Is there any data to support the use of bivalirudin over heparin in patients on VA-ECMO without ongoing concerns for HIT?

Multiple recent meta-analyses and retrospective studies suggest that bivalirudin may reduce the risk of circuit thrombosis, major bleeding, and in-hospital mortality compared to heparin in VA-ECMO patients, even in the absence of HIT.[1][2][3][4][5][6][7][8] Some studies also report improved time in therapeutic range and fewer dose adjustments with bivalirudin, although overall rates of bleeding and thrombosis are similar between bivalirudin and heparin in most analyses.[9][10]

The majority of available data are derived from retrospective observational studies, and no large prospective randomized trials have directly compared bivalirudin and heparin in VA-ECMO patients without HIT. Several meta-analyses and systematic reviews caution that, w...