{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,12]],"date-time":"2026-05-12T05:45:19Z","timestamp":1778564719525,"version":"3.51.4"},"reference-count":68,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2021,9,1]],"date-time":"2021-09-01T00:00:00Z","timestamp":1630454400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100018982","name":"Fondazione Bambino Ges\u00f9","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100018982","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:p>Pediatric mechanical circulatory support (MCS) is considered a strategy for heart failure management as a bridge to recovery and transplantation or as a destination therapy. The final outcome is significantly impacted by the number of complications that may occur during MCS. Children on ventricular assist devices (VADs) and extracorporeal membrane oxygenation (ECMO) are at high risk for bleeding and thrombotic complications that are managed through anticoagulation. The first detailed guideline in pediatric VADs (Edmonton Anticoagulation and Platelet Inhibition Protocol) was based on conventional antithrombotic drugs, such as unfractionated heparin (UFH) and warfarin. UFH is the first-line anticoagulant in pediatric MCS, although its profile is not considered optimal in pediatric setting. The broad variation in heparin doses among children is associated with frequent occurrence of cerebrovascular accidents, bleeding, and thrombocytopenia. Direct thrombin inhibitors (DTIs) have been utilized as alternative strategies to heparin. Since 2018, bivalirudin has become the chosen anticoagulant in the long-term therapy of patients undergoing MCS implantation, according to the most recent protocols shared in North America. This article provides a review of the non-traditional anticoagulation strategies utilized in pediatric MCS, focusing on pharmacodynamics, indications, doses, and monitoring aspects of bivalirudin. Moreover, it exposes the efforts and the collaborations among different specialized centers, which are committed to an ongoing learning in order to minimize major complications in this special pediatric population. Further prospective trials regarding DTIs in a pediatric MCS setting are necessary and in specific well-designed randomized control trials between UFH and bivalirudin. To conclude, based on the reported literature, the clinical use of the bivalirudin in pediatric MCS seems to be a value added in controlling and maybe reducing thromboembolic complications. Further research is necessary to confirm all the results provided by this literature review.<\/jats:p>","DOI":"10.3389\/fcvm.2021.671241","type":"journal-article","created":{"date-parts":[[2021,9,4]],"date-time":"2021-09-04T00:34:44Z","timestamp":1630715684000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":7,"title":["Pediatric Mechanical Circulatory Support: Pathophysiology of Pediatric Hemostasis and Available Options"],"prefix":"10.3389","volume":"8","author":[{"given":"Chiara","family":"Giorni","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alessandra","family":"Rizza","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Isabella","family":"Favia","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Antonio","family":"Amodeo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Fabrizio","family":"Chiusolo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sergio G.","family":"Picardo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matteo","family":"Luciani","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Giovina","family":"Di Felice","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Luca","family":"Di Chiara","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2021,9,1]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"507","DOI":"10.1182\/asheducation-2018.1.507","article-title":"Adult and pediatric mechanical circulation: a guide for the hematologist","volume":"30","author":"Baumann Kreuziger","year":"2018","journal-title":"Hematol Am Soc Hematol Educ Program"},{"key":"B2","doi-asserted-by":"publisher","first-page":"129","DOI":"10.1053\/j.semtcvs.2018.01.001","article-title":"Potential impact of the proposed revised UNOS thoracic organ allocation system","volume":"30","author":"Rao","year":"2018","journal-title":"Semin Thorac Cardiovasc Surg."},{"key":"B3","doi-asserted-by":"publisher","first-page":"440","DOI":"10.1056\/NEJMoa1610426","article-title":"A fully magnetically levitated circulatory pump for advanced heart","volume":"376","author":"Mehra","year":"2017","journal-title":"N Engl J Med."},{"key":"B4","article-title":"The blood -surface interface","volume-title":"Cardiopulmonary Bypass: Principles and Practice 3 ed","author":"Edmunds","year":"2008"},{"key":"B5","doi-asserted-by":"publisher","first-page":"M790","DOI":"10.1097\/00002480-199507000-00122","article-title":"Pathophysiologic role of contact activation in bleeding followed by thromboembolic complications after implantation of a ventricular assist device","volume":"41","author":"Himmelreich","year":"1995","journal-title":"ASAIO J."},{"key":"B6","doi-asserted-by":"publisher","first-page":"276","DOI":"10.1097\/PCC.0000000000000345","article-title":"Hemorrhagic complications in pediatric cardiac patients on extracorporeal membrane oxygenation: an analysis of the extracorporeal life support organization registry","volume":"16","author":"Verho","year":"2015","journal-title":"Pediatr Crit Care Med"},{"key":"B7","doi-asserted-by":"publisher","first-page":"532","DOI":"10.1056\/NEJMoa1014164","article-title":"Prospective trial of a pediatric ventricular assist device","volume":"367","author":"Fraser","year":"2012","journal-title":"N Eng J Med"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1751","DOI":"10.1016\/j.athoracsur.2015.06.020","article-title":"Epidemiology of stroke in pediatric cardiac surgical patients supported with extracorporeal membrane oxygenation","volume":"100","author":"Verho","year":"2015","journal-title":"Ann Thorac Surg."},{"key":"B9","doi-asserted-by":"publisher","first-page":"85","DOI":"10.1016\/j.healun.2016.01.1228","article-title":"Outcomes of pediatric patients supported with continuous-flow ventricular assist devices: A report from the Pediatric Interagency Registry for Mechanical Circulatory Support (PediMACS)","volume":"35","author":"Rossano","year":"2016","journal-title":"JHLT."},{"key":"B10","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1097\/00043426-199021000-00019","article-title":"Development of the hemostatic system in the neonate and young infant","volume":"12","author":"Andrew","year":"1990","journal-title":"Am J Pediatr Hematol Oncol."},{"key":"B11","doi-asserted-by":"publisher","first-page":"362","DOI":"10.1160\/TH05-01-0047","article-title":"Developmental haemostasis. 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