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Sethasathien S, Phinyo P, Sittiwangkul R, Silvilairat S. Comparative effectiveness among thromboprophylaxis strategies after the Fontan operation: A systematic review and network meta-analysis. Thromb Res 2024; 241:109093. [PMID: 39003950 DOI: 10.1016/j.thromres.2024.109093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 05/17/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION A variety of thromboprophylaxis regimens have been administered in patients following the Fontan procedure. However, consensus guidelines regarding the optimal thromboprophylaxis strategy have not yet been developed. METHOD A network meta-analysis was conducted to evaluate the comparative effectiveness among available thromboprophylaxis regimens and major bleeding events associated with these regimens. RESULTS A total of 28 comparative studies with 4430 Fontan patients were included. The incidence of thromboembolic events (TE) was significantly lower in individuals who underwent thromboprophylaxis compared to those who did not. Compared to a no-treatment strategy, nonvitamin K oral anticoagulants (NOACs) showed the largest treatment effect for preventing TE (OR = 0.08, 95 % CI 0.03 to 0.21), followed by warfarin (OR = 0.16, 95 % CI 0.10 to 0.27), and aspirin (OR = 0.23, 95 % CI 0.14 to 0.38). Indeed, NOACs were significantly more effective than aspirin in preventing TE (OR = 0.35, 95 % CI 0.14 to 0.84). Aspirin was associated with the lowest occurrence of major bleeding events, followed by NOACs, no medication, and warfarin. NOACs were shown to possess a highly favorable overall profile. CONCLUSION Prescribing thromboprophylaxis drugs, either antiplatelets or anticoagulants, may be more effective in preventing TE after the Fontan operation than not doing so. Among the included regimens, NOACs demonstrated significantly greater efficacy than aspirin; however, they did not show statistically significant superiority over warfarin. Aspirin exhibited lower rates of major bleeding compared to both NOACs and warfarin. Overall, NOACs tended to offer the most advantageous balance of efficacy and safety. However, the findings should be interpreted considering the certainty and limitations of the evidence, including potential residual confounding in observational studies.
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Affiliation(s)
- Saviga Sethasathien
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Musculoskeletal Science and Translational Research (MSTR), Chiang Mai University, Chiang Mai, Thailand
| | - Rekwan Sittiwangkul
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suchaya Silvilairat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Payne RM, Burns KM, Glatz AC, Male C, Donti A, Brandão LR, Balling G, VanderPluym CJ, Bu'Lock F, Kochilas LK, Stiller B, Cnota JF, Rahkonen O, Khan A, Adorisio R, Stoica S, May L, Burns JC, Saraiva JFK, McHugh KE, Kim JS, Rubio A, Chía-Vazquez NG, Meador MR, Dyme JL, Reedy AM, Ajavon-Hartmann T, Jarugula P, Carlson-Taneja LE, Mills D, Wheaton O, Monagle P. Apixaban for Prevention of Thromboembolism in Pediatric Heart Disease. J Am Coll Cardiol 2023; 82:2296-2309. [PMID: 38057072 DOI: 10.1016/j.jacc.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Children with heart disease frequently require anticoagulation for thromboprophylaxis. Current standard of care (SOC), vitamin K antagonists or low-molecular-weight heparin, has significant disadvantages. OBJECTIVES The authors sought to describe safety, pharmacokinetics (PK), pharmacodynamics, and efficacy of apixaban, an oral, direct factor Xa inhibitor, for prevention of thromboembolism in children with congenital or acquired heart disease. METHODS Phase 2, open-label trial in children (ages, 28 days to <18 years) with heart disease requiring thromboprophylaxis. Randomization 2:1 apixaban or SOC for 1 year with intention-to-treat analysis. PRIMARY ENDPOINT a composite of adjudicated major or clinically relevant nonmajor bleeding. Secondary endpoints: PK, pharmacodynamics, quality of life, and exploration of efficacy. RESULTS From 2017 to 2021, 192 participants were randomized, 129 apixaban and 63 SOC. Diagnoses included single ventricle (74%), Kawasaki disease (14%), and other heart disease (12%). One apixaban participant (0.8%) and 3 with SOC (4.8%) had major or clinically relevant nonmajor bleeding (% difference -4.0 [95% CI: -12.8 to 0.8]). Apixaban incidence rate for all bleeding events was nearly twice the rate of SOC (100.0 vs 58.2 per 100 person-years), driven by 12 participants with ≥4 minor bleeding events. No thromboembolic events or deaths occurred in either arm. Apixaban pediatric PK steady-state exposures were consistent with adult levels. CONCLUSIONS In this pediatric multinational, randomized trial, bleeding and thromboembolism were infrequent on apixaban and SOC. Apixaban PK data correlated well with adult trials that demonstrated efficacy. These results support the use of apixaban as an alternative to SOC for thromboprophylaxis in pediatric heart disease. (A Study of the Safety and Pharmacokinetics of Apixaban Versus Vitamin K Antagonist [VKA] or Low Molecular Weight Heparin [LMWH] in Pediatric Subjects With Congenital or Acquired Heart Disease Requiring Anticoagulation; NCT02981472).
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Affiliation(s)
- R Mark Payne
- Riley Hospital for Children, Wells Center for Pediatric Research, Department of Pediatrics, Division of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | - Kristin M Burns
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Andrea Donti
- IRCCS- Azienda Ospedaliera-Universitaria, Ospedale di S. Orsola, Bologna, Italy
| | - Leonardo R Brandão
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada; Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Gunter Balling
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Christina J VanderPluym
- Heart Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frances Bu'Lock
- East Midlands Congenital Heart Centre and University of Leicester, University Hospitals of Leicester NHS Trust, Leicester, England
| | - Lazaros K Kochilas
- Children's Healthcare of Atlanta and the Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology, University Heart Centre, Medical Center-University of Freiburg, Freiburg, Germany
| | - James F Cnota
- Heart Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Otto Rahkonen
- New Children's Hospital, Helsinki University Central Hospital, Department of Pediatric Cardiology, Helsinki, Finland
| | - Asra Khan
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Rachele Adorisio
- Heart Failure, Transplant and Mechanical Assist Devices, Bambino Gesù Hospital and Research Institute, Rome, Italy
| | - Serban Stoica
- Bristol Children's Hospital and the Heart Institute, Bristol, United Kingdom
| | - Lindsay May
- University of Utah: Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Jane C Burns
- Rady Children's Hospital San Diego, University of California-San Diego, La Jolla, California, USA
| | | | - Kimberly E McHugh
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John S Kim
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Agustin Rubio
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Nadia G Chía-Vazquez
- Pediatric Cardiology Department, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Marcie R Meador
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Joshua L Dyme
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | - Alison M Reedy
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | | | | | | | - Donna Mills
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | | | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Haematology Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Haematology, Royal Children's Hospital, Melbourne, Victoria, Australia; Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
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Van den Eynde J, Possner M, Alahdab F, Veldtman G, Goldstein BH, Rathod RH, Hoskoppal AK, Saraf A, Feingold B, Alsaied T. Thromboprophylaxis in Patients With Fontan Circulation. J Am Coll Cardiol 2023; 81:374-389. [PMID: 36697138 PMCID: PMC11040452 DOI: 10.1016/j.jacc.2022.10.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The optimal strategy for thromboprophylaxis in patients with a Fontan circulation is unknown. OBJECTIVES The aim of this study was to compare the efficacy and safety of aspirin, warfarin, and nonvitamin K oral anticoagulants (NOACs) in a network meta-analysis. METHODS Relevant studies published by February 2022 were included. The primary efficacy outcome was thromboembolic events; major bleeding was a secondary safety outcome. Frequentist network meta-analyses were conducted to estimate the incidence rate ratios (IRRs) of both outcomes. Ranking of treatments was performed based on probability (P) score. RESULTS A total of 21 studies were included (26,546 patient-years). When compared with no thromboprophylaxis, NOAC (IRR: 0.11; 95% CI: 0.03-0.40), warfarin (IRR: 0.23; 95% CI: 0.14-0.37), and aspirin (IRR: 0.24; 95% CI: 0.15-0.39) were all associated with significantly lower rates of thromboembolic events. However, the network meta-analysis revealed no significant differences in the rates of major bleeding (NOAC: IRR: 1.45 [95% CI: 0.28-7.43]; warfarin: IRR: 1.38 [95% CI: 0.41-4.69]; and aspirin: IRR: 0.72 [95% CI: 0.20-2.58]). Rankings, which simultaneously analyze competing interventions, suggested that NOACs have the highest P score to prevent thromboembolic events (P score 0.921), followed by warfarin (P score 0.582), aspirin (P score 0.498), and no thromboprophylaxis (P score 0.001). Aspirin tended to have the most favorable overall profile. CONCLUSIONS Aspirin, warfarin, and NOAC are associated with lower risk of thromboembolic events. Recognizing the limited number of patients and heterogeneity of studies using NOACs, the results support the safety and efficacy of NOACs in patients with a Fontan circulation.
