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Adrizain R, Rayani P, Hapsari P, Indriasari V, Desiana K, Alam A, Setiabudi D, Chairulfatah A. A rare case study of pyoderma gangrenosum with dilated cardiomyopathy and multiple cerebral infarct in malnourished children. Heliyon 2024; 10:e30838. [PMID: 38778983 PMCID: PMC11109809 DOI: 10.1016/j.heliyon.2024.e30838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 12/26/2022] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
Pyoderma gangrenosum (PG) is an extremely rare case of sterile necrotic ulcerative disease associated with malnutrition as a predisposition factor. It is unclear, though, whether dilated cardiomyopathy, which affects blood flow and results in stenosis in the arteries, could play a role as an etiology. In this study, a case of pyoderma gangrenosum in a 10-year-old boy complicated by dilated cardiomyopathy, a previous history of cerebrovascular disease, and a malnourished condition were reported. The patient was reported to have exudative necrotic lesions in both legs. Lesions began as small, multiple, itchy lesions on both legs, which later became blisters and scuffed, and progressed into painful, peeled-off lesions with pus, bleeding, redness around lesions, and maggots within a month. A high fever was an accompanying symptom. The multidisciplinary team was involved to provide a comprehensive treatment for this patient. Antibiotics and necrotomy debridement were performed several times. Anticoagulant treatment was indicated as the coagulation markers were increased and echocardiography suggested thrombus in the left ventricle. The underlying condition that increases the risk of pyoderma gangrenosum should be corrected. The patient was discharged after a clinical improvement, although the continuation of outpatient monitoring was required. Our report suggests that a chronic condition of dilated cardiomyopathy that affects normal blood flow leads to malnutrition, the formation of thrombus, and stenosis of a peripheral artery, all of which contributed to pyoderma gangrenosum. Therefore, early surgical treatment, antibiotic administration, and anticoagulant treatment were recommended.
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Affiliation(s)
- Riyadi Adrizain
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia
| | - Putria Rayani
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia
| | - Putie Hapsari
- Vascular and Endovascular Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia
| | - Vita Indriasari
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia
| | - Karina Desiana
- Pediatric Resident, Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia
| | - Anggraini Alam
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia
| | - Djatnika Setiabudi
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia
| | - Alex Chairulfatah
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia
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Hirono K, Takarada S, Miyao N, Nakaoka H, Ibuki K, Ozawa S, Origasa H, Ichida F. Thromboembolic events in left ventricular non-compaction: comparison between children and adults - a systematic review and meta-analysis. Open Heart 2022; 9:openhrt-2021-001908. [PMID: 35613828 PMCID: PMC9134208 DOI: 10.1136/openhrt-2021-001908] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 05/09/2022] [Indexed: 01/02/2023] Open
Abstract
Objective Left ventricular non-compaction (LVNC) is morphologically characterised by excessive trabeculations and deep recesses in the ventricular wall. The risk of thromboembolic disease in the paediatric patients with LVNC has not been clearly established. We conducted this systematic review to evaluate the prevalence and incidence of thromboembolism (TE) in paediatric and adult patients with LVNC and searched for risk factors for TE to explore management strategies. Methods The primary outcome was the prevalence and incidence of TE in the patients with LVNC. The secondary outcome was the TE and mortality and heart transplantation rates between paediatric and adult patients with LVNC. We searched for studies published in MEDLINE, Embase and Cochrane Central Register of Controlled Trials between January 1950 and December 2020. A systematic search of keywords related to LVNC, anticoagulants/antiplatelets and TE was conducted. Studies that did not present original research, non-human studies, duplicated studies were excluded. Results Fifty-seven studies met the inclusion criteria. A total of 726 paediatric and 3862 adult patients were included. The mean prevalence rates of TE in the paediatric and adult patients with LVNC were 2.6% and 6.2% (I2=0%; p<0.450 and I2=73.7%; p<0.001), respectively. The mean annual incidences of TE in paediatric and adult patients with LVNC were 1.4% and 2.9% (I2=99.4%; p<0.001 and I2=99.5%; p<0.001), respectively. Multivariate logistic regression analysis showed that TE was associated with left ventricular ejection fraction in <40% of paediatric patients (OR, 9.47; 95% CI, 1.35 to 188.23; p=0.0225). Conclusions The prevalence and incidence rates in paediatric patients were lower than those in adult patients. TE was associated with a reduced systolic function in paediatric patients with LVNC.
