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Agarwal S, Foster KL, Anum SJ, Shapiro MC, Han H, Scheurer ME, Airewele G, Sartain SE. Hospital acquired venous thromboembolism in children with sickle cell disease. Pediatr Hematol Oncol 2024; 41:459-469. [PMID: 38836515 DOI: 10.1080/08880018.2024.2362147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 04/20/2024] [Accepted: 05/27/2024] [Indexed: 06/06/2024]
Abstract
Sickle cell disease (SCD) is well recognized as a hypercoagulablestate, however, it remains unclear whether a subgroup of children with SCD at higher risk of venous thromboembolic event (VTE) during hospitalization may benefit from thromboprophylaxis. Our objectives were to describe the clinical characteristics, outcomes and recurrence of hospital acquired VTE in patients with SCD younger than 21 years. This was a single center retrospective study. Data regarding demographics, reason for admission, location of VTE, risk factors like central venous catheter (CVC), intensive care unit (ICU) admission among others were extracted from electronic medical records over a 10-year study period (2011-2021). Recurrence of VTE at 1 and 5 years was assessed. Descriptive statistics were used as indicated. We identified a total of 20 VTE events over the 10-year study period. Six of these events occurred in those younger than 12 years of age. Fourteen (70%) VTE events occurred in the HbSS or HbSβThal0 genotypes compared to 6 (30%) in HbSC. Most common VTE was isolated pulmonary embolism (PE) (n = 10, 50%). VTE were most often associated with acute chest syndrome (ACS) (n = 14, 70%), ICU admissions (n = 10, 50%) and CVC (n = 5/9, 55%). One patient died from the VTE event. One patient with additional underlying risk factors had a recurrent VTE at 13 months. Our study suggests that ICU admission, ACS and presence of CVC increases the risk of VTE in children and young adults with SCD, but larger studies are indicated to validate our findings.
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Affiliation(s)
- Shreya Agarwal
- Department of Pediatrics, Division of Hematology, University of California, San Francisco, California, USA
| | - Kayla L Foster
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Shaniqua J Anum
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Mary C Shapiro
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - HyoJeong Han
- Department of Pediatrics, Division of Hematology-Oncology, Children's National Medical Center, Washington, District Columbia, USA
| | - Michael E Scheurer
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
- Center for Epidemiology and Population Health, Baylor College of Medicine, Houston, Texas, USA
| | - Gladstone Airewele
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Sarah E Sartain
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
- Texas Children's Cancer and Hematology Center, Houston, Texas, USA
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Albisetti M, Tartakovsky I, Halton J, Bomgaars L, Chalmers E, Mitchell LG, Luciani M, Nurmeev I, Gorbatikov K, Miede C, Brueckmann M, Brandão LR. Dabigatran for Treatment and Secondary Prevention of Venous Thromboembolism in Pediatric Congenital Heart Disease. J Am Heart Assoc 2024; 13:e028957. [PMID: 38348778 PMCID: PMC11010117 DOI: 10.1161/jaha.122.028957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/02/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Congenital heart disease (CHD) is common in children and associated with greater risk of thrombotic complications. Management of these complications with standard-of-care treatment is suboptimal for these children. METHODS AND RESULTS The effectiveness and safety of dabigatran were demonstrated in pivotal pediatric studies for the treatment of acute venous thromboembolism (VTE; NCT01895777) and secondary VTE prevention (NCT02197416). We report safety and efficacy outcomes from subgroup analyses of these studies for children with CHD (diagnosed according to local practice) and those without. In NCT01895777, 17/21 (81.0%) and 16/27 (59.3%) patients with CHD (including cyanotic) treated with dabigatran and standard of care, respectively, met the primary end point (complete thrombus resolution, freedom from recurrent VTE, and freedom from VTE-related death; odds ratio [OR], 0.34 [95% CI, 0.08-1.23]). In patients without CHD, 41.0% (n=64) versus 34.9% (n=22) achieved this end point with the respective treatments (OR, 0.77 [95% CI, 0.42-1.41]). Although numerical differences were observed, no heterogeneity in treatment effect of dabigatran on the composite primary end point was detected in patients with and without CHD (interaction P =0.2674). In NCT02197416, recurrent VTE at 12 months occurred in 0/17 patients with CHD versus 3/194 (1.5%) without. No patient with CHD experienced major or clinically relevant nonmajor bleeding events. CONCLUSIONS Data on favorable anticoagulant alternatives for the unmet needs of children with CHD are emerging, and our exploratory results suggest that dabigatran could be an appropriate treatment choice, although challenging sample size limitations in pediatric studies require cautious interpretation of findings. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01895777, NCT02197416.