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Affiliation(s)
- Jef Van den Eynde
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland, USA; Department of Cardiovascular Diseases, University Hospitals Leuven and Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium. https://twitter.com/JefVandenEynde
| | - Mathias Possner
- Cardiology Department, Cantonal Hospital St Gallen, St Gallen, Switzerland; University Heart Center Zurich, Department of Cardiology, University of Zurich, Zurich, Switzerland. https://twitter.com/m_possner
| | - Fares Alahdab
- Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Gruschen Veldtman
- Scottish Adult Congenital Cardiac Service, Golden Jubilee Hospital, Glasgow, Scotland, United Kingdom
| | - Bryan H Goldstein
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rahul H Rathod
- Department of Cardiology, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Arvind K Hoskoppal
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anita Saraf
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Brian Feingold
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tarek Alsaied
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Jobran AW, Hijjeh N, Haymouni N, Sbeitan I, Abdelraziq S, Rizik R, Darsalim A, Abutaqa M, Shrateh ON. Successful stenting of an obstructed Glenn anastomosis in a 20-month-old child. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Prophylactic Enoxaparin Against Catheter-Associated Thrombosis in Postoperative Cardiac Children: An Interrupted Time Series Analysis. Pediatr Crit Care Med 2022; 23:774-783. [PMID: 35699766 DOI: 10.1097/pcc.0000000000003010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The effectiveness of pharmacologic prophylaxis against catheter-associated thrombosis in children is unclear. We evaluated the compliance and outcomes associated with a prophylactic enoxaparin protocol in postoperative cardiac children. DESIGN The protocol was implemented as a quality improvement initiative and then analyzed using interrupted time series method. Data collected from November 2014 to December 2018 were divided into preprotocol (period 1), protocol implementation (period 2), and protocol revision (period 3). SETTING A 12-bed academic pediatric cardiac ICU. PATIENTS Children less than or equal to 18 years old with congenital heart disease admitted postoperatively with central venous catheter in situ for greater than or equal to 1 day. INTERVENTIONS Before 2016, prophylactic enoxaparin was administered according to physician preference. In January 2016, an enoxaparin protocol was implemented with a goal anti-Xa range of 0.25-0.49 international units/mL. Protocol was revised in February 2017 to increase the starting dose by 25% for infants less than 1 year old. MEASUREMENTS AND MAIN RESULTS We analyzed 780 hospitalizations from 636 children. Median percentage of catheter-days on prophylactic enoxaparin was 33% (interquartile range [IQR], 23-47%), 42% (IQR, 30-51%), and 38% (IQR, 35-52%) in periods 1-3, respectively. Percentage of catheter-days on enoxaparin showed immediate increase of 90% (95% CI, 17-210%) between periods 1 and 2 and sustained increase of 2% (95% CI, 0.3-4%) between periods 2 and 3. Median rates of thrombosis per 1,000 catheter-days were 5.8 (IQR, 0-9.3), 3.8 (IQR, 0-12), and 0 (IQR, 0-5.3) in periods 1-3, respectively. Rate of thrombosis showed immediate decrease of 67% (95% CI, 12-87%) between periods 1 and 2 and sustained decrease of 11% (95% CI, 2-18%) between periods 1 and 3. CONCLUSIONS The temporal association between increase in percentage of catheter-days on enoxaparin and decrease in rate of thrombosis suggests the effectiveness of prophylactic enoxaparin.
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Prodhan P, Steiner M, Greiten LE. Systemic-to-Pulmonary Artery Shunt Thromboprophylaxis: Searching for the Holy Grail. Pediatr Crit Care Med 2022; 23:757-759. [PMID: 36053038 DOI: 10.1097/pcc.0000000000003034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Parthak Prodhan
- Pediatric Cardiology/Pediatric Critical Care, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Marie Steiner
- Pediatric Cardiothoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Lawrence E Greiten
- Pediatric Critical Care/Pediatric Hematology-Oncology, University of Minnesota, Minneapolis, MN
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Boucher AA, Heneghan JA, Jang S, Spillane KA, Abarbanell AM, Steiner ME, Meyer AD. A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease. Front Surg 2022; 9:907782. [PMID: 35774388 PMCID: PMC9237365 DOI: 10.3389/fsurg.2022.907782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/26/2022] [Indexed: 11/18/2022] Open
Abstract
Congenital heart disease encompasses a range of cardiac birth defects. Some defects require early and complex surgical intervention and post-operative thromboprophylaxis primarily for valve, conduit, and shunt patency. Antiplatelet and anticoagulant management strategies vary considerably and may or may not align with recognized consensus practice guidelines. In addition, newer anticoagulant agents are being increasingly used in children, but these medications are not addressed in most consensus statements. This narrative review evaluated the literature from 2011 through 2021 on the topic of postoperative thromboprophylaxis after congenital heart disease operations. The search was focused on the descriptions and results of pediatric studies for replacement and/or repair of heart valves, shunts, conduits, and other congenital heart disease operations. Wide variability in practice exists and, as was true a decade ago, few randomized controlled trials have been conducted. Aspirin, warfarin, and perioperative heparin remain the most commonly used agents with varying dosing, duration, and monitoring strategies, making comparisons difficult. Only recently have data on direct oral anticoagulants been published in children, suggesting evolving paradigms of care. Our findings highlight the need for more research to strengthen the evidence for standardized thromboprophylaxis strategies.
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Affiliation(s)
- Alexander A. Boucher
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Correspondence: Alexander A. Boucher Julia A. Heneghan
| | - Julia A. Heneghan
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Correspondence: Alexander A. Boucher Julia A. Heneghan
| | - Subin Jang
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Kaitlyn A. Spillane
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
| | - Aaron M. Abarbanell
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
| | - Marie E. Steiner
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Andrew D. Meyer
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
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Impact of Medical Interventions and Comorbidities on Norwood Admission for Patients with Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2022; 43:267-278. [PMID: 35034159 DOI: 10.1007/s00246-022-02818-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
The purpose of these analyses was to determine how specific comorbidities and medical interventions impact risk of inpatient mortality in those with hypoplastic left heart syndrome undergoing Norwood procedure. The secondary aims were to determine the impact of these on billed charges, postoperative length of stay, and risk of cardiac arrest. Admissions from 2004 to 2015 in the Pediatric Health Information System database with hypoplastic left heart syndrome and Norwood procedure were identified. Admission characteristics, patient interventions, and the presence of comorbidities were captured. A total of 5,138 admissions were identified meeting inclusion criteria. Of these 829 (16.1%) experienced inpatient mortality, and 352 (6.7%) experienced cardiac arrest. The frequency of inpatient mortality did not significantly change over the course of the study era. The frequency of cardiac arrest significantly decreased from 7.4% in 2004 to 4.3% in 2015 (p = 0.04). The frequency of pharmacologic therapies, particularly vasoactive use, decreased as the study period progressed. Regression analyses demonstrated a significant association between cardiac arrest and inpatient mortality with arrhythmias, acute kidney injury, and pulmonary hypertension. Similarly, regression analyses demonstrated a significant association between increase in billed charges and length of stay with year of surgery, presence of heart failure, syndromes, and acute kidney injury. For patients with hypoplastic left heart syndrome undergoing the Norwood procedure, the frequency of pharmacologic therapies and cardiac arrest has decreased over time. There are significant associations between acute kidney injury, arrythmias, and pulmonary hypertension with cardiac arrest and mortality.
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Sinning C, Zengin E, Blankenberg S, Rickers C, von Kodolitsch Y, Diller G, Kirchhof P. Anticoagulation management in adult patients with congenital heart disease: a narrative review. Cardiovasc Diagn Ther 2021; 11:1324-1333. [PMID: 35070801 PMCID: PMC8748474 DOI: 10.21037/cdt-20-631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/29/2020] [Indexed: 12/01/2023]
Abstract
With improvements in treatment of congenital heart disease more paediatric patients are surviving with palliative or corrective interventions during childhood, thus becoming adults with congenital heart disease (ACHD). Overall, the ACHD population is at a higher risk of arrhythmias and stroke. The abnormal structure and function of their corrected hearts suggests that in addition to established stroke risk factors, such as prior stroke or older age, additional stroke risk factors need to be considered to determine the risk and establish the indication for oral anticoagulation (OAC) in ACHD patients. In structurally normal hearts non-vitamin-K oral anticoagulants (NOACs) offer at least equal stroke prevention with a better safety profile compared to vitamin K antagonists (VKA) in patients with atrial fibrillation (AF) or pulmonary embolism. Current guidelines recommend NOACs in ACHD patients with simple lesions and indication for OAC, while there is less certainty about their safety in ACHD patients with moderate or complex congenital heart disease such as patients with transposition of the great arteries (TGA) after atrial switch operation (Senning or Mustard operation), Fontan circulation or congenital corrected transposition of the great arteries (ccTGA). This review summarises the available evidence characterising stroke risk in patients with ACHD and the use of anticoagulants and interventional therapies to reduce that risk.
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Affiliation(s)
- Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Science (DZHK) Hamburg/Lübeck/Kiel, Hamburg, Germany
- Adult Congenital Heart Disease Section, University Heart Center Hamburg, Hamburg, Germany
| | - Elvin Zengin
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- Adult Congenital Heart Disease Section, University Heart Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Science (DZHK) Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Carsten Rickers
- Adult Congenital Heart Disease Section, University Heart Center Hamburg, Hamburg, Germany
| | - Yskert von Kodolitsch
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Gerhard Diller
- Department of Cardiology III, University Hospital Münster, Münster, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Science (DZHK) Hamburg/Lübeck/Kiel, Hamburg, Germany
- Institute of Cardiovascular Sciences and SWBH and UHB NHS Trusts, Birmingham, UK
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McCrindle BW, Michelson AD, Van Bergen AH, Suzana Horowitz E, Pablo Sandoval J, Justino H, Harris KC, Jefferies JL, Miriam Pina L, Peluso C, Nessel K, Lu W, Li JS. Thromboprophylaxis for Children Post-Fontan Procedure: Insights From the UNIVERSE Study. J Am Heart Assoc 2021; 10:e021765. [PMID: 34558312 PMCID: PMC8751951 DOI: 10.1161/jaha.120.021765] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with single-ventricle physiology who undergo the Fontan procedure are at risk for thrombotic events associated with significant morbidity and mortality. The UNIVERSE Study evaluated the efficacy and safety of a novel liquid rivaroxaban formulation, using a body weight-adjusted dosing regimen, versus acetylsalicylic acid (ASA) in children post-Fontan. Methods and Results The UNIVERSE Study was a randomized, multicenter, 2-part, open-label study of rivaroxaban, in children who had undergone a Fontan procedure, to evaluate its dosing regimen, safety, and efficacy. Part A was the single-arm part of the study that determined the pharmacokinetics/pharmacodynamics and safety of rivaroxaban in 12 participants before proceeding to part B, whereby 100 participants were randomized 2:1 to open-label rivaroxaban versus ASA. The study period was 12 months. A total of 112 participants were enrolled across 35 sites in 10 countries. In part B, for safety outcomes, major bleeding occurred in one participant on rivaroxaban (epistaxis that required transfusion). Clinically relevant nonmajor bleeding occurred in 6% of participants on rivaroxaban versus 9% on ASA. Trivial bleeding occurred in 33% of participants on rivaroxaban versus 35% on ASA. For efficacy outcomes, 1 participant on rivaroxaban in part B had a pulmonary embolism (2% overall event rate); and for ASA, 1 participant had ischemic stroke and 2 had venous thrombosis (9% overall event rate). Conclusions In this study, participants who received rivaroxaban for thromboprophylaxis had a similar safety profile and fewer thrombotic events, albeit not statistically significant, compared with those in the ASA group. Registration URL: https://www.clinicaltrials.gov. Identifier: NCT02846532.
