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Background: Heparin has been the anticoagulant of choice for Neonatal ECMO for the past thirty years. It has the benefit of being well studied and having a low production cost. As bivalirudin is a newer anticoagulant, it has not been as widely studied and has a higher production cost, many centers are concerned about changing to a newer, more expensive agent. Bivalirudin has been studied from both an efficacy and cost perspective in adult patients (Sun et al 2021) and pediatric VAD populations (Burnstein et al 2023). While some safety and efficacy data exist for neonates, there are few if any cost analyses between Heparin and Bivalirudin. Methods: This was a single center, retrospective study conducted over 51 months in neonates receiving heparin or bivalirudin at an 86-bed, Level 4 NICU. The primary objective was to evaluate the price per ECMO hour, incidence of intracranial hemorrhage (ICH), and survival rates were examined. Data from 68 patients was collected (diagnosis, gestational age, anticoagulation type and cost, ECMO duration, number and cost of component changes, anticoagulation lab costs and frequency, ICH occurrence, and survival outcome). Total cost per ECMO hour was calculated. Drug costs were calculated utilizing average wholesale price (AWP). Quantitative analysis was conducted using two-tailed tests and chi-squared analyses. Significance was set at p = 0.05. Results: No significant differences between weight and gestational age were noted. Thirty-nine patients received continuous infusion heparin, and 29 received bivalirudin infusions with short periods of heparin for trialing off ECMO per hospital protocol. No statistically significant difference was found in cost per ECMO hour between bivalirudin ($54.14) and heparin ($58.27). There was a trend towards significance in survival for patients treated with bivalirudin compared to heparin, with a statistically significant decrease in ICH seen with bivalirudin (p < 0.05). Conclusion: Our study is one of the first to illustrate that the cost difference per hour of ECMO between heparin and bivalirudin is negligible, approximately $4.00. Additional analysis utilizing proprietary, center specific, contract pricing revealed cost savings with bivalirudin. Additionally, there was a clinically and statistically significant reduction in ICH using bivalirudin over heparin. While our data did not show a statistically significant difference in survival, our data did trend towards significance. As this was a small sample size and single center study, wide study across the ECMO community is warranted.




Presented at the Extracorporeal Life Support Organization 34th Annual Conference, Seattle, WA; Sep 28-Oct 1, 2023.

“It's so expensive and isn’t any better! Or is it?” A Comparative Analysis of Price per ECMO Hour, Intracranial Hemorrhage, and Survival Rates in Neonates on Bivalirudin vs. Heparin

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