Bleeding and Thrombotic Events During Extracorporeal Membrane Oxygenation for Postcardiotomy Shock.

Abstract Background Anticoagulation management during veno-arterial extracorporeal membrane oxygenation (ECMO) is particularly difficult in postcardiotomy shock patients given a significant bleeding risk. We sought to determine the effect of anticoagulation on bleeding and thrombosis risk for postcardiotomy shock patients on ECMO. Methods We retrospectively reviewed patients who received ECMO for postcardiotomy shock from July 2007 through July 2019. Characteristics of patients who developed bleeding and thrombosis were investigated and risk factors were assessed via multi-level logistic regression. Results Of the 152 patients who received ECMO for postcardiotomy shock, 33 (23%) developed 40 thrombotic events and 64 (45%) developed 86 bleeding events. Predictors of bleeding were intraoperative packed red blood cell transfusion (OR 1.05, 95% CI [1.01-1.09]), platelet transfusion (OR 1.10, 95% CI [1.05-1.16]), international normalized ratio (OR 1.18, 95% CI [1.02-1.37]), and activated partial thromboplastin time (aPTT) greater than 60 seconds (OR 2.32, 95% CI [1.14-4.73]). Predictors of thrombosis were anticoagulation use (OR 0.39, 95% CI [0.19-0.79]), surgical venting (OR 3.07, 95% CI [1.29-7.31]), hemoglobin (OR 1.38, 95% CI [1.06-1.79]), and central cannulation (OR 2.06, 95% CI [1.03-4.11]). The daily predicted probability of thrombosis was between 0.075 and 0.038 in those who did not receive anticoagulation and decreased to between 0.030 and 0.013 in those who received anticoagulation at aPTTs between 25 and 80 seconds. Conclusions Anticoagulation can reduce thromboembolic events in postcardiotomy shock patients on ECMO, but bleeding risk may outweigh this benefit at aPTTs greater than 60 seconds.