDW, et al. Unloading the left ventricle in venoarterial ECMO: in whom, when, and how?Circulation2023; 147(16): 1237–1250.
14.
KrishnaMZacharowskiK.Principles of intra-aortic balloon pump counterpulsation. Contin Educ Anaesth Crit Care Pain2009; 9(1): 24–28.
15.
GonzálezLSChaneyMA.Intraaortic balloon pump counterpulsation, Part I: history, technical aspects, physiologic effects, contraindications, medical applications/outcomes. Anesth Analg2020; 131(3): 776.
16.
KellyJMalloyRKnowlesD.Comparison of anticoagulated versus non-anticoagulated patients with intra-aortic balloon pumps. Thromb J2021; 19(1): 46.
PeltanIDVande VusseLKMaierRV, et al. An international normalized ratio-based definition of acute traumatic coagulopathy is associated with mortality, venous thromboembolism, and multiple organ failure after injury. Crit Care Med2015; 43(7): 1429–1438.
19.
MehranRRaoSVBhattDL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation2011; 123(23): 2736–2747.
20.
AliJMAbu-OmarY.Complications associated with mechanical circulatory support. Ann Transl Med2020; 8(13): 835–835.
21.
ReedBNDiDomenicoRJAllenderJE, et al. Survey of anticoagulation practices with the Impella percutaneous ventricular assist device at high-volume centers. J Intervent Cardiol2019; 2019: 3791307.
22.
BeaversCJDiDomenicoRJDunnSP, et al. Optimizing anticoagulation for patients receiving Impella support. Pharmacotherapy2021; 41(11): 932–942.
23.
DavidaviciusGGodinoCShannonJ, et al. Incidence of overall bleeding in patients treated with intra-aortic balloon pump during percutaneous coronary intervention: 12-year Milan experience. JACC Cardiovasc Interv2012; 5(3): 350–357.
24.
GautamSCLimJJaarBG.Complications associated with continuous RRT. Kidney2022; 3(11): 1980.
25.
DroegeCAErnstNEMessingerNJ, et al. Evaluation of thrombocytopenia in critically ill patients receiving continuous renal replacement therapy. Ann Pharmacother2018; 52(12): 1204–1210.
26.
FerreiraJAJohnsonDW.The incidence of thrombocytopenia associated with continuous renal replacement therapy in critically ill patients. Ren Fail2015; 37(7): 1232–1236.
27.
OuweneelDMde BrabanderJKaramiM, et al. Real-life use of left ventricular circulatory support with Impella in cardiogenic shock after acute myocardial infarction: 12 years AMC experience. Eur Heart J Acute Cardiovasc Care2019; 8(4): 338–349.
28.
SubramaniamAVBarsnessGWVallabhajosyulaS, et al. Complications of temporary percutaneous mechanical circulatory support for cardiogenic shock: an appraisal of contemporary literature. Cardiol Ther2019; 8(2): 211–228.
29.
PucherPHCummingsIGShipoliniAR, et al. Is heparin needed for patients with an intra-aortic balloon pump?Interact Cardiovasc Thorac Surg2012; 15(1): 136–139.
30.
ChengRHachamovitchRMakkarR, et al. Lack of survival benefit found with use of intraaortic balloon pump in extracorporeal membrane oxygenation: a pooled experience of 1517 patients. J Invasive Cardiol2015; 27(10): 453–458.
31.
de JongMMLorussoRAl AwamiF, et al. Vascular complications following intra-aortic balloon pump implantation: an updated review. Perfusion2018; 33(2): 96–104.
32.
Chen-yangJLi-liZJian-anW, et al. Anticoagulation therapy in intra-aortic balloon counterpulsation: does IABP really need anti-coagulation?J Zhejiang Univ Sci A2003; 4(5): 607–611.
RemmelinkMSjauwKDHenriquesJP, et al. Effects of mechanical left ventricular unloading by Impella on left ventricular dynamics in high-risk and primary percutaneous coronary intervention patients. Catheter Cardiovasc Interv2010; 75(2): 187–194.
35.
JenningsDLNemerovskiCWKalusJS.Effective anticoagulation for a percutaneous ventricular assist device using a heparin-based purge solution. Ann Pharmacother2013; 47(10): 1364–1367.
36.
ParkTKYangJHChoiSH, et al. Clinical impact of intra-aortic balloon pump during extracorporeal life support in patients with acute myocardial infarction complicated by cardiogenic shock. BMC Anesthesiol2014; 14: 27.
37.
OmarHRMirsaeidiMSociasS, et al. Plasma free hemoglobin is an independent predictor of mortality among patients on extracorporeal membrane oxygenation support. PLoS One2015; 10(4): e0124034.
