Activated Factor VII Use for Refractory Hemorrhage on ECMO

Introduction: Hemorrhagic complications are common during extracorporeal membrane oxygenation (ECMO). Recombinant activated factor VII (rFVIIa) may be used to control acute hemorrhage but carries a high risk of arterial thrombosis, and data supporting its application during ECMO are lacking. The objective of this study is to describe the effectiveness and safety of rFVIIa in patients supported by ECMO.


Methods: This was a single-center retrospective observational study of adult patients who received rFVIIa during ECMO support from 2018-2025. The primary outcome was the successful achievement of hemostasis, defined as a reduction in chest tube output in the 24 hours following an intravenous systemic dose or by direct visualization on subsequent bronchoscopy for doses administered endobronchially. Thrombotic complications at any point during the hospitalization were also captured.


Results: We identified five administrations of rFVIIa in patients supported by ECMO. rFVIIa was given intravenously (doses of 1 mg, 3 mg, 7 mg) in three cases and by visual direct endobronchial instillation during flexible bronchoscopy (doses of 2 mg diluted in 50 cc normal saline) in two cases. Most patients (80%) were on veno-arterial ECMO. Indications for ECMO included postcardiotomy shock (60%), cardiogenic shock secondary to fulminant myocarditis (20%), and refractory pulmonary hemorrhage (20%). Two of the three patients with systemic delivery and both patients with endobronchial delivery achieved successful hemostasis. Two thrombotic complications were identified in the systemic group. One patient had occlusive thrombosis of multiple continuous dialysis filters within the first twelve hours following 3 mg intravenous rFVIIa, and another experienced deep vein thrombosis nine days after 1 mg intravenous rFVIIa. Three patients died during their index hospital stay.


Conclusions: The use rFVIIa for acute hemorrhage during ECMO resulted in successful hemostasis a majority of the time, however, intravenous rFVIIa was complicated by clinically relevant thrombosis. The use of intravenous rFVIIa requires careful risk-benefit consideration, while endobronchial rFVIIa may be an option for refractory pulmonary hemorrhage.