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Affiliation(s)
- Manuela Albisetti
- Hematology Department University Children's Hospital Zürich Switzerland
| | | | - Jacqueline Halton
- Children's Hospital of Eastern Ontario University of Ottawa Ottawa Ontario Canada
| | - Lisa Bomgaars
- Department of Pediatrics Texas Children's Hospital, Baylor College of Medicine Houston TX USA
| | | | | | - Matteo Luciani
- Pediatric Hematology/Oncology Department Pediatric Hospital Bambino Gesù Rome Italy
| | - Ildar Nurmeev
- Pediatric Hospital, Republic of Tatarstan Kazan Medical University Kazan Russian Federation
| | - Kirill Gorbatikov
- Pediatric Cardiovascular Surgery Regional Hospital #1 Tyumen Region Russian Federation
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbH Ingelheim Germany
- First Department of Medicine Faculty of Medicine Mannheim of the University of Heidelberg Mannheim Germany
| | - Leonardo R Brandão
- The Hospital for Sick Children University of Toronto Toronto Ontario Canada
- Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
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Avila L, Betensky M, Cohen C, Ahuja S, Goldenberg N, Zia A. Clinical care of pediatric patients with or at risk of postthrombotic syndrome: guidance from the ISTH SSC Subcommittee on pediatric and neonatal thrombosis and hemostasis. J Thromb Haemost 2024; 22:365-378. [PMID: 37866514 DOI: 10.1016/j.jtha.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Affiliation(s)
- Laura Avila
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Marisol Betensky
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Thrombosis Program and Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA
| | - Clay Cohen
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas, USA
| | - Sanjay Ahuja
- Division of Pediatric Hematology/Oncology, University Hospitals Cleveland Medical Center, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
| | - Neil Goldenberg
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Thrombosis Program and Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA; Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ayesha Zia
- Departments of Pediatrics, Division of Hematology/Oncology, University of Texas Southwestern Medical Center, Children's Health, Dallas, Texas, USA.
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Haddad RN, Gaudin R, Bonnet D, Malekzadeh-Milani S. Postoperative catheter thrombaspiration to open an occluded right ventricle-to-pulmonary artery conduit in child. Eur J Cardiothorac Surg 2024; 65:ezae055. [PMID: 38366617 DOI: 10.1093/ejcts/ezae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/18/2024] [Accepted: 02/13/2024] [Indexed: 02/18/2024] Open
Abstract
We report on a 6-year-old girl (18 kg/120 cm) who was diagnosed on day 6 postoperative with an occlusive thrombosis of a right ventricle-to-pulmonary artery conduit in the setting of a Ross procedure that was performed for severe native aortic valve insufficiency secondary to late diagnosis of bacterial endocarditis. We applied the Indigo® aspiration system from Penumbra® (Alameda, USA) to mechanically dissolve and remove the thrombus, restore flow, gradually wean from extracorporeal support, and replace the conduit after 4 days. The patient experiences good surgical outcomes at 3 months of follow-up.
