European practices on antithrombotic management during percutaneous mechanical circulatory support in adults: an international survey of the ACVC Association of the ESC joint with EuroELSO
Authors: Van Edom C , Castelein T , Gramegna M , Huber K , Leonardi S , Mueller T , Pappalardo F , Price S , Schaubroeck H , Schrage B , Swol J , Tavazzi G , Vercaemst L , Vranckx P , Vandenbriele C 
Published: May 2024

Abstract

Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fonds Wetenschappelijk Onderzoek Flanders.

Background/introduction
Bleeding and thrombotic complications impair the outcomes of patients on percutaneous mechanical circulatory support (pMCS) with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and/or microaxial flow pumps such as the Impella™. Very recent MCS-trials still show a 23.9% moderate/major bleeding incidence during V-A ECMO. Antithrombotic practices are an important determinant of the meticulous coagulopathic risk management, but guidelines here are non-existing.

Purpose
Providing an overview of the current European practices in antithrombotic management in adults on pMCS is a first but crucial step to design trials, standardize practice and improve outcome.

Methods
This online cross-sectional survey was distributed via a digital newsletter and social media platforms through the Association of Acute Cardiovascular Care (ACVC) and the European Extracorporeal Life Support Organization (EuroELSO). The survey was accessible between 17.04 and 23.05.2023. The target population were European clinicians involved in adult critical care and pMCS-management.

Results
We included responses from 105 different units from 26 European countries. 72.4% Of the European responders have an institutional anticoagulation protocol installed. Unfractionated heparin is the predominantly used anticoagulant (Impella™: 97.0% and V-A ECMO: 96.1%). Argatroban is the preferred alternative in case of heparin-induced thrombocytopenia (Impella™: 52.3% and V-A ECMO: 50.7%). 10.8% And 14.5% of the anticoagulation protocols rely on anti-factor-Xa assay with activated partial thromboplastin time (APTT) in parallel for Impella™ and V-A ECMO, respectively. Up to 43.1% (Impella™) and 32.9% (V-A ECMO) of the European respondents rely on a monitoring strategy with APTT alone. Anticoagulant targets for heparin vary significantly between institutions. 54.0% And 42.7% of the European survey participants administer dual antiplatelet therapy (DAPT) during Impella™ and V-A ECMO support after acute coronary syndrome without percutaneous coronary intervention (PCI), increasing to 93.7% and 84.0% after recent PCI, respectively. Typical thresholds for transfusion or administration of blood products without acute bleeding also vary substantially and are frequently not predefined.

Conclusion
Large heterogeneity in antithrombotic practices is observed across Europe. Consequently, device-associated coagulopathic complications may largely vary due to non-standardized management and heterogeneity between institutions. This survey underpins the importance of urgent prospective trials investigating important basic questions concerning antithrombotic therapy during pMCS (anticoagulation targets, monitoring strategy, concomitant use of DAPT among others).