Direct thrombin inhibitors (DTIs) are an alternative to unfractionated heparin during pediatric ECMO. We aimed to describe their use and limitations across Europe.

Fifty-two pediatric EuroELSO centers were surveyed from July to December 2025. Thirty-seven respondents were analyzed across 11 countries.

Most centers (n = 30, 81.1%) were referral sites for pediatric cardiothoracic surgery and 20 (54.1%) also provided non-ECMO mechanical support (i.e., ventricular assist devices [VADs]). Seventeen (45.9%) centers reported having used DTIs for the maintenance of systemic anticoagulation during ECMO at least once over the last years. Of these 17 centers, only 3 (17.6%) use DTIs as a first-line anticoagulant for pediatric ECMO. Most centers (n = 11/17, 64.7%) reserve DTIs for specific situations, such as VAD patients or suspected heparin-induced thrombocytopenia. Among the 17 respondents who reported using DTIs, bivalirudin (BIV) was identified as the preferred agent by 16 (94.1%). Dedicated protocols for DTIs management are implemented in 12 (70.6%) out of these 17 centers. Activated partial prothrombin time is the primary assay for monitoring BIV anticoagulation. From the 16 centers using BIV, only 4 (25.0%) reported having specific assays available. The main reported barrier for DTIs implementation was the lack of guidelines and published protocols (n = 14/20, 70.0%).

Although recent studies have discussed the interest in DTIs, their adoption as first-line anticoagulant during pediatric ECMO remains limited. Findings from this survey indicate the need for more evidence of DTIs clinical benefit, as well as robust guidelines regarding their protocolized use during pediatric ECMO.