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Affiliation(s)
- Raymond N Haddad
- Centre de Référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Regis Gaudin
- Centre de Référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Damien Bonnet
- Centre de Référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris Cité, Paris, France
| | - Sophie Malekzadeh-Milani
- Centre de Référence Malformations Cardiaques Congénitales Complexes-M3C, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
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Sullivan PM, Takao C, Patel ND, Ing FF. Central Vein Recanalization and Rehabilitation in Pediatric Patients: Changing the Paradigm for Chronic Occlusions. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100547. [PMID: 39129793 PMCID: PMC11307983 DOI: 10.1016/j.jscai.2022.100547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/20/2022] [Accepted: 11/08/2022] [Indexed: 08/13/2024]
Abstract
Background Chronic total occlusions in the central venous system limit access and increase morbidity in chronically ill pediatric patients. We report the results of transcatheter recanalization of occluded central veins using angioplasty and stenting. Methods Patients undergoing successful intervention for venous chronic total occlusions at our institution between April 2013 and December 2019 were retrospectively reviewed. Results Sixty-eight occluded central veins in 29 patients underwent recanalization with angioplasty (26 veins) or stenting (42 veins). The indications included limited access for catheterization or central line maintenance (19 patients), limb swelling (4 patients), superior vena cava syndrome (3 patients), and pleural effusion (3 patients). The primary risk factor for occlusion was a history of central venous lines after surgery or extracorporeal membrane oxygenation support in 76% of the patients. The median age and weight at the time of initial intervention were 5.8 years and 14.5 kg, respectively. There were no major complications. Of 10 patients with symptoms of venous congestion, 8 experienced symptomatic improvement. Twenty-two patients (59 veins) underwent 44 recatheterizations during a median follow-up duration of 288 days. Early reintervention was typically planned. The median time to recatheterization was 71 days. Twenty-one veins reoccluded and required repeat recanalization. Reocclusion was associated with persistent upstream collateral vein decompression, as determined using postintervention venography (odds ratio, 14.2; 95% CI, 3.3-62.6; P < .001), which was thought to indicate persistently poor venous inflow. Reinterventions were performed on 40 veins. Fifty-two veins that were followed up (88%) remained patent after the most recent intervention. Conclusions Invasive transcatheter rehabilitation of occluded central veins has the potential to preserve critical access sites and improve the symptoms of venous congestion in pediatric patients. Reinterventions are common for reocclusion, restenosis, and somatic growth.
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Affiliation(s)
| | - Cheryl Takao
- Children’s Hospital Los Angeles Heart Institute, Los Angeles, California
| | - Neil D. Patel
- Children’s Hospital Los Angeles Heart Institute, Los Angeles, California
| | - Frank F. Ing
- Division of Cardiology, University of California, Davis Children’s Hospital, Sacramento, California
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Stephens ET, Nguyen ATH, Jaffray J, Branchford B, Amankwah EK, Goldenberg NA, Faustino EVS, Zakai NA, Stillings A, Krava E, Young G, Fargo JH. Risk of venous thromboembolism in pediatric hospitalized patients undergoing noncardiac surgery: A report from the Children's Hospital-Acquired Thrombosis consortium. Res Pract Thromb Haemost 2022; 6:e12810. [PMID: 36254253 PMCID: PMC9561357 DOI: 10.1002/rth2.12810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/17/2022] [Accepted: 08/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Surgery is a known risk factor for hospital-acquired venous thromboembolism (HA-VTE) in children. Objectives To assess whether the odds of HA-VTE differs across six anatomic sites of noncardiac surgery and to identify risk factors for HA-VTE in these children. Methods This was a multicenter, case-control study. Anatomic sites of surgery and risk factors for HA-VTE were collected on hospitalized pediatric patients who had undergone a single noncardiac surgery and developed HA-VTE (cases), and those who did not develop HA-VTE (controls), via the Children's Hospital-Acquired Thrombosis (CHAT) Registry. Logistic regression estimated the odds ratio (OR) and 95% confidence intervals (CIs) between six anatomic sites of surgery and 16 putative HA-VTE risk factors. Variables with a p value of 0.10 or less in unadjusted analyses were included in adjusted models for further evaluation. The final model used backward selection, with a significance level of 0.05. Results From January 2012 to March 2020, 163 cases (median age, 5.7 years; interquartile range [IQR], 0.3-14.2) and 208 controls (median age of 7.5 years; IQR, 3.7-12.9) met our criteria. There was no statistically significant increased odds of VTE among the types of noncardiac surgery. In the final adjusted model, central venous catheter (CVC; OR, 14.69; 95% CI, 7.06-30.55), intensive care unit (ICU) stay (OR, 5.31; 95% CI, 2.53-11.16), and hospitalization in the month preceding surgery (OR, 2.75; 95% CI, 1.24-6.13) were each independently significant risk factors for HA-VTE. Conclusion In children undergoing noncardiac surgery, placement of CVCs, admission/transfer to the ICU, or hospitalization in the month prior to surgery were positively associated with HA-VTE.
