PB1004 - D-dimer monitoring to guide anticoagulation management in patients receiving venoarterial-extracorporeal membrane oxygenation: a retrospective cohort study

Background: There is an urgent need to investigate optimal anticoagulation strategies for patients undergoing venoarterial-extracorporeal membrane oxygenation (VA-ECMO) in order to mitigate bleeding and thrombotic events. D-dimer serves as a common and sensitive marker of hypercoagulability or thrombosis.

Aims: To investigate the potential utility of D-dimer monitoring in guiding anticoagulation management among patients receiving VA-ECMO.

Methods: Adult patients who underwent VA-ECMO at two centers were screened and categorized into two groups based on their respective anticoagulation management strategies. All patients were managed by a rapid-response multidisciplinary team. In the control group (before May 2019, n=57), patients consistently received higher intensity anticoagulation therapy with target anti-Xa levels between 0.2-0.5 U/mL. In the D-dimer-monitored group (after May 2019, n=86), heparin infusion was initiated at low intensity with target anti-factor Xa activity (anti-Xa) levels between 0.0–0.2 U/mL. For patients without active bleeding, intensity was gradually adjusted to higher levels (0.2-0.5 U/ml of anti-Xa activity) only under specific conditions: firstly, if D-dimer levels increased >1.5 times compared to previous results and exceeded four times the upper reference limit; secondly, if thrombosis was confirmed; otherwise, low intensity remained unchanged. The primary outcomes included incidence of major bleedings, thrombotic events and in-hospital mortality.

Results: A total of 139 patients received VA-ECMO were included in the analysis. During VA-ECMO, there were 41 major bleeding events and 22 thrombotic events observed. In comparison to the control group, the D-dimer-guided group exhibited a significantly lower incidence of bleeding events (21.4% vs 41.8%, 18/84 vs 23/55, hazard ratio (HR):0.52, 95%CI: 0.14-0.87, p=0.01). However, no significant difference was found in the incidence of thrombotic events between the two groups (14/84 vs 8/55, HR:1.09, 95%CI:0.58-1.64, p=0.82).

Conclusion(s): D-dimer-guided anticoagulation management has the potential to mitigate bleeding events without concomitant increase in thrombotic events among patients undergoing VA-ECMO.