Abstract
BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR), involving VA-ECMO during refractory cardiac arrest, has been linked to improved outcomes. While systemic anticoagulation is commonly used to prevent circuit thrombosis, bleeding and thrombotic complications remain frequent, and the need for early anticoagulation remains debated. METHODS: This single-center retrospective study included patients with refractory cardiac arrest who underwent ECPR between February 2020 and April 2025. Clinical data were extracted from medical records to assess the impact of an anticoagulation-free strategy during the first 24 h on bleeding, thrombosis, and outcomes. RESULTS: Patients were divided into two groups based on whether systemic anticoagulation was administered within the first 24 h following ECPR initiation: the non-anticoagulation group (n = 51) and the anticoagulation-free group (n = 50). Compared with the anticoagulation group, the anticoagulation-free group had a significantly lower incidence of bleeding events (72.5% vs. 50.0%, P = 0.021), while the incidence of thrombotic events did not differ significantly between the two groups (17.6% vs. 22.0%, P = 0.585). The anticoagulation-free group had the lowest demand for the rate of blood product use compare to anticoagulation group (64.0% vs. 80.4%, P = 0.044). Anticoagulation-free within the first 24 h, a higher SAVE score, and successful weaning from VA-ECMO were all independent predictors of 30-day survival. CONCLUSION: The anticoagulation-free strategy within the first 24 h of ECPR in patients with refractory cardiac arrest was associated with a reduced risk of bleeding, without a significant increase in thrombotic events. This anticoagulation strategy may contribute to improved clinical outcomes in this high-risk population.