Anticoagulation management for patients with multisystem inflammatory syndrome in children requiring extracorporeal membrane oxygenation

Background: Multisystem Inflammatory Syndrome in Children (MIS-C) is a post-infectious syndrome after SARS-CoV-2. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is occasionally required, however MIS-C patients are prothrombotic which complicates VA-ECMO management. This case series describes a cohort of MIS -C patients requiring VA-ECMO, anticoagulation strategies and the use of catheter directed thrombolysis. Case summary: There were 7 patients, all male, 5 Black, 1 Hispanic, 1 White. Median age, ICU stay, and duration of VA-ECMO were 13 years (4-15), 13 days (6-17), and 7 days (3-8) respectively. There were no deaths. Median time to ventricular recovery 9.5 days (3-21). Four developed thrombus on VA-ECMO. Heparin was used in 6 and 2 converted to bivalirudin due to heparin insensitivity and thrombus. Median heparin dose was 17 mu/kg/h, with Anti-Xa 0.75 U/mL (0.1-1.1). Median bivalirudin dose was 0.58 mg/kg/h (0.05-1.15) and PTT 80 s (73-89). Two developed venous thromboembolism and 2 thrombosed cannulae. Conclusion: MIS-C patients on VA-ECMO may have heparin resistance and require direct thrombin inhibitors. Further studies are required to understand optimal anticoagulation.