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Affiliation(s)
- Brian W McCrindle
- The Hospital for Sick Children University of Toronto Toronto ON Canada
| | | | | | - Estela Suzana Horowitz
- Institute of Cardiology of Rio Grande do Sul/University Foundation of Cardiology Porto Alegre Brazil
| | | | | | - Kevin C Harris
- Children's Heart CentreBC Children's Hospital Vancouver BC Canada
| | - John L Jefferies
- The Cardiac Institute University of Tennessee Health Science Center Memphis TN
| | | | | | | | - Wentao Lu
- Janssen Research and Development, LLC Raritan NJ
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Pulcine E, Seed M, Brandão LR, Slim M, Palasamudram S, Shroff M, Moharir M, deVeber G, Dlamini N. Hemorrhagic transformation and stroke recurrence in children with cardiac disease receiving antithrombotic therapy for secondary stroke prevention. J Thromb Haemost 2021; 19:2428-2439. [PMID: 34152075 DOI: 10.1111/jth.15428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 05/20/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antithrombotic therapy is currently recommended for stroke prevention in pediatric cardioembolic stroke where the recurrence risk is high; however, safety concerns remain. The primary objective of this study was to evaluate clinical and radiographic predictors of hemorrhagic transformation and stroke recurrence in children with cardiac disease to ascertain the safety and failure rates for secondary stroke prevention. METHODS This was a single-center, retrospective analysis of a prospectively enrolled cohort of children with radiologically confirmed cardioembolic stroke from January 2003 to December 2017 treated with institutional guidelines. RESULTS Eighty-two children met inclusion criteria (male 44 [54%]; neonates 23 [28%]; median age 0.43 years [0.08-4.23]). Hemorrhagic transformation occurred in 20 (24%) with the majority (75% of 20) being petechial and asymptomatic. One death (1%) was reported from hemorrhagic transformation. Four children (5%) had major extracranial hemorrhage. Most (95%) received antithrombic therapy, with anticoagulation being favored (82%). Greater stroke volume was associated with hemorrhagic transformation using the pediatric Alberta Stroke Program Early CT Score (6.1 ± 3.3 vs. 3.5 ± 2.3; p = .006). Stroke recurred in 11 (13%) children at a median 32 days (5.5-93) from the index event and the majority (90%) were on treatment at the time of recurrence. Children with univentricular physiology were less likely to have hemorrhagic transformation (RR 0.31; 95% CI 0.09-0.96, p = .04); however, they had higher rates of recurrent stroke before final palliative repair. CONCLUSIONS In spite of the 24% hemorrhagic transformation rate, antithrombotic therapy has a positive risk-balance in certain cardioembolic stroke subgroups, particularly in those with single-ventricle physiology, when accounting for stroke volume.
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Affiliation(s)
- Elizabeth Pulcine
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mike Seed
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Mahmoud Slim
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sunitha Palasamudram
- Division of Diagnostic Imaging, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Manohar Shroff
- Division of Diagnostic Imaging, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mahendranath Moharir
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gabrielle deVeber
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nomazulu Dlamini
- Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
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12
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Zhu P, Willmann S, Zhou W, Yang H, Michelson AD, McCrindle BW, Li JS, Harris KC, Pina LM, Weber T, Nessel K, Lesko LJ, Kubitza D, Zannikos P. Dosing Regimen Prediction and Confirmation with Rivaroxaban for Thromboprophylaxis in Children after the Fontan Procedure: Insights from the Phase III UNIVERSE Study. J Clin Pharmacol 2021; 62:220-231. [PMID: 34524700 PMCID: PMC9303933 DOI: 10.1002/jcph.1966] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/10/2021] [Indexed: 11/09/2022]
Abstract
Thrombosis remains an important complication for children with single ventricle physiology post-Fontan procedure and effective thromboprophylaxis is an important unmet medical need. To obviate conventional dose-finding studies and expedite clinical development, a rivaroxaban dose regimen for this indication was determined utilizing a model-informed drug development approach. A physiologically based pharmacokinetic (PBPK) rivaroxaban model was used to predict a pediatric dosing regimen that would produce drug exposures similar to that of 10 mg once daily in adults. This regimen was used in an open-label, multicenter Phase 3 study, which investigated the use of rivaroxaban for thromboprophylaxis in post-Fontan patients 2 to 8 years of age. The pharmacokinetics (PK) of rivaroxaban was assessed in Part A (n = 12) and in Part B (n = 64) of UNIVERSE. The safety and efficacy in the rivaroxaban group were compared to those in the acetylsalicylic acid group for 12 months. Pharmacodynamic endpoints were assessed in both parts of the study. Rivaroxaban exposures achieved in Part A and B were similar to the adult reference exposures. Prothrombin time also showed similarity to the adult reference. Exposure-response analysis did not identify a quantitative relationship between rivaroxaban exposures and efficacy/safety outcomes within the observed exposure ranges. A body-weight based dose regimen selected by PBPK modeling was shown in the UNIVERSE study to be appropriate for thromboprophylaxis in the post-Fontan pediatric population. Model-based dose selection can support pediatric drug development and bridge adult dose data to pediatrics, thereby obviating the need for dose-finding studies in pediatric programs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Peijuan Zhu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Stefan Willmann
- Bayer AG, Pharmaceuticals, Research and Development, Wuppertal, Germany
| | - Wangda Zhou
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Haitao Yang
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Alan D Michelson
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian W McCrindle
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Kevin C Harris
- Children's Heart Centre, BC Children's Hospital, Vancouver, BC, Canada
| | | | - Traci Weber
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | | | | | - Dagmar Kubitza
- Bayer AG, Pharmaceuticals, Research and Development, Wuppertal, Germany
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13
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Farias M, Fleishman CE, Nykanen D, DeCampli WM. Clinical update on the hybrid comprehensive stage II operation. JTCVS OPEN 2021; 7:327-335. [PMID: 36003736 PMCID: PMC9390143 DOI: 10.1016/j.xjon.2021.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/19/2022]
Abstract
Objective We previously described the hybrid comprehensive stage II operation as an alternate surgical procedure for a subset of patients with single ventricle congenital heart disease with adequate native ascending aortic outflow. Here we provide a clinical update on the 4 patients who have undergone this procedure. Methods After undergoing a hybrid approach to the stage I Norwood palliation, the hybrid comprehensive stage II procedure was performed with an incision to the main pulmonary artery (PA), dilation of the ductal stent, creation of a stented baffle between the branch PAs, and a bidirectional Glenn connection. With this approach, dissection of the distal arch and creation of a Damus-Kaye-Stansel anastomosis was avoided. A standard Fontan procedure was planned after the usual period of growth. Results The first patient, who had trisomy 21 and elevated PA pressures, died postoperatively due to left PA thrombosis. The subsequent 3 patients survived the procedure and remain clinically well. All have required catheterizations for reintervention on their stented intrapulmonary baffles and ductal arches, and all have undergone successful completion of their Fontan procedures. Conclusions The hybrid comprehensive stage II is a feasible, less complex alternative to the conventional comprehensive stage II operation in a subset of patients with single ventricle physiology. Early postoperative anticoagulation therapy to avoid PA thrombosis is recommended, and restenting of the ductal arch is anticipated. Although the long-term consequences of separate outflow tracts supplying the upper and lower body is unknown, the 3 surviving patients with this circulation are doing well with their Fontan circulation at midterm follow-up.
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Affiliation(s)
- Michael Farias
- The Heart Center, Arnold Palmer Hospital for Children Orlando, Fla
| | | | - David Nykanen
- The Heart Center, Arnold Palmer Hospital for Children Orlando, Fla
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14
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Abdelghani E, Cua CL, Giver J, Rodriguez V. Thrombosis Prevention and Anticoagulation Management in the Pediatric Patient with Congenital Heart Disease. Cardiol Ther 2021; 10:325-348. [PMID: 34184214 PMCID: PMC8555036 DOI: 10.1007/s40119-021-00228-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 01/19/2023] Open
Abstract
Thrombosis is one of the most frequent complications affecting children with congenital heart disease (CHD). Palliative and reparative cardiac surgeries are some of the main players contributing to the thrombosis risk in this patient population. Additional risk factors related to the CHD itself (e.g., cardiac dysfunction, arrhythmias, and polycythemia in cyanotic cardiac disorders) can contribute to thrombogenicity alone or combined with other factors. Thrombotic complications have been recognized as a significant cause of morbidity and mortality in this patient population. Here, we provide an overview of the pathophysiology and risk factors for thrombosis as well as the indications for and use of different anticoagulation, antiplatelet, and thrombolytic agents. In addition, we describe some of most common thrombotic complications and their management in the pediatric CHD population.
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Affiliation(s)
- Eman Abdelghani
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Clifford L Cua
- Heart Center, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, USA. .,Department of Pediatrics, The Ohio State University, Columbus, OH, USA.
| | - Jean Giver
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University, Columbus, OH, USA
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15
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Faustino EVS, Raffini LJ, Hanson SJ, Cholette JM, Pinto MG, Li S, Kandil SB, Nellis ME, Shabanova V, Silva CT, Tala JA, McPartland T, Spinella PC. Age-Dependent Heterogeneity in the Efficacy of Prophylaxis With Enoxaparin Against Catheter-Associated Thrombosis in Critically Ill Children: A Post Hoc Analysis of a Bayesian Phase 2b Randomized Clinical Trial. Crit Care Med 2021; 49:e369-e380. [PMID: 33566465 PMCID: PMC7979442 DOI: 10.1097/ccm.0000000000004848] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We explored the age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin against central venous catheter-associated deep venous thrombosis in critically ill children. DESIGN Post hoc analysis of a Bayesian phase 2b randomized clinical trial. SETTING Seven PICUs. PATIENTS Children less than 18 years old with newly inserted central venous catheter. INTERVENTIONS Enoxaparin started less than 24 hours after insertion of central venous catheter and adjusted to anti-Xa level of 0.2-0.5 international units/mL versus usual care. MEASUREMENTS AND MAIN RESULTS Of 51 children randomized, 24 were infants less than 1 year old. Risk ratios of central venous catheter-associated deep venous thrombosis with prophylaxis with enoxaparin were 0.98 (95% credible interval, 0.37-2.44) in infants and 0.24 (95% credible interval, 0.04-0.82) in older children greater than or equal to 1 year old. Infants and older children achieved anti-Xa level greater than or equal to 0.2 international units/mL at comparable times. While central venous catheter was in situ, endogenous thrombin potential, a measure of thrombin generation, was 223.21 nM.min (95% CI, 8.78-437.64 nM.min) lower in infants. Factor VIII activity, a driver of thrombin generation, was also lower in infants by 45.1% (95% CI, 15.7-74.4%). Median minimum platelet count while central venous catheter was in situ was higher in infants by 39 × 103/mm3 (interquartile range, 17-61 × 103/mm3). Central venous catheter:vein ratio was not statistically different. Prophylaxis with enoxaparin was less efficacious against central venous catheter-associated deep venous thrombosis at lower factor VIII activity and at higher platelet count. CONCLUSIONS The relatively lesser contribution of thrombin generation on central venous catheter-associated thrombus formation in critically ill infants potentially explains the age-dependent heterogeneity in the efficacy of prophylaxis with enoxaparin.
