European practices on antithrombotic management during percutaneous mechanical circulatory support in adults: a survey of the Association for Acute CardioVascular Care of the ESC and the European branch of the Extracorporeal Life Support Organization

Abstract

Aims Bleeding and thrombotic complications compromise outcomes in patients undergoing percutaneous mechanical circulatory support (pMCS) with veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and/or microaxial flow pumps like Impella (TM). Antithrombotic practices are an important determinant of the coagulopathic risk, but standardization in the antithrombotic management during pMCS is lacking. This survey outlines European practices in antithrombotic management in adults on pMCS, making an initial effort to standardize practices, inform future trials, and enhance outcomes.Methods and results This online cross-sectional survey was distributed through digital newsletters and social media platforms by the Association of Acute Cardiovascular Care and the European branch of the Extracorporeal Life Support Organization. The survey was available from 17 April 2023 to 23 May 2023. The target population were European clinicians involved in care for adults on pMCS. We included 105 responses from 26 European countries. Notably, 72.4% of the respondents adhered to locally established anticoagulation protocols, with unfractionated heparin (UFH) being the predominant anticoagulant (Impella (TM): 97.0% and V-A ECMO: 96.1%). A minority of the respondents, 10.8 and 14.5%, respectively, utilized the anti-factor-Xa assay in parallel with activated partial thromboplastin time for UFH monitoring during Impella (TM) and V-A ECMO support. Anticoagulant targets varied across institutions. Following acute coronary syndrome without percutaneous coronary intervention (PCI), 54.0 and 42.7% were administered dual antiplatelet therapy during Impella (TM) and V-A ECMO support, increasing to 93.7 and 84.0% after PCI.Conclusion Substantial heterogeneity in antithrombotic practices emerged from participants' responses, potentially contributing to variable device-associated bleeding and thrombotic complications.

Graphical Abstract AMICS, acute myocardial infarction-induced cardiogenic shock; PCI, percutaneous coronary intervention; SAPT, single antiplatelet therapy; DAPT, dual antiplatelet therapy; APTT, activated partial thromboplastin time; ACT, activated clotting time; anti-Xa assay, heparin anti-factor-Xa assay; V-A ECMO, veno-arterial extracorporeal membrane oxygenation.