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Affiliation(s)
| | | | - Julie Jaffray
- Children's Hospital Los AngelesLos AngelesCaliforniaUSA
- Keck School of Medicine of the University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Brian Branchford
- Versiti Blood Research InstituteMilwaukeeWisconsinUSA
- Medical College of Wisconsin Division of Hematology and OncologyMilwaukeeWisconsinUSA
| | | | - Neil A. Goldenberg
- All Children's Hospital Johns Hopkins MedicineAll Children's Research InstituteSt. PetersburgFloridaUSA
| | | | - Neil A. Zakai
- MedicineUniversity of Vermont College of MedicineColchesterVermontUSA
| | - Amy Stillings
- Children's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Emily Krava
- Children's Hospital Los AngelesLos AngelesCaliforniaUSA
| | - Guy Young
- Children's Hospital Los AngelesLos AngelesCaliforniaUSA
- USC Keck School of MedicineLos AngelesCaliforniaUSA
| | - John H. Fargo
- Akron Children's HospitalAkronOhioUSA
- Northeast Ohio Medical UniversityRootstownOhioUSA
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7
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Risk Factors of Thrombotic Complications and Antithrombotic Therapy in Paediatric Cardiosurgical Patients. ACTA BIOMEDICA SCIENTIFICA 2021. [DOI: 10.29413/abs.2021-6.2.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The development of cardiosurgical care for paediatric and neonatal patients is undergoing the rapid growth. Complex, multi-stage reconstructive operations and the use of invasive monitoring are associated with high risk of venous and arterial thrombosis.The cardiac surgery patient is inherently unique, since it requires controlled anticoagulation during cardiopulmonary bypass. Moreover, the most cardiovascular pediatric patients require antithrombotic measures over the perioperative period. In addition to medication support with the use of various groups of antithrombotic agents, vascular access management is justified in order to minimize the risk of thromboembolic complications, which can affect both the functional status, and common and inter-stage mortality.The purpose of this review was to systematize the available data on risk factors contributing to the development of thrombotic complications in patients with congenital heart disease.An information search was carried out using Internet resources (PubMed, Web of Science, eLibrary.ru); literature sources for period 2015–2020 were analysed. As a result of the analysis of the literature data age-dependent features of the haemostatic system, and associated with the defect pathophysiology, and undergone reconstructive interventions were described. The issues of pathophysiology of univentricular heart defects and risk factors associated with thrombosis were also covered.Moreover, aspects of intraoperative anti-thrombotic support are discussed, as well as measures to prevent thromboembolic complications in this population.Coordinated actions of haematologists, cardiologists, anaesthesiologists, intensivists, and cardiac surgeons will allow achieving a fine balance between risks of bleeding and thrombosis in the population of paediatric patients undergoing cardiovascular surgery.