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Affiliation(s)
| | - Leslie J Raffini
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Sheila J Hanson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Jill M Cholette
- Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Matthew G Pinto
- Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital, Valhalla, NY
| | - Simon Li
- Department of Pediatrics, New York Medical College, Maria Fareri Children's Hospital, Valhalla, NY
| | - Sarah B Kandil
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Marianne E Nellis
- Department of Pediatrics, NY Presbyterian Hospital/Weill Cornell Medicine, New York, NY
| | | | - Cicero T Silva
- Department of Diagnostic Radiology, Yale School of Medicine, New Haven, CT
| | - Joana A Tala
- Pediatric Intensive Care Unit, Yale-New Haven Children's Hospital, New Haven, CT
| | - Tara McPartland
- Yale Center for Clinical Investigation, Yale School of Medicine, New Haven, CT
| | - Philip C Spinella
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
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16
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Ono M, Kido T, Burri M, Anderl L, Ruf B, Cleuziou J, Strbad M, Hager A, Hörer J, Lange R. Risk Factors for Thrombus Formation at Stage 2 Palliation and Its Effect on Long-Term Outcome in Patients With Univentricular Heart. Semin Thorac Cardiovasc Surg 2021; 34:669-679. [PMID: 33691189 DOI: 10.1053/j.semtcvs.2021.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 02/01/2021] [Indexed: 01/19/2023]
Abstract
Thrombus formation is a feared complication following bidirectional cavopulmonary shunt (BCPS). We aimed to investigate the effect of thrombus formation on outcome. BCPS was performed in 525 patients at our center between 1998 and 2018. The impacts of thrombus formation on survival and probability of Fontan completion were analyzed, and risk factors for thrombus formation were examined. Thrombus formation occurred in 30 patients (5.7%). Compared with the remaining 495 patients, there was no significant difference in the median age at BCPS (4.9 vs 4.7 months; P = 0.587). However, unbalanced atrioventricular septal defects (17 vs 5%; P = 0.008) and preoperative ventricular dysfunction (23.3 vs 8%; P = 0.004) were more frequent in patients who developed a thrombus. Thrombolytic therapy was performed in all patients and surgical thrombus removal was required in 13 patients. In-hospital mortality was higher in patients with thrombus (30.0 vs 2.2%; P < 0.001). Of 505 hospital survivors, an estimated survival at 1 year after hospital discharge following BCPS was 84.4% (95% CI, 76.1-92.7%) in patients with thrombus and 96.8% (95% CI, 96.0-97.6%) in those without (P < 0.001). Cumulative incidence of Fontan completion at 3 years after BCPS was 52.8% (95% CI, 30.3-75.2%) in patients with thrombus and 90.1% (95% CI, 87.2-92.9%) in those without (P = 0.004). Higher left atrial pressure (OR = 1.165; P = 0.029) and longer cardiopulmonary bypass time (OR = 1.013, P = 0.001) at BCPS were independent risk factors for thrombus formation after BCPS. Thrombus formation after BCPS poses a significant risk for survival and Fontan completion. Preoperative higher left atrial pressure and longer cardiopulmonary bypass time are significant risk factors.
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Affiliation(s)
- Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany.
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Germany
| | - Lisa Anderl
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
| | - Bettina Ruf
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technische Universität München, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany; German Center for Cardiovascular Research, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technische Universität München, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Germany; German Center for Cardiovascular Research, Munich, Germany
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17
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Kato A, Sato J, Yoshii K, Yoshida S, Nishikawa H, Ohashi N, Sakurai T, Sakurai H, Hata T, Yoshikawa T. The mid-term outcome of Fontan conversion compared with primary total cavopulmonary connection. J Cardiol 2021; 78:213-218. [PMID: 33648806 DOI: 10.1016/j.jjcc.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/09/2021] [Accepted: 02/04/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The indication of Fontan conversion (FC) from atriopulmonary connection (APC) to total cavopulmonary connection (TCPC) is unclear. We sought to analyze the mid-term outcome of prophylactic and therapeutic Fontan conversion compared with that of primary TCPC. METHODS Patients with a univentricular heart who underwent cardiac catheterization at >18 years of age between July 2005 and July 2019 were included and divided into three groups: symptomatic APC patients who underwent therapeutic FC (t-FC, n = 13), asymptomatic APC patients after prophylactic FC (p-FC, n = 15), and patients who had primary TCPC procedure (pTCPC, n = 24). RESULTS The mean last follow up was at the age of 32.0 ± 7.8, 26.8 ± 3.8, and 27.3 ± 7 years (p = 0.07) in t-FC, p-FC, and pTCPC, respectively. There was no late death. All of t-FC and 12 (80%) of p-FC cases underwent concomitant arrhythmic surgery. Consequently, five and four patients in t-FC and p-FC groups required pacemaker implantations mostly due to sinus node dysfunction. Thromboembolism was seen in 2 cases in both t-FC (15%) and p-FC (13%), and 1 case in pTCPC (4%) (p = 0.50). The last cardiac catheterization was performed at the age of 29.5 ± 8.5, 24.6 ± 3.8, and 26.3 ± 7.1 years (p = 0.11) in t-FC, p-FC, and pTCPC patients, respectively. There was no significant difference in central venous pressure, aortic pressure, and cardiac index among the three groups. There was no late supraventricular tachyarrhythmic event seen in t-FC and p-FC, whereas two patients in pTCPC had newly developed atrial flutter. CONCLUSIONS FC is a safe and feasible procedure to bring APC patients back onto the same track of primary TCPC patients in terms of hemodynamics as well as arrhythmia. The antiarrhythmic procedure should be carefully chosen because sinus node dysfunction can frequently occur and FC itself would reduce the risk of arrhythmia.
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Affiliation(s)
- Atsuko Kato
- Department of Pediatric Cardiology, JCHO Chukyo Hospital, Nagoya, Japan; Department of Pediatrics, Fujita Health University, Toyoake, Japan.
| | - Jun Sato
- Department of Pediatric Cardiology, JCHO Chukyo Hospital, Nagoya, Japan
| | - Kimihiro Yoshii
- Department of Pediatric Cardiology, JCHO Chukyo Hospital, Nagoya, Japan
| | - Shuichiro Yoshida
- Department of Pediatric Cardiology, JCHO Chukyo Hospital, Nagoya, Japan
| | - Hiroshi Nishikawa
- Department of Pediatric Cardiology, JCHO Chukyo Hospital, Nagoya, Japan
| | - Naoki Ohashi
- Department of Pediatric Cardiology, JCHO Chukyo Hospital, Nagoya, Japan
| | - Takahisa Sakurai
- Department of Cardiovascular Surgery, JCHO Chukyo Hospital, Nagoya, Japan
| | - Hajime Sakurai
- Department of Cardiovascular Surgery, JCHO Chukyo Hospital, Nagoya, Japan
| | - Tadayoshi Hata
- Department of Pediatrics, Fujita Health University, Toyoake, Japan
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18
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Lubert AM, Redington AN. Commentary: Aspirin versus warfarin in patients with a Fontan circulation-the clot thickens. J Thorac Cardiovasc Surg 2021; 162:1231-1233. [PMID: 33593610 DOI: 10.1016/j.jtcvs.2021.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Adam M Lubert
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Adult Congenital Heart Disease Program, Cincinnati, Ohio.
| | - Andrew N Redington
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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19
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White MH, Kelleman M, Sidonio RF, Kochilas L, Patel KN. Incidence and Timing of Thrombosis After the Norwood Procedure in the Single-Ventricle Reconstruction Trial. J Am Heart Assoc 2020; 9:e015882. [PMID: 33283593 PMCID: PMC7955374 DOI: 10.1161/jaha.120.015882] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 10/12/2020] [Indexed: 01/19/2023]
Abstract
Background Thrombosis is common in infants undergoing staged surgeries for single-ventricle congenital heart disease. The reported incidence and timing of thrombosis varies widely, making it difficult to understand the burden of thrombosis and develop approaches for prevention. We aimed to determine the timing and cumulative incidence of thrombosis following the stage I Norwood procedure and identify clinical characteristics associated with thrombosis. Methods and Results We analyzed data from the Pediatric Heart Network Single Ventricle Reconstruction trial from 2005 to 2009 and identified infants with first-time thrombotic events. In 549 infants, the cumulative incidence of thrombosis was 21.2% (n=57) from stage I through stage II. Most events occurred during stage I (n=35/57, 65%), with a median time to thrombosis of 15 days. We used a Cox proportional hazards model to estimate the association of clinical variables with thrombosis. After adjusting for baseline variables, boys had a higher hazard of thrombosis (adjusted hazard ratio [HR], 2.69; 95% CI, 1.44-5.05; P=0.002), non-hypoplastic left heart syndrome cardiac anatomy was associated with a higher early hazard of thrombosis (adjusted HR, 3.93; 95% CI, 1.89-8.17; P<0.001), and longer cardiopulmonary bypass time was also associated with thrombosis (per 10-minute increase, adjusted HR, 1.07; 95% CI, 1.01-1.12; P=0.02). Lower oxygen saturation after the Norwood procedure increased the hazard for thrombosis in the unadjusted model (HR, 1.08; 95% CI, 1.02-1.14; P=0.011). Conclusions Thrombosis affects 1 in 5 infants through Stage II discharge, with most events occurring during stage I. Male sex, non-hypoplastic left heart syndrome anatomy, longer cardiopulmonary bypass time, and lower stage I oxygen saturation were associated with thrombosis.
