From
StayCurrentMD
Timing and anticoagulation strategies for CDH repair on ECMO
Chapter 1 of 4
Case presentation
Clinical scenario and bivalirudin introduction
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Bivalirudin is used as the sole anticoagulant drip for ECMO in CDH cases at the speaker's institution
Most places still use heparin for ECMO anticoagulation, but the practice is shifting quickly toward bivalirudin
Bivalirudin levels can be monitored with a dilute thrombin time, which any lab can create
Dilute thrombin time is 5 times more specific and sensitive than PTT for monitoring bivalirudin
Bivalirudin has a very short half-life of approximately 20 minutes, allowing immediate on/off effects
Bivalirudin has much less variability between patients in anticoagulation effectiveness compared to heparin
Switching to early CDH repair on ECMO is challenging for lower-volume institutions (1-2 cases per year) and requires whole team buy-in
Building a team for early ECMO repair requires showing data and involving anesthesiologists and neonatologists who run the pump
Early CDH repair on ECMO results in very little edema and is very similar to doing a repair off ECMO
It is impossible to be 100% certain which babies will require late repair because they cannot come off ECMO, and late repair is the worst time to operate
Early CDH repair on ECMO promotes good lung growth
Cannula position is important, and left-sided heart disease is a big contributor to overall cardiac function in CDH cases
Out of 90 centers contributing to the CDH study group, almost 80% are performing early repair on ECMO
The data on early ECMO repair for CDH has shifted significantly over the last 3 years
Bivalirudin is a direct thrombin inhibitor used to prevent blood clots, especially during cardiac and vascular procedures
With bivalirudin, surgery can be performed after 8 hours of ECMO initiation as long as anticoagulation levels are stable
Some groups perform risk stratification after ECMO initiation: high-risk babies get early repair, lower-risk babies are weaned off ECMO before repair
It is not possible to reliably predict which babies can come off ECMO without repair
Early repair places patients in a much better position to come off ECMO urgently if needed
CDH repair can be safely performed on ECMO with minimal to no bleeding complications when meticulous operative techniques are used
The optimal window for early CDH repair on ECMO is between 8 to 24 hours
Bivalirudin is a safe anticoagulant for CDH repair on ECMO
A smaller consistent surgical team can enhance outcomes for CDH repair on ECMO