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García-Boyano M, Caballero-Caballero JM, García Fernández de Villalta M, Gutiérrez Alvariño M, Blanco Bañares MJ, Climent Alcalá FJ. Risk factors determining central venous access device-associated deep vein thrombosis resolution in children: a retrospective study. Eur J Pediatr 2021; 180:1907-1914. [PMID: 33555427 DOI: 10.1007/s00431-021-03985-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 11/25/2022]
Abstract
The risk factors associated with the probability of central venous access device (CVAD)-associated deep vein thrombosis (DVT) resolution have been hardly evaluated in children. Current guidelines suggest anticoagulation for a maximum of 3 months in patients with provoked DVT if the provoking factor is resolved. To know if the thrombus will resolve after anticoagulant therapy will help to choose whether to initiate and/or continue this treatment or not. We did a retrospective study of 85 pediatric patients (45 girls, 40 boys) with CVAD-associated DVT to examine the risk factors associated with lack of thrombus resolution in the first 6 months after diagnosis. Sixty-two children had their thrombosis resolved after a median of 50 days (p25-p75 25-97) since diagnosis. In multivariate analysis, variables significantly associated with no resolution were total occlusion (OR 12.50, 95% CI 2.99-52.14, p=.001), location in upper extremity, head, and neck veins (OR 17.70, 95% CI 1.64-191.43, p=.018); collateral circulation in the first 45 days after diagnosis (OR 33.55, 95% CI 2.42-464.71, p=.009); and having between 0 and 3 prothrombotic risk factors at diagnosis (OR 6.20, 95% CI 1.21-31.75, p=.029).Conclusion: CVAD-associated DVT resolution in children in the first 6 months since diagnosis was significantly lower if the thrombosis was occlusive, if it was located in the upper extremity, head, and neck veins; if collateral circulation was seen on ultrasound in the first 45 days; and/or when the patient showed less prothrombotic risk factors at diagnosis. What is Known: • The risk factors associated with central venous access device-associated deep vein thrombosis resolution have been hardly evaluated in children. • Current guidelines suggest anticoagulation for a maximum of 3 months in provoked vein thrombosis if the provoking factor is resolved. What is New: • Thrombus resolution was lower if it was occlusive, located in the upper extremity veins, if collateral circulation was seen, and with less prothrombotic risk factors at diagnosis. • To know if the thrombus will resolve after anticoagulation will help to choose whether to initiate and/or continue it or not.
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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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Engel ER, Nguyen ATH, Amankwah EK, Albisetti M, Brandão LR, Goldenberg NA, Betensky M. Predictors of postthrombotic syndrome in pediatric thrombosis: A systematic review and meta-analysis of the literature. J Thromb Haemost 2020; 18:2601-2612. [PMID: 32614496 DOI: 10.1111/jth.14984] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Postthrombotic syndrome (PTS) is a significant complication of pediatric deep venous thrombosis (DVT). There is a gap in the understanding of the risk factors associated with the development of pediatric PTS preventing the early identification of those patients at greatest risk, and the development of risk-stratified interventions. OBJECTIVES To conduct a systematic review and meta-analysis of the literature on prognostic factors for PTS development in pediatric patients. METHODS A systematic search of MEDLINE, EMBASE, and the Cochrane Library from 1960 to December 2018 was performed. Eligible studies reported at least one prognostic factor for PTS development in patients < 21 years of age with a radiographically confirmed DVT. To be included in the meta-analysis, prognostic factors had to be reported in at least three published studies. RESULTS AND CONCLUSIONS Twelve studies (n = 1160 patients) met criteria for inclusion. Ninety-three percent of patients with an extremity DVT (n = 1076) were assessed for PTS. PTS developed in 40% (n = 434) of these patients. Central venous catheter-associated DVT (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.08-2.98), complete veno-occlusion (OR, 1.89; 95% CI, 1.04-3.46), and incomplete DVT resolution (OR, 2.07; 95% CI, 1.4-3.07) were identified as candidate prognostic factors for pediatric PTS. These findings should be interpreted in the context of the heterogeneity of the included studies and the limitations of current pediatric PTS assessment tools. Further, the predictive value of these prognostic factors will need to be validated in future collaborative prospective multicenter studies that maximize the homogeneity of pediatric DVT patients.