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Affiliation(s)
- Michael H. White
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaDepartment of PediatricsEmory UniversityAtlantaGA
| | - Michael Kelleman
- Department of PediatricsSchool of MedicineEmory UniversityAtlantaGA
| | - Robert F. Sidonio
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaDepartment of PediatricsEmory UniversityAtlantaGA
| | - Lazaros Kochilas
- Department of PediatricsEmory University School of Medicine and Children’s Healthcare of AtlantaAtlantaGA
| | - Kavita N. Patel
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of AtlantaDepartment of PediatricsEmory UniversityAtlantaGA
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20
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New options for anticoagulation in congenital and pediatric acquired heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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21
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Eason AJ, Crethers D, Ghosh S, Stansfield BK, Polimenakos AC. Central Vascular Thrombosis in Neonates with Congenital Heart Disease Awaiting Cardiac Intervention. Pediatr Cardiol 2020; 41:1340-1345. [PMID: 32472152 DOI: 10.1007/s00246-020-02383-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/22/2020] [Indexed: 01/19/2023]
Abstract
Central vascular thrombosis (CVT) in critically ill neonates carries significant clinical implications. Neonates with congenital heart disease (CHD) awaiting cardiac intervention might be associated with increased risk of thrombosis. Outcome analysis was undertaken. An analysis of 77 neonates with CHD who were admitted to the NICU prior to cardiac intervention between January 2015 and December 2016 was undertaken. Patients requiring extracorporeal life support prior to any cardiac intervention, or receiving prophylactic anticoagulation not related to central vascular catheter (CVC) were excluded. Diagnosis of CVT was provided based on clinical indication and verified with imaging that warranted anticoagulation therapy. Location of CVC and extent of CVT along with treatments, outcomes, and vascular access types and durations were assessed. Logistic regression multivariate analysis was used to assess predictors of outcome. Neonates with CHD were complicated with CVT in 10.4%. Longer duration of CVC was also associated with thrombosis in neonates with CHD (72.7 days vs. 29.3 days, p < 0.001). Independent predictors of outcome included lower gestational age and CHD with single-ventricle (SV) anatomy (p < 0.05). In neonates with CHD awaiting cardiac intervention risk of CVT is substantial. Duration CVC, lower gestational age and SV anatomy are risk determinants of outcome. Standardized development of customized surveillance protocols tailored to this unique subsets of neonates and adherence to quality guidelines can influence outcome.
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Affiliation(s)
- Alexander J Eason
- Division of Neonatology, Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Danielle Crethers
- Division of Pediatric and Congenital Heart Surgery, Department of Surgery, Augusta University, Augusta, GA, USA
| | - Santu Ghosh
- Division of Biostatistics and Data Science, Department of Population Health, Augusta University, Augusta, GA, USA
| | - Brian K Stansfield
- Division of Neonatology, Department of Pediatrics, Augusta University, Augusta, GA, USA
| | - Anastasios C Polimenakos
- Division of Pediatric and Congenital Heart Surgery, Department of Surgery, Augusta University, Augusta, GA, USA. .,Medical College of Georgia, Congenital and Pediatric Cardiothoracic Surgery, Children's Hospital of Georgia, 1120 15th Street BAA 8222, Augusta, GA, 30912, USA.
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22
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Assessment of antiplatelet therapy response in pediatric patients following cardiac surgery by microfluidic assay. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2019.101191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Schlueter SM, Wilhelm M, Anagnostopoulos PV, Al-Subu AM. Pulmonary Embolism in a Neonate Following Modified Norwood Procedure With Sano Shunt. World J Pediatr Congenit Heart Surg 2020; 10:638-640. [PMID: 31496419 DOI: 10.1177/2150135119853283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pulmonary embolism is a rare but potentially fatal complication in neonates with congenital heart disease. The authors report a case of pulmonary embolism in the immediate postoperative period following modified Norwood procedure with Sano shunt. In addition, this report discusses the initial evaluation and available anticoagulation options to treat pulmonary embolism in children with congenital heart disease.
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Affiliation(s)
- Sarah M Schlueter
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael Wilhelm
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Petros V Anagnostopoulos
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Awni M Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Ali U, Goldenberg N, Foreman C, Crawford Lynn L, Honjo O, O'Leary J, Faraoni D. Association Between Cyanosis, Transfusion, and Thrombotic Complications in Neonates and Children Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 34:349-355. [DOI: 10.1053/j.jvca.2019.07.123] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/04/2019] [Accepted: 07/09/2019] [Indexed: 01/19/2023]
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Abstract
A 7-month-old infant presented with bilateral blocked cavo-pulmonary anastomosis within 2 months of surgery. Due to extreme haemodynamic instability, surgical options were abandoned and rescue intervention from left jugular line was planned. Acute thrombosis of the left-sided Glenn was noted with significant anastomotic narrowing. Successful rescue thrombolysis was done using recombinant tissue plasminogen activator (Alteplase) along with balloon dilatation of the attenuated segments.
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A multi-national trial of a direct oral anticoagulant in children with cardiac disease: Design and rationale of the Safety of ApiXaban On Pediatric Heart disease On the preventioN of Embolism (SAXOPHONE) study. Am Heart J 2019; 217:52-63. [PMID: 31493728 DOI: 10.1016/j.ahj.2019.08.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/01/2019] [Indexed: 12/16/2022]
Abstract
Anticoagulation in children is problematic for multiple reasons. Currently used anticoagulants have significant disadvantages and may negatively affect quality of life (QOL). This manuscript describes the design, rationale, and methods of a prospective, randomized, open label phase II multi-national clinical trial of a direct oral anticoagulant (DOAC), apixaban, in children and infants with congenital and acquired heart disease. This trial is designed to gather preliminary safety and pharmacokinetics (PK) data, as well as generate data on QOL of individuals taking apixaban compared to the standard of care (SOC) anticoagulants vitamin K antagonists (VKA) or low molecular weight heparin (LMWH). A key issue this trial seeks to address is the practice of using therapeutics tested in adult trials in the pediatric population without robust pediatric safety or efficacy data. Pediatric heart diseases are not common, and specific diagnoses often meet the criteria of a rare disease; thus, statistical efficacy may be difficult to achieve. This trial will provide valuable PK and safety data intended to inform clinical practice for anticoagulation in pediatric heart diseases, a setting in which a fully powered phase III clinical trial is not feasible. A second consideration this trial addresses is that metrics besides efficacy, such as QOL, have not been traditionally used as endpoints in regulated anticoagulation studies yet may add substantial weight to the clinical decision for use of a DOAC in place of VKA or LMWH. This study examines QOL related to both heart disease and anticoagulation among children randomized to either SOC or apixaban. There are considerable strengths and benefits to conducting a clinical trial in pediatric rare disease populations via an industry-academic collaboration. The SAXOPHONE study represents a collaboration between Bristol-Myers Squibb (BMS)/Pfizer Alliance, and the National Heart, Lung, and Blood Institute's (NHLBI) Pediatric Heart Network (PHN) and may be an attractive model for future pediatric drug trials.
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 435] [Impact Index Per Article: 87.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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Pina LM, Dong X, Zhang L, Samtani MN, Michelson AD, Justino H, Bonnet D, Harris KC, Jefferies J, McCrindle BW, Li JS. Rivaroxaban, a direct Factor Xa inhibitor, versus acetylsalicylic acid as thromboprophylaxis in children post-Fontan procedure: Rationale and design of a prospective, randomized trial (the UNIVERSE study). Am Heart J 2019; 213:97-104. [PMID: 31132584 DOI: 10.1016/j.ahj.2019.04.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 04/16/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Fontan procedure is the final step of the 3-stage palliative procedure commonly performed in children with single ventricle physiology. Thrombosis remains an important complication in children after this procedure. To date, guideline recommendations for the type and duration of thromboprophylaxis after Fontan surgery are mainly based on extrapolation of knowledge gained from adults at risk for thrombosis in other clinical settings. Warfarin is being used off-label, and because of its multiple interactions with other drugs and food, a new alternative is highly desirable. Rivaroxaban, a direct Factor Xa inhibitor with a predictable pharmacokinetic profile, is a candidate to address this medical need. STUDY DESIGN The UNIVERSE study is a prospective, open-label, active-controlled, multicenter study in children 2 to 8 years of age who have single ventricle physiology and had the Fontan procedure within the 4 months preceding enrollment. This study consists of 2 parts. In Part A, rivaroxaban pharmacokinetics, pharmacodynamics, safety, and tolerability are assessed to validate the pediatric dosing selected. In Part B, safety and efficacy of rivaroxaban versus acetylsalicylic acid are evaluated for thromboprophylaxis in children post-Fontan procedure. Children in each part will receive study drug for 12 months. Part A has been completed with 12 children enrolled. Enrollment into Part B is currently ongoing. CONCLUSIONS The UNIVERSE study aims to provide dosing, pharmacokinetics/pharmacodynamics, safety, and efficacy information on the use of rivaroxaban, an oral anticoagulant, versus acetylsalicylic acid, an antiplatelet agent, in children with single ventricle physiology after the Fontan procedure.
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Affiliation(s)
| | - Xiangwen Dong
- Janssen Research and Development, LLC., Raritan, NJ 08869
| | - Liping Zhang
- Janssen Research and Development, LLC., Raritan, NJ 08869
| | | | | | | | | | - Kevin C Harris
- Children's Heart Centre, BC Children's Hospital, Vancouver, BC V6H 3N1, Canada
| | - John Jefferies
- The Heart Institute, Cincinnati Children's Hospital Medical Centre, Cincinnati, OH 45229
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Manlhiot C, McCrindle BW, Williams S, Menjak IB, O'Shea S, Chan AK, Brandão LR. Characterization of Post-Thrombotic Syndrome in Children with Cardiac Disease. J Pediatr 2019; 207:42-48. [PMID: 30528575 DOI: 10.1016/j.jpeds.2018.10.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/21/2018] [Accepted: 10/26/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess the validity of existing clinical scales assessing the presence of physical and functional abnormalities for diagnosing post-thrombotic syndrome (PTS) in children, including specific evaluation of use in children with congenital heart disease (CHD). STUDY DESIGN One hundred children aged >2 years (average age, 6 years), including 33 with CHD and previously proven extremity deep vein thrombosis (DVT), 37 with CHD and no previous DVT, and 30 healthy siblings, were blindly assessed for PTS using the modified Villalta Scale (MVS). All patients aged <6 years underwent neurodevelopmental testing and an age-appropriate quality of life assessment. RESULTS The MVS identified mild PTS in 20 children and moderate PTS in 1 child (including 14 of 33 [42%] in the CHD/DVT group, 5 of 37 [14%] in the CHD/no DVT group, and 2 of 30 controls [7%]). The diagnosis of PTS was confirmed clinically in 14 patients, all of whom had previous thrombosis and 1 of whom was MVS-negative. MVS had an accuracy of 91% and performed reasonably well as a screening tool but poorly as a diagnostic tool. MVS reliability was acceptable. Children with PTS had similar quality of life as those without PTS but had higher rates of neurodevelopmental delays in gross motor skills (70% vs 24%; P = .02) and problem-solving indicators (60% vs 15%; P = .008). CONCLUSIONS Using the MVS scale for PTS screening in children with CHD is feasible and reliable, and the scale has good correlation with a clinical diagnosis of PTS despite a high prevalence of false-positive findings. Further research is needed to determine the clinical relevance of PTS in this population.
