Background: 

Compared to heparin, there is limited evidence of the benefits of bivalirudin in the patients with extracorporeal membrane oxygenation (ECMO).

Methods: 

We searched for studies comparing bivalirudin anticoagulation with heparin anticoagulation in ECMO patients in the PubMed, Embase, and Cochrane Library databases from inception to March 28, 2024. ECMO patients were divided into the bivalirudin experimental group and the heparin control group. Collected data were mortality rate, duration of ECMO, successful decannulation rate, incidence of thrombotic events, incidence of bleeding events, activated partial thromboplastin time values, platelet transfusion requirements, and other indicators for ECMO patients in the bivalirudin and heparin groups. StataMP17 and RevMan 5.4 software for data analysis and visualization were used.

Results: 

A total of 11 papers that met the inclusion criteria were included. Compared to the traditional heparin anticoagulation group, the bivalirudin anticoagulation group had a lower mortality rate (odds ratios [OR] = 0.74, 95% confidence intervals [CI; 0.56, 0.99], Z = 2.01, P = .04) and incidence of thrombotic events (OR = 0.52, 95% CI [0.38, 0.71], Z = 4.11, P < .0001); meanwhile, the ECMO decannulation success rate (OR = 1.87, 95% CI [1.2, 2.92], Z = 2.75, P = .006) was higher, with statistically significant differences between the 2 groups. In ECMO patients, there were no significant differences between bivalirudin and heparin in terms of ECMO duration, incidence of bleeding events, platelet transfusion requirements, and activated partial thromboplastin time, with no statistical significance between the 2. Subgroup analysis suggested that the mortality rate in the veno-venous group was lower than that in the control group, but the difference was not statistically significant (OR = 0.52, 95% CI [0.27, 0.99], Z = 1.99, P = .05). The mortality rate in the non-veno-venous group was lower than that in the control group, with no statistically significant difference (OR = 0.82, 95% CI [0.61, 1.11], Z = 1.26, P = .21).

Conclusion: 

Bivalirudin anticoagulation significantly reduced the mortality rate and incidence of thrombotic events in ECMO patients, while significantly increasing the success rate of ECMO decannulation. However, due to clinical heterogeneity and institutional variability in monitoring and transfusion practices, these findings should be interpreted with caution. Further stratified research is needed to confirm these outcomes across different ECMO subgroups.