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Affiliation(s)
- Elissa R Engel
- Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Anh Thy H Nguyen
- Epidemiology and Biostatistics Unit, Johns Hopkins All Children's Health Informatics, St. Petersburg, FL, USA
| | - Ernest K Amankwah
- Epidemiology and Biostatistics Unit, Johns Hopkins All Children's Health Informatics, St. Petersburg, FL, USA
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, FL, USA
| | - Manuela Albisetti
- Hematology Department, University Children's Hospital, Zürich, Switzerland
| | - Leonardo R Brandão
- Division of Pediatric Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Neil A Goldenberg
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, FL, USA
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marisol Betensky
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins All Children's Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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11
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Jones S, Monagle P, Newall F. Do asymptomatic clots in children matter? Thromb Res 2020; 189:24-34. [DOI: 10.1016/j.thromres.2020.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 01/28/2023]
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12
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High-dose heparin is associated with higher bleeding and thrombosis rates in pediatric patients following cardiac surgery. J Thorac Cardiovasc Surg 2019; 158:1199-1206. [DOI: 10.1016/j.jtcvs.2019.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/04/2019] [Accepted: 06/08/2019] [Indexed: 12/16/2022]
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Cholette JM, Faraoni D, Goobie SM, Ferraris V, Hassan N. Patient Blood Management in Pediatric Cardiac Surgery: A Review. Anesth Analg 2019; 127:1002-1016. [PMID: 28991109 DOI: 10.1213/ane.0000000000002504] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Affiliation(s)
- Jill M Cholette
- From the Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts.,Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Ferraris
- Department of Surgery, University of Kentucky Chandler Medical Center & Lexington Veterans Affairs Medical Center, Lexington, Kentucky
| | - Nabil Hassan
- Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois
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Steen EH, Lasa JJ, Nguyen TC, Keswani SG, Checchia PA, Anders MM. Central Venous Catheter-Related Deep Vein Thrombosis in the Pediatric Cardiac Intensive Care Unit. J Surg Res 2019; 241:149-159. [PMID: 31026793 DOI: 10.1016/j.jss.2019.03.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/08/2019] [Accepted: 03/22/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Central venous catheter (CVC) use is common in the management of critically ill children, especially those with congenital heart disease. CVCs are known to augment the risk of deep vein thrombosis (DVT), but data on CVC-associated DVTs in the pediatric cardiac intensive care unit (CICU) are limited. In this study, we aim to identify the incidence of and risk factors for CVC-related DVT in this high-risk population, as its complications are highly morbid. MATERIALS AND METHODS The PC4 database and a radiologic imaging database were retrospectively reviewed for the demographics and outcomes of patients admitted to the Texas Children's Hospital CICU requiring CVC placement, as well as the incidence of DVT and its complications. RESULTS Between January 2017 and December 2017, 1215 central lines were placed over 851 admissions. DVT was diagnosed in 8% of admissions with a CVC, 29% of which demonstrated thrombus in the inferior vena cava. The risk factors significantly associated with DVT included the presence of >1 line, higher total line hours, longer intubation times, and extended CICU stay. A diagnosis of low cardiac output syndrome, sepsis, central line-associated bloodstream infection, and cardiac catheterization were also significant risk factors. Interestingly, cardiac surgery with cardiopulmonary bypass appeared to be protective of clot development. DVT was a highly significant risk factor for mortality in these patients. CONCLUSIONS CVC-related DVTs in critically ill children with congenital heart disease are associated with higher risks of morbidity and mortality, highlighting the need for well-designed studies to determine the best preventative and treatment strategies and to establish guidelines for appropriate monitoring and follow-up of these patients.