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Affiliation(s)
- Cedric Manlhiot
- Labatt Family Heart Centre, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Brian W McCrindle
- Labatt Family Heart Centre, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Suzan Williams
- Division of Haematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ines B Menjak
- Labatt Family Heart Centre, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sunita O'Shea
- Labatt Family Heart Centre, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anthony K Chan
- Division of Haematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Division of Haematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
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Abstract
OBJECTIVE Shunt-related adverse events are frequent in infants after modified Blalock-Taussig despite use of acetylsalicylic acid prophylaxis. A higher incidence of acetylsalicylic acid-resistance and sub-therapeutic acetylsalicylic acid levels has been reported in infants. We evaluated whether using high-dose acetylsalicylic acid can decrease shunt-related adverse events in infants after modified Blalock-Taussig. METHODS In this single-centre retrospective cohort study, we included infants ⩽1-year-old who underwent modified Blalock-Taussig placement and received acetylsalicylic acid in the ICU. We defined acetylsalicylic acid treatment groups as standard dose (⩽7 mg/kg/day) and high dose (⩾8 mg/kg/day) based on the initiating dose. RESULTS There were 34 infants in each group. Both groups were similar in age, gender, cardiac defect type, ICU length of stay, and time interval to second stage or definitive repair. Shunt interventions (18 versus 32%, p=0.16), shunt thrombosis (14 versus 17%, p=0.74), and mortality (9 versus 12%, p=0.65) were not significantly different between groups. On multiple logistic regression analysis, single-ventricle morphology (odds ratio 5.2, 95% confidence interval of 1.2-23, p=0.03) and post-operative red blood cells transfusion ⩾24 hours [odds ratio 15, confidence interval of (3-71), p<0.01] were associated with shunt-related adverse events. High-dose acetylsalicylic acid treatment [odds ratio 2.6, confidence interval of (0.7-10), p=0.16] was not associated with decrease in these events. CONCLUSIONS High-dose acetylsalicylic acid may not be sufficient in reducing shunt-related adverse events in infants after modified Blalock-Taussig. Post-operative red blood cells transfusion may be a modifiable risk factor for these events. A randomised trial is needed to determine appropriate acetylsalicylic acid dosing in infants with modified Blalock-Taussig.
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31
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Klaassen IL, Sol JJ, Suijker MH, Fijnvandraat K, van de Wetering MD, Heleen van Ommen C. Are low-molecular-weight heparins safe and effective in children? A systematic review. Blood Rev 2019; 33:33-42. [DOI: 10.1016/j.blre.2018.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/16/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
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Kim JS, Kaufman J, Patel SS, Manco-Johnson M, Di Paola J, da Cruz EM. Antiplatelet Effect of Ketorolac in Children After Congenital Cardiac Surgery. World J Pediatr Congenit Heart Surg 2018; 9:651-658. [DOI: 10.1177/2150135118799041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Ketorolac is used for pediatric analgesia after surgery despite its known platelet inhibition via the arachidonic acid (AA) pathway. The degree of platelet inhibitory effect after cardiac surgery is not well characterized. Thromboelastography with platelet mapping (TEG-PM) is emerging as a frequently used test to evaluate platelet inhibition via the AA pathway. Methods: Post hoc analysis of a data set collected in a prospective observational cohort study evaluating platelet inhibition in children after congenital heart surgery with cardiopulmonary bypass (CPB). Categorization into two groups: (1) received ketorolac and (2) did not receive ketorolac for analgesia after surgery. The TEG-PM was evaluated at two time points (prior to surgery and 12-48 hours after CPB). Results: Fifty-three children were studied; mean age was 6.6 (range: 0.07-16.7) years and 45% (n = 24) were female. Participants were distributed into two groups by ketorolac use, 41 within the ketorolac group and 12 in the no ketorolac group. All 41 participants who received ketorolac had platelet inhibition and 11 (91.7%) of 12 participants who did not receive ketorolac had normal platelet function after surgery ( P < .0001). There was no difference in patient characteristics or clinical data between the two groups. Conclusions: Ketorolac use in a cohort of children after congenital cardiac surgery was associated with platelet inhibition via the AA pathway when evaluated by TEG-PM.
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Affiliation(s)
- John S. Kim
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Jon Kaufman
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Sonali S. Patel
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Marilyn Manco-Johnson
- Department of Pediatrics, Hemophilia and Thrombosis Center, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Jorge Di Paola
- Department of Pediatrics, Hemophilia and Thrombosis Center, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Eduardo M. da Cruz
- Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO, USA
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Davis JAM, Miller-Tate H, Texter KM. Launching a New Strategy for Multidisciplinary Management of Single-Ventricle Heart Defects. Crit Care Nurse 2018; 38:60-71. [PMID: 29437079 DOI: 10.4037/ccn2018190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Children born with single-ventricle heart defects, particularly hypoplastic left heart syndrome, have a lifetime high risk of mortality and comorbidities. They have complex medical challenges in addition to their cardiac needs, including growth and feeding complications and neurodevelopmental issues. These concerns require a coordinated effort among specialties to help patients maximize their potential. Additionally, because many complex heart defects are diagnosed prenatally, coordination of care between the pre- and postnatal care teams is imperative. Nursing leadership improves program coordination and efficiency. The purpose of this article is to describe the development and implementation of our hospital's synchronized, multidisciplinary team to support children with single-ventricle heart defects and their families. (Critical Care Nurse. 2018;38[1]:60-71).
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Affiliation(s)
- Jo Ann M Davis
- Jo Ann M. Davis is the single ventricle advanced practice nurse at Nationwide Children's Hospital in Columbus, Ohio. .,Holly Miller-Tate is a nurse clinician at Nationwide Children's Hospital and plays a key role on the single-ventricle team. .,Karen M. Texter is the director of fetal echocardiography and the single-ventricle team at Nationwide Children's Hospital.
| | - Holly Miller-Tate
- Jo Ann M. Davis is the single ventricle advanced practice nurse at Nationwide Children's Hospital in Columbus, Ohio.,Holly Miller-Tate is a nurse clinician at Nationwide Children's Hospital and plays a key role on the single-ventricle team.,Karen M. Texter is the director of fetal echocardiography and the single-ventricle team at Nationwide Children's Hospital
| | - Karen M Texter
- Jo Ann M. Davis is the single ventricle advanced practice nurse at Nationwide Children's Hospital in Columbus, Ohio.,Holly Miller-Tate is a nurse clinician at Nationwide Children's Hospital and plays a key role on the single-ventricle team.,Karen M. Texter is the director of fetal echocardiography and the single-ventricle team at Nationwide Children's Hospital
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Establishment of prophylactic enoxaparin dosing recommendations to achieve targeted anti-factor Xa concentrations in children with CHD. Cardiol Young 2018; 28:715-718. [PMID: 29490713 DOI: 10.1017/s1047951118000173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Enoxaparin may be used to prevent central venous catheter-related thrombosis in patients with CHD. We aimed to determine whether current enoxaparin dosing regimens effectively achieve anti-factor Xa concentrations within prophylactic goal ranges in this patient population. METHODS We implemented a formal protocol aimed at reducing central venous catheter-related thrombosis in children with CHD in January, 2016. Standard empiric prophylactic enoxaparin dosing regimens were used - for example, 0.75 mg/kg/dose every 12 hours for patients <2 months of age and 0.5 mg/kg/dose every 12 hours for patients ⩾2 months of age - with anti-factor Xa goal range of 0.25-0.49 IU/ml. Patients <2 years of age who received enoxaparin and had at least one valid steady-state anti-factor Xa measurement between 25 January, 2016 and 31 August, 2016 were retrospectively reviewed. RESULTS During the study period, 47 patients had 186 anti-factor Xa concentrations measured, of which 20 (11%) were above and 112 (60%) were below the prophylactic goal range. Anti-factor Xa concentrations within the goal range were ultimately achieved in 31 patients. Median dose required to achieve anti-factor Xa concentrations within the prophylactic range was 0.89 mg/kg/dose (25, 75%: 0.75, 1.11) for patients <2 months (n=23 patients) and 0.79 mg/kg/dose (25, 75%: 0.62, 1.11) for patients ⩾2 months (n=8 patients). CONCLUSIONS Enoxaparin doses required to achieve prophylactic anti-factor Xa concentrations in young children with CHD were consistently higher than the currently recommended prophylactic dosing regimens. Further study is needed to determine whether dose titration to achieve prophylactic anti-factor Xa concentrations is effective in preventing central venous catheter-related thrombosis.
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Agarwal A, Firdouse M, Brar N, Yang A, Lambiris P, Chan AK, Mondal TK. Incidence and Management of Thrombotic and Thromboembolic Complications Following the Superior Cavopulmonary Anastomosis Procedure: A Literature Review. Clin Appl Thromb Hemost 2017; 24:405-415. [PMID: 29277101 PMCID: PMC6714653 DOI: 10.1177/1076029617739702] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The objective of this literature review was to estimate the incidence of thrombosis and thromboembolism associated with the superior cavopulmonary anastomosis (SCPA) procedure and its variants and to examine current thromboprophylaxis regimens utilized. MEDLINE and EMBASE were searched from inception to August 2017 for all prospective and retrospective cohort studies explicitly reporting incidence of thrombosis, thromboembolism, or shunt occlusion in neonates, infants, and children undergoing 1 or more variants of the SCPA procedure. End points included thrombotic events and thromboembolic events (strokes and pulmonary embolisms) as primary outcomes, and overall mortality as a secondary outcome, at the last available follow-up time point. Of 1303 unique references identified, 13 cohort studies were deemed eligible. Reported incidence of thrombosis and thromboembolic events ranged from 0% to 28.0% and from 0% to 12.5%, respectively. Reported incidence of major bleeding events ranged from 0% to 2.9%. Reported overall mortality ranged from 2.5% to 50.5% across studies. Thromboprophylaxis protocols varied across institutions and studies, most commonly involving unfractionated heparin (UFH), warfarin, enoxaparin, acetylsalicylic acid (ASA), or combinations of ASA and warfarin, ASA and low-molecular-weight heparin (LMWH), UFH and LMWH, and UFH and ASA; several studies did not specify a protocol. Due to substantial variability in reported event rates, no clear correlation was identified between prophylaxis protocols and postoperative thrombotic complications. Despite guidance recommending postoperative UFH as standard practice, thromboprophylaxis protocols varied across institutions and studies. More robust trials evaluating different thromboprophylaxis regimens for the management of these patients are warranted.
