High Rate of Hemorrhagic Complications in COVID-19 Patients Requiring ECMO Support in Spite of Conservative Anticoagulation Strategies

Background: Increased rate of thrombotic events have been described in severe COVID-19 disease leading to liberal anticoagulation strategies in patients requiring ECMO support, which might be associated to increased risk of hemorrhagic complications We present our experience with a conservative anticoagulation approach Objectives and Methods: Data of eight COVID-19 patients requiring veno-venous (VV) ECMO support between 3/1-8/20/20 was retrospectively analyzed All patients received anticoagulation with IV heparin with therapeutic target PTT 50-70 seconds Primary goal was incidence of major hemorrhagic complications, and secondary goals to determine relationship to anticoagulation range, and patient clinical outcome Results: Mean age was 52 years (36-62) Six (75%) patients were male Patients received ECMO support for 25 days (10-39) Therapeutic anticoagulation range was achieved 33% (24-49%) of the time, while patients remained sub-therapeutic (PTT70") 3% of the time INR was normal (<1 2) in all patients, and thrombocytopenia (platelet count < 100,000) was observed in 3 patients (37 5%) Major bleeding complications included cerebral in 4 (50%), oro-pharyngeal in 2 (25%), and spontaneous psoas hematoma in 2 (25%) patients No clear correlation was observed between supratherapeutic anticoagulation and development of hemorrhagic complications Seven ECMO circuits were exchanged in 6 patients at 13 5 days (9-19) Four (50%) patients were decannulated, and 3 (37 5%) discharged from the hospital alive Conclusions: Conservative anticoagulation strategies during V-V ECMO support for COVID-19 led to high rate of ECMO circuit exchange but did not prevent hemorrhagic complications Additional risk factors for bleeding should be considered in these patients