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Affiliation(s)
- Emily H Steen
- Department of Surgery, Baylor College of Medicine, Houston, Texas; Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Javier J Lasa
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Trung C Nguyen
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Sundeep G Keswani
- Laboratory for Regenerative Tissue Repair, Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Paul A Checchia
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Marc M Anders
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
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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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Albisetti M, Biss B, Bomgaars L, Brandão LR, Brueckmann M, Chalmers E, Gropper S, Harper R, Huang F, Luciani M, Manastirski I, Mitchell LG, Tartakovsky I, Wang B, Halton JML. Design and rationale for the DIVERSITY study: An open-label, randomized study of dabigatran etexilate for pediatric venous thromboembolism. Res Pract Thromb Haemost 2018; 2:347-356. [PMID: 30046738 PMCID: PMC6055566 DOI: 10.1002/rth2.12086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 01/26/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The current standard of care (SOC) for pediatric venous thromboembolism (VTE) comprises unfractionated heparin (UFH), or low-molecular-weight heparin (LMWH) followed by LMWH or vitamin K antagonists, all of which have limitations. Dabigatran etexilate (DE) has demonstrated efficacy and safety for adult VTE and has the potential to overcome some of the limitations of the current SOC. Pediatric trials are needed to establish dosing in children and to confirm that results obtained in adults are applicable in the pediatric setting. OBJECTIVES To describe the design and rationale of a planned phase IIb/III trial that will evaluate a proposed dosing algorithm for DE and assess the safety and efficacy of DE versus SOC for pediatric VTE treatment. PATIENTS/METHODS An open-label, randomized, parallel-group noninferiority study will be conducted in approximately 180 patients aged 0 to <18 years with VTE, who have received initial UFH or LMWH treatment and who are expected to require ≥3 months of anticoagulation therapy. Patients will receive DE or SOC for 3 months. DE will be administered twice daily as capsules, pellets, or an oral liquid formulation according to patient age. Initial doses will be calculated using a proposed dosing algorithm. RESULTS There will be two coprimary endpoints: a composite efficacy endpoint comprising the proportion of patients with complete thrombus resolution, freedom from recurrent VTE and VTE-related mortality, and a safety endpoint: freedom from major bleeding events. CONCLUSION Findings will provide valuable information regarding the efficacy and safety of DE for the treatment of pediatric VTE. ClinicalTrials.gov registration number: NCT01895777.
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Affiliation(s)
- Manuela Albisetti
- Hematology DepartmentUniversity Children's HospitalZürichSwitzerland
| | - Branislav Biss
- Department of Clinical DevelopmentBoehringer Ingelheim RCV GmbH & Co. KGViennaAustria
| | - Lisa Bomgaars
- Department for PediatricsBaylor College of MedicineHoustonTXUSA
| | - Leonardo R. Brandão
- Department of PediatricsDivision of Hematology/OncologyUniversity of TorontoThe Hospital for Sick ChildrenTorontoONCanada
| | - Martina Brueckmann
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH& Co. KGIngelheimGermany
- Faculty of Medicine MannheimUniversity of HeidelbergMannheimGermany
| | | | - Savion Gropper
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH& Co. KGIngelheimGermany
| | - Ruth Harper
- Boehringer Ingelheim LtdBracknellBerkshireUK
| | - Fenglei Huang
- Translational Medicine and Clinical PharmacologyBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
| | - Matteo Luciani
- OncoHematology DepartmentBambino Gesù Children's HospitalRomeItaly
| | - Ivan Manastirski
- Department of Clinical DevelopmentBoehringer Ingelheim RCV GmbH & Co. KGViennaAustria
| | | | - Igor Tartakovsky
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH& Co. KGIngelheimGermany
| | - Bushi Wang
- Biostatistics and Data SciencesBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