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Affiliation(s)
- Arnav Agarwal
- 1 Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.,2 School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Firdouse
- 1 Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada.,2 School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nishaan Brar
- 2 School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andy Yang
- 3 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Panos Lambiris
- 4 University Health Network Library and Information Services, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anthony K Chan
- 1 Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Tapas Kumar Mondal
- 1 Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
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Silvey M, Hall M, Bilynsky E, Carpenter SL. Increasing rates of thrombosis in children with congenital heart disease undergoing cardiac surgery. Thromb Res 2017; 162:15-21. [PMID: 29253719 DOI: 10.1016/j.thromres.2017.12.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine thrombosis incidence, morbidities, and mortality of children with congenital heart disease who develop thrombosis after cardiac surgery. MATERIALS AND METHODS This retrospective study reviewed patients <18 years old within the Pediatric Health Information System (PHIS) database who underwent cardiac surgery from 2004-2012. Thrombosis rates were compared for each procedure. Mortality was modeled using proportional hazards, adjusting for important clinical and demographic factors. RESULTS Of 91909 CHD patients who underwent surgery, 2655 (2.9%) developed thrombosis within the ensuing 12 months. The rate of thrombosis increased 253% (p<0.001), from 1.7% in 2004 to 4.4% in 2012. Systemic to pulmonary shunt placement (34.3%) and septostomy (26.1%) had the highest thrombosis percentages. Children <28 days had the highest prevalence (61%). Those with thrombosis had longer lengths of stay than those without [median 27 hospital days and 10 ICU days vs. 6 and 2 (p<0.001)]. Mean risk-adjusted cost was higher with thrombosis; $126,257 vs. $40,773 (p<0.001). Thrombosis was also associated with higher rates of bacteremia [8.3% vs. 3.4%, p<0.001], endocarditis [0.7% vs. 0.2%, p<0.001], and mortality [12.3% vs. 0.8%, p<0.001]. The adjusted hazard ratio for mortality in patients with thrombosis was 5.5 (95% CI: 4.6-6.5). CONCLUSIONS Thrombosis rates in CHD patients after cardiac surgery is increasing. Thrombosis is associated with longer hospital stay, increased ICU days, and cost. CHD patients with thrombosis also have increased bacteremia and mortality rates. More research is needed to understand contributors to thrombosis which may help develop strategies to mitigate morbidity and mortality.
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Affiliation(s)
- Michael Silvey
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, United States.
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS, United States
| | - Eryn Bilynsky
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, United States
| | - Shannon L Carpenter
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, United States
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Nichay NR, Gorbatykh YN, Kornilov IA, Soynov IA, Kulyabin YY, Gorbatykh AV, Ivantsov SM, Bogachev-Prokophiev AV, Karaskov AM. Risk Factors For Unfavorable Outcomes After Bidirectional Cavopulmonary Anastomosis. World J Pediatr Congenit Heart Surg 2017; 8:575-583. [DOI: 10.1177/2150135117728505] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Bidirectional cavopulmonary anastomosis (BCPA) is an important preliminary step toward the Fontan procedure; thus, understanding of risk factors for morbidity and mortality after BCPA may ultimately promote improved rates of success with Fontan completion and general survival. This study evaluated survival and predictors of unfavorable outcomes in patients after BCPA. Methods: Clinical data of 157 patients who underwent BCPA from 2003 to 2015 at a single center were retrospectively analyzed. Results: Three-year and nine-year survival after BCPA were 87.1% ± 2.8% and 85.8% ± 2.9%, respectively. Freedom from unfavorable outcomes (mortality, BCPA takedown, nonsuitability for Fontan procedure) was 83.8% ± 3.1% at three years and 73.5% ± 4.8% at nine years. Multivariate proportional hazards regression analysis revealed that total anomalous pulmonary venous connection (TAPVC; hazard ratio [HR]: 3.74, 95% confidence interval [CI]: 1.35-10.36; P = .01) and increased mean pressure in BCPA circuit (HR: 1.17, 95% CI: 1.02-1.34; P = .03) were independent risk factors for unfavorable outcomes. Postoperative mean pressure in BCPA circuit in patients with poor outcomes was median 16 mm Hg (interquartile range [IQR]: 14-18 mm Hg) versus median 14 mm Hg (IQR: 12-15.5 mm Hg) in patients with favorable outcomes ( P < .01). Preoperative (HR: 1.87, 95% CI: 1.20-2.91; P < .01) and postoperative atrioventricular valve regurgitation (AVVR; HR: 2.22, 95% CI: 1.24-3.94; P < .01) were also associated with unfavorable outcome in univariate Cox regression. Conclusions: Elevated mean pressure in the BCPA circuit is the main predictor of unfavorable outcome; therefore, thorough preoperative examination and careful patient selection are critical points for successful intermediate-stage and later Fontan completion. Total anomalous pulmonary venous connection and insufficient correction of AVVR worsen the prognosis in this patient group.
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Affiliation(s)
- Nataliya R. Nichay
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Yuriy N. Gorbatykh
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Igor A. Kornilov
- Department of Anesthesiology, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Ilya A. Soynov
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Yuriy Y. Kulyabin
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Artem V. Gorbatykh
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Sergey M. Ivantsov
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Alexander V. Bogachev-Prokophiev
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
| | - Alexander M. Karaskov
- Department of Congenital Heart Disease, Siberian Biomedical Research Center, Ministry of Health Russian Federation, Novosibirsk, Russian Federation
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Katneni UK, Hunt R, Hettiarachchi GK, Hamasaki-Katagiri N, Kimchi-Sarfaty C, Ibla JC. Compounding variants rescue the effect of a deleterious ADAMTS13 mutation in a child with severe congenital heart disease. Thromb Res 2017; 158:98-101. [PMID: 28866379 DOI: 10.1016/j.thromres.2017.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/29/2017] [Accepted: 08/23/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Upendra K Katneni
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, United States
| | - Ryan Hunt
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, United States
| | - Gaya K Hettiarachchi
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, United States
| | - Nobuko Hamasaki-Katagiri
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, United States
| | - Chava Kimchi-Sarfaty
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, United States.
| | - Juan C Ibla
- Department of Anesthesiology Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
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Schilling C, Dalziel K, Iyengar AJ, d’Udekem Y. The Cost Differential Between Warfarin Versus Aspirin Treatment After a Fontan Procedure. Heart Lung Circ 2017; 26:e44-e47. [DOI: 10.1016/j.hlc.2017.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 01/23/2017] [Accepted: 02/01/2017] [Indexed: 10/20/2022]
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Variability of antithrombotics use in patients with hypoplastic left heart syndrome and its variants following first- and second-stage palliation surgery: a national report using the National Pediatric Cardiology Quality Improvement Collaborative registry. Cardiol Young 2017; 27:731-738. [PMID: 27981915 DOI: 10.1017/s1047951116001189] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED Purpose Patients with hypoplastic left heart syndrome and its variants following palliation surgery are at risk for thrombosis. This study examines variability of antithrombotic practice, the incidence of interstage shunt thrombosis, and other adverse events following Stage I and Stage II palliation within the National Pediatric Cardiology Quality Improvement Collaborative registry. METHODS We carried out a multicentre, retrospective review using the National Pediatric Cardiology Quality Improvement Collaborative registry including patients from 2008 to 2013 across 52 surgical sites. Antithrombotic medications used at Stage I and Stage II discharge were evaluated. Variability of antithrombotics use at the individual patient level and intersite variability, incidence of shunt thrombosis, and other adverse events such as cardiac arrest, seizure, stroke, and need for cardiac catheterisation intervention in the interstage period were identified. Antithrombotic strategies for hybrid Stage I patients were evaluated but they were excluded from the variability and outcomes analysis. RESULTS A total of 932 Stage I and 923 Stage II patients were included in the study: 93.8% of Stage I patients were discharged on aspirin and 4% were discharged on no antithrombotics, and 77% of Stage II patients were discharged on aspirin and 17.5% were discharged on no antithrombotics. Only three patients (0.2%) presented with interstage shunt thrombosis. The majority of patients who died during interstage or required shunt dilation and/or stenting were discharged home on aspirin. CONCLUSION Aspirin is the most commonly used antithrombotic following Stage I and Stage II palliation. There is more variability in the choice of antithrombotics following Stage II compared with Stage I. The incidence of interstage shunt thrombosis and associated adverse events was rare.
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Silvey M, Brandão LR. Risk Factors, Prophylaxis, and Treatment of Venous Thromboembolism in Congenital Heart Disease Patients. Front Pediatr 2017; 5:146. [PMID: 28674685 PMCID: PMC5476169 DOI: 10.3389/fped.2017.00146] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 06/09/2017] [Indexed: 01/19/2023] Open
Abstract
Congenital heart disease (CHD) is a common condition in the pediatric population, affecting up to 1% of all live births (i.e., around 40,000 newborns/year in the United States). Although CHD does have a wide range of severity, by the age of 5 years approximately 80% of patients will require at least one surgical intervention to achieve a complete/palliative cardiac repair. Today, in light of their much-improved surgical survival, the care of these patients focuses on morbidity prevention and/or treatment. One such morbidity has been the increased frequency of thrombotic occlusions [e.g., cardioembolic arterial ischemic strokes; arterial, cardiac, and/or newly created shunt thrombosis; venous thromboembolism (VTE)]. Patients with CHD are at high risk of developing thrombosis due to the disruption of blood flow, CHD-related coagulopathy, inflammation, and/or platelet activation secondary to extracorporeal circulation support required during open-heart surgery or as a bridge to recovery, which can increase thrombus formation. In this article, we will discuss how the coagulation system is altered in patients with CHD in regard to the patient's anatomy, procedures they undergo to correct their congenital heart defect, and other risk factors that may increase their thrombotic risk, focusing on VTE. We will also discuss the most recently published reports pertaining to guidelines on prophylaxis and treatment of VTE in this population. Finally, we will briefly address the long-term VTE outcomes for patients with CHD.
