Anticoagulation in the setting of concomitant temporary mechanical circulatory support: Experience from a quaternary care center in the Middle East and review of the literature

Background: The combination of VA-ECMO and Impella^®, known as “ECpella” offers an alternative to the method of left ventricle unloading with intra-aortic balloon pump (IABP). Limited information is available to inform anticoagulation management in cases of concomitant use of Mechanical Circulatory Support (MCS) devices. Methods: This retrospective study included 34 patients receiving hemodynamic support through concomitant MCS for cardiogenic shock for a duration exceeding 24 h. Data collection included patients’ demographics, comorbidities, transfusion requirements, anticoagulation protocol, time within therapeutic anticoagulation range, and incidence of bleeding or ischemic events. Results: Survival to discharge was 32.4% (11 out of 34). Of the 34 patients, 28 patients were treated with a combination of VA-ECMO and IABP (82.4%), while 6 patients (17.6%) were supported with the ECpella. Patients in the VA-ECMO with IABP group had a longer hospital stay (median = 30 days, IQR = 20–43.5) when compared to the ECpella group (median = 21.5 days, IQR = 6–63). Bleeding was documented in a similar proportion in both arms of the investigation (89% in the VA-ECMO with IABP group and 83% in the ECpella group). Thrombosis was more common in the VA-ECMO with IABP group (17.9%) as compared to the ECpella group (16.7%). Conclusion: Cardiogenic shock requiring concomitant MCS which includes VA-ECMO presents a challenging clinical scenario where the risks of bleeding and thrombosis have to be balanced. Our experience, and review of the literature, highlight the need for further investigation via large retrospective registry analysis as well as randomized controlled trials.