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Efficacy and safety of recombinant tissue plasminogen activator for venous thrombosis after paediatric heart surgery. Cardiol Young 2018; 28:214-221. [PMID: 28889818 DOI: 10.1017/s104795111700172x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Reports in the literature of treatment with recombinant tissue plasminogen activator following cardiac surgery are limited. We reviewed our experience to provide a case series of the therapeutic use of tissue plasminogen activator for the treatment of venous thrombosis in children after cardiac surgery. The data describe the morbidity, mortality, and clinical outcomes of tissue plasminogen activator administration for treatment of venous thrombosis in children following cardiac surgery. DESIGN The study was designed as a retrospective case series. SETTING The study was carried out in a 25-bed cardiac intensive care unit in an academic, free-standing paediatric hospital. Patients All children who received tissue plasminogen activator for venous thrombosis within 60 days of cardiac surgery, a total of 13 patients, were included. Interventions Data was collected, collated, and analysed as a part of the interventions of this study. Measurements and main results Patients treated with tissue plasminogen activator were principally young infants (median 0.2, IQR 0.07-0.58 years) who had recently (22, IQR 12.5-27.3 days) undergone cardiac surgery. Hospital mortality was high in this patient group (38%), but there was no mortality attributable to tissue plasminogen activator administration, occurring within <72 hours. There was one major haemorrhagic complication that may be attributable to tissue plasminogen activator. Complete or partial resolution of venous thrombosis was confirmed using imaging in 10 of 13 patients (77%), and tissue plasminogen activator administration was associated with resolution of chylous drainage, with no drainage through chest tubes, at 10 days after tissue plasminogen activator treatment in seven of nine patients who had upper-compartment venous thrombosis-associated chylothorax. CONCLUSIONS On the basis of our experience with administration of tissue plasminogen activator in children after cardiac surgery, tissue plasminogen activator is both safe and effective for resolution of venous thrombosis in this high-risk population.
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Vosicka K, Qureshi MI, Shapiro SE, Lim CS, Davies AH. Post thrombotic syndrome following deep vein thrombosis in paediatric patients. Phlebology 2017; 33:185-194. [PMID: 28121229 DOI: 10.1177/0268355516686597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Although well characterised in adults, less is known about post-thrombotic syndrome in children. In this review, current knowledge regarding paediatric post-thrombotic syndrome is summarised, with particular emphasis on pathophysiology, aetiology, diagnosis and management. Methods A Medline literature review was performed using search terms 'post thrombotic syndrome', 'post phlebitic syndrome', paediatric and children. Relevant articles were identified and included for summation analysis. Results The incident of paediatric venous thromboembolism is rising. Deep vein thrombosis can cause venous hypertension through a combination of venous reflux, venous obstruction and impairment of the calf muscle pump, leading to development of post-thrombotic syndrome. In children, this is more likely to occur if deep vein thrombosis diagnosis and treatment are delayed, if a higher number of vessels are involved, and if factors such as D-dimer are elevated at diagnosis and throughout treatment. Post-thrombotic syndrome occurs in about 26% of paediatric deep vein thrombosis, though the results of individual studies vary widely. A number of tools exist to diagnose paediatric post-thrombotic syndrome, including the modified Villalta scale and Manco-Johnson instrument. Once post-thrombotic syndrome develops, the mainstay of treatment remains supportive, with little evidence of benefit from pharmacological measures. Conclusion Surgical or interventional treatment is not advised except in exceptional cirumstances, due to variable prognosis of PTS in paediatric populations with rising incidence of paediatric venous thromboembolism, it follows that the prevalence of post-thrombotic syndrome in children may also increase. Evidence-based venous thromboembolism prevention strategies need to be implemented for prevention of deep vein thrombosis, but when it does occur, deep vein thrombosis requires prompt and effective treatment to prevent post-thrombotic syndrome. Optimum treatment strategies for post-thrombotic syndrome require further investigation.
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Affiliation(s)
- Klara Vosicka
- 1 Department of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Mahim I Qureshi
- 1 Department of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Susan E Shapiro
- 2 Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford Comprehensive Biomedical Resource Centre, Oxford, UK
| | - Chung S Lim
- 1 Department of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
| | - Alun H Davies
- 1 Department of Vascular Surgery, Imperial College London, Charing Cross Hospital, London, UK
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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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