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Affiliation(s)
- Michael Silvey
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, United States
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Agarwal A, Firdouse M, Brar N, Yang A, Lambiris P, Chan AK, Mondal TK. Incidence and Management of Thrombotic and Thromboembolic Complications Following the Norwood Procedure: A Systematic Review. Clin Appl Thromb Hemost 2016; 23:911-921. [DOI: 10.1177/1076029616679506] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: The stage 1 Norwood procedure and its variants represent the first step of palliation for hypoplastic left heart syndrome. Although appropriate postoperative thromboprophylaxis is integral, significant variance remains across institutional practices. The purpose of this systematic review is to estimate the incidence of thrombosis and thromboembolism following the Norwood or modified Blalock-Taussig shunt procedure and examine current thromboprophylaxis regimens. Methods: Ovid MEDLINE and Embase were searched from January 2000 to June 2016 for primary studies explicitly reporting incidence of thrombosis, thromboembolism (strokes and pulmonary embolisms), or shunt occlusion in neonates, infants, and children undergoing the Norwood procedure or any variant. All-cause mortality was a secondary outcome of interest. Results: Of 887 identified articles, 15 cohort studies were deemed eligible, the majority including modified Blalock-Taussig shunt patients. Reported incidence of thrombosis ranged from 0% to 40%; thromboembolic events were rarely reported. Overall mortality ranged from 4.5% to 31.3% across studies. Although most studies involved the long-term acetylsalicylic acid use, thromboprophylaxis strategies varied across studies. Due to substantial variability in event rates, no correlation was identified with thrombotic complications. Discussion: Clinical practice guidelines recommend that patients receive intraoperative unfractionated heparin therapy and either aspirin or no antithrombotic therapy postoperatively. Our findings suggest a substantial risk of thrombosis and thromboembolism and demonstrate substantial variation in thromboprophylaxis practices. Conclusion: Although postoperative thromboprophylaxis seems optimal, it remains controversial whether the long-term aspirin use is most effective. Our findings highlight the lack of a gold-standard thromboprophylaxis strategy and emphasize the need for more consistency.
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Affiliation(s)
- Arnav Agarwal
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Firdouse
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nishaan Brar
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andy Yang
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Panos Lambiris
- University Health Network Library and Information Services, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anthony K. Chan
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Tapas K. Mondal
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
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Faraoni D, Gardella KM, Odegard KC, Emani SM, DiNardo JA. Incidence and Predictors for Postoperative Thrombotic Complications in Children With Surgical and Nonsurgical Heart Disease. Ann Thorac Surg 2016; 102:1360-7. [DOI: 10.1016/j.athoracsur.2016.03.083] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/30/2016] [Accepted: 03/22/2016] [Indexed: 01/19/2023]
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Abstract
This review attempts to answer the common questions faced by a clinician regarding thromboembolism and thromboprophylaxis in patients following Fontan surgery. The review is in an easy to understand question and answer format and discusses the currently available literature on the subject in an attempt to arrive at practical clinically relevant solutions. Patients who have undergone the Fontan operation are at a high risk for thromboembolism. Based on available evidence, there is a strong rationale for thromboprophylaxis. However, it is not clear as to which agent should be administered to prevent thromboembolic events. While the available evidence suggests that antiplatelet agents alone may be as good as oral anticoagulants, there is a need for a large multicenter randomized control trial comparing these two common strategies to deliver a clear verdict.
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Affiliation(s)
- Sangeetha Viswanathan
- Department of Paediatric Cardiology, SRM Institute of Medical Sciences, Chennai, Tamil Nadu, India
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Abstract
OBJECTIVES The objective of this article is to review the particular tendencies as well as specific concerns of bleeding and clotting in children with critical cardiac disease. DATA SOURCE MEDLINE and PubMed. CONCLUSION Children with critical heart disease are at particular risk for bleeding and clotting secondary to intrinsic as well as extrinsic factors. We hope that this review will aid the clinician in managing the unique challenges of bleeding and clotting in this patient population, and serve as a springboard for much needed research in this area.
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Tissue Plasminogen Activator Use in Children: Bleeding Complications and Thrombus Resolution. J Pediatr 2016; 171:67-72.e1-2. [PMID: 26707578 DOI: 10.1016/j.jpeds.2015.11.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/02/2015] [Accepted: 11/06/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review our institutional experience with tissue plasminogen activator (tPA) to determine outcomes related to bleeding complications and thrombus resolution. STUDY DESIGN We performed a retrospective review of all patients who received systemic tPA for thrombolysis. Data points included location of thrombus, initial and maximum tPA dose, and duration of tPA. The primary endpoint was bleeding complication. RESULTS Between 2005 and 2014, 46 patients received systemic tPA for thrombolysis: 17 (37%) were patients with a primary cardiac diagnosis, there were 17 (37%) hematology/oncology patients, and 12 (26%) patients with noncardiac, nonhematology/oncology diagnoses. The indication for tPA was central venous thrombus (n = 23), pulmonary artery thrombus (n = 9), and cardiac or aortic thrombus (n = 14). Bleeding complications occurred in 15 patients (33%). Median initial tPA dose in the bleeding complication group was 0.10 mg/kg/h vs 0.03 mg/kg/h in the group without bleeding complication group (P = .01). Cardiac patients experienced more bleeding complications (P = .01). Multivariate analysis indicated that dose of tPA (P = .01) and diagnostic category (P < .01) were associated with bleeding complication. Complete thrombus resolution occurred in 21 patients, partial in 10 patients, and no resolution in 15 patients. Complete resolution of thrombus was not associated with diagnosis, thrombus location, tPA dose, or duration. CONCLUSIONS Cardiac patients appear to be at highest risk of bleeding complication; bleeding complications were associated with higher doses of tPA, and cardiac patients were the cohort who received the highest doses of tPA. Higher tPA doses are associated with increased risk of bleeding complication but are not associated with successful thrombus resolution.
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Anticoagulation and Thrombolysis. Pediatr Crit Care Med 2016; 17:S77-88. [PMID: 26945332 DOI: 10.1097/pcc.0000000000000623] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Thrombotic complications are increasingly being recognized as a significant cause of morbidity and mortality in pediatric and congenital heart disease. The objective of this article is to review the medications currently available to prevent and treat such complications. DATA SOURCES Online searches were conducted using PubMed. STUDY SELECTION Studies were selected for inclusion based on their scientific merit and applicability to the pediatric cardiac population. DATA EXTRACTION Pertinent information from each selected study or scientific review was extracted for inclusion. DATA SYNTHESIS Four classes of medications were identified as potentially beneficial in this patient group: anticoagulants, antiplatelet agents, thrombolytic agents, and novel oral anticoagulants. Data on each class of medication were synthesized into the follow sections: mechanism of action, pharmacokinetics, dosing, monitoring, reversal, considerations for use, and evidence to support. CONCLUSIONS Anticoagulants, antiplatelet agents, and thrombolytic agents are routinely used successfully in the pediatric patient with heart disease for the prevention and treatment of a wide range of thrombotic complications. Although the novel oral anticoagulants have been approved for a limited number of indications in adults, studies on the safety and efficacy of these agents in children are pending.
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Manlhiot C, Brandão LR, Schwartz SM, Sivarajan VB, Williams S, Collins TH, McCrindle BW. Management and Outcomes of Patients with Occlusive Thrombosis after Pediatric Cardiac Surgery. J Pediatr 2016; 169:146-53. [PMID: 26589345 DOI: 10.1016/j.jpeds.2015.10.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 08/24/2015] [Accepted: 10/13/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate management and outcomes of thrombosis after pediatric cardiac surgery and stratify thrombi according to risk of short- and long-term complications to better guide therapeutic choices. STUDY DESIGN Retrospective review was performed of 513 thrombi (400 occlusive) diagnosed after 213 pediatric cardiac operations. Long-term outcomes over time were assessed with the use of parametric hazard regression models. RESULTS Serious complications and/or high-intensity treatment occurred with 17%-24% of thrombi depending on location, most commonly in thrombi affecting the cardiac and cerebral circulation. Bleeding complications affected 13% of patients; associated factors included thrombolytics (OR 8.7, P < .001), greater daily dose of unfractionated heparin (OR 1.25 per 5 U/kg/day, P = .03), and extracorporeal support (OR 4.5, P = .007). Radiologic thrombus persistence was identified in 30% ± 3% at 12 months; associated factors included extracorporeal support (hazard ratio [HR] 1.9, P = .003), venous (HR 1.7, P = .003), and occlusive thrombi at presentation (HR 1.8, P = .001); greater oxygen saturation before surgery (HR 1.13/10%, P = .05) and thrombi in femoral veins (HR 1.9, P = .001) were associated with increased hazard of resolution. Freedom from postthrombotic syndrome was 83% ± 4% at 6 years, greater number of persistent vessel segment occlusions (HR 1.8/vessel, P = .001) and greater fibrinogen at diagnosis (HR 1.1 per g/L, P = .02) were associated with increased hazard. CONCLUSIONS Thrombosis outcomes after pediatric cardiac surgery remain suboptimal. Given that more intensive treatment would likely increase the risk of bleeding, the focus should be on both thrombosis-prevention strategies, as well as in tailoring therapy according to a thrombosis outcome risk stratification approach.
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Affiliation(s)
- Cedric Manlhiot
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Leonardo R Brandão
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Steven M Schwartz
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - V Ben Sivarajan
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Tanveer H Collins
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
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Nair AB, Oishi P. Venovenous Extracorporeal Life Support in Single-Ventricle Patients with Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:66. [PMID: 27446889 PMCID: PMC4923132 DOI: 10.3389/fped.2016.00066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/01/2016] [Indexed: 02/05/2023] Open
Abstract
There is new and growing experience with venovenous extracorporeal life support (VV ECLS) for neonatal and pediatric patients with single-ventricle physiology and acute respiratory distress syndrome (ARDS). Outcomes in this population have been defined but could be improved; survival rates in single-ventricle patients on VV ECLS for respiratory failure are slightly higher than those in single-ventricle patients on venoarterial ECLS for cardiac failure (48 vs. 32-43%), but are lower than in patients with biventricular anatomy (58-74%). To that end, special consideration is necessary for patients with single-ventricle physiology who require VV ECLS for ARDS. Specifically, ARDS disrupts the balance between pulmonary and systemic blood flow through dynamic alterations in cardiopulmonary mechanics. This complexity impacts how to run the VV ECLS circuit and the transition back to conventional support. Furthermore, these patients have a complicated coagulation profile. Both venous and arterial thrombi carry marked risk in single-ventricle patients due to the vulnerability of the pulmonary, coronary, and cerebral circulations. Finally, single-ventricle palliation requires the preservation of low resistance across the pulmonary circulation, unobstructed venous return, and optimal cardiac performance including valve function. As such, the proper timing as well as the particular conduct of ECLS might differ between this population and patients without single-ventricle physiology. The goal of this review is to summarize the current state of knowledge of VV ECLS in the single-ventricle population in the context of these special considerations.
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Affiliation(s)
- Alison B Nair
- Department of Pediatrics, University of California San Francisco , San Francisco, CA , USA
| | - Peter Oishi
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA; Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
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