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Affiliation(s)
- Keiichi Hirono
- Department of Pediatrics and Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - Shinya Takarada
- Department of Pediatrics and Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - Nariaki Miyao
- Department of Pediatrics and Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - Hideyuki Nakaoka
- Department of Pediatrics and Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - Keijiro Ibuki
- Department of Pediatrics and Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - Sayaka Ozawa
- Department of Pediatrics and Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - Hideki Origasa
- Department of Pediatrics and Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare, Otawara, Japan
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Odaman Al I, Oymak Y, Erdem M, Tahta N, Okur Acar S, Mese T, Yilmazer MM, Gözmen S, Zihni C, Calkavur S, Karapinar TH. Assessment of clinical characteristics and treatment outcomes of pediatric patients with intracardiac thrombosis: a single-center experience. Blood Coagul Fibrinolysis 2022; 33:34-41. [PMID: 34799505 DOI: 10.1097/mbc.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The prevalence of intracardiac thrombus (ICT) is gradually increasing, though it is rare among children. Data related to the occurrence of ICT among children are limited, and treatment recommendations have been made utilizing adult guidelines. The primary objective of this study is to determine associated factors, management, and outcomes of intracardiac thrombosis in children. Between January 2013 and January 2020, patients diagnosed with ICT at the Pediatric Hematology-Oncology and Pediatric Cardiology departments in our hospital were included in the study. Demographic characteristics, clinical and laboratory findings, treatment protocols, and outcomes were analyzed retrospectively. The median age at diagnosis was 10.5 months (2 days to 14.5 years), and the median follow-up period was 6.5 months (1 month to 3.1 years). The most common primary diagnoses of the patients, in order of frequency, were heart disease (n: 8), metabolic disease (n: 3), prematurity and RDS (n: 3), burns (n: 2), pneumonia (n: 2), and asphyxia (n: 2). CVC was present in 19/23 of the patients. The reasons for CVC insertion were the need for plasmapheresis in one patient with a diagnosis of HUS and the need for well tolerated vascular access because of long-term hospitalization in others. LMWH was administered to all patients as first-line therapy. Complete response was achieved in 19 (79%) of 24 patients and 4 patients (16.6%) were unresponsive to medical treatment. It was found out that the thrombus location, type, sepsis, and hemoculture positivity, as well as the presence of CVC, had no impact on treatment response (chi-square P = 0.16, 0.12, 0.3, 0.49, 0.56). Moreover, no correlation was determined between thrombus size and treatment response (Mann Whitney U test P = 0.47). The mortality rate was determined to be 12.5% (3/24). Spontaneous occurrence of ICT is rare in childhood, without any underlying primary disease or associated factor. The presence of CVC, sepsis, and heart disease are factors associated with ICT. The success rate is increased with medical treatment. There was no significant difference in treatment response between the newborn and 1 month to 18-year-old patient group. It has been demonstrated that thrombus size, type, localization; sepsis, and hemoculture positivity had no impact on the treatment response.
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Affiliation(s)
| | - Yeşim Oymak
- Department of Pediatric Hematology and Oncology
| | - Melek Erdem
- Department of Pediatric Hematology and Oncology
| | | | | | | | | | | | | | - Sebnem Calkavur
- Department of Neonatology, Dr Behçet Uz Traning and Research Hospital, İzmir, Turkey
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ENNOBLE-ATE trial: an open-label, randomised, multi-centre, observational study of edoxaban for children with cardiac diseases at risk of thromboembolism. Cardiol Young 2021; 31:1213-1219. [PMID: 34344494 DOI: 10.1017/s1047951121002523] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Children with cardiac diseases suffer from significant morbidity and mortality secondary to thromboembolic complications. Anticoagulant agents currently used for thromboprophylaxis have many limitations, including subcutaneous administration (low molecular weight heparins) and requirement for frequent monitoring via venipuncture (vitamin K antagonists). Edoxaban is an oral direct factor Xa inhibitor without need of monitoring. In the treatment of venous thromboembolism in adults, edoxaban has shown to be effective and safe.This manuscript summarises the rationale and design of a phase 3, open-label, randomised controlled trial to evaluate and compare the safety and efficacy of edoxaban against standard of care (namely, vitamin K antagonist and low molecular weight heparin) in children with cardiac diseases.A goal of 150 children with cardiac diseases at risk of thromboembolic complications who need primary or secondary anticoagulant prophylaxis will be recruited. Eligible children between 6 months and <18 years of age will be randomised in a ratio of 2 to 1 for edoxaban versus standard of care. Randomisation will be stratified based on underlying cardiac disease and concomitant use of aspirin for patients other than Kawasaki disease. The primary outcome will be safety, comprised of major and clinically relevant non-major bleeding in first 3 months of treatment. Bleeding beyond 3 months, symptomatic and asymptomatic thromboembolic events, and pharmacokinetic and pharmacodynamic parameters will be evaluated as secondary outcomes.Randomised controlled anticoagulation trials are challenging in children. This study will evaluate a potentially valuable alternative of oral anticoagulant prophylactic use in children with cardiac diseases.
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Bendahmash A, Almanie S, Alwadai A. Intracardiac thrombus formation and thromboembolic events in children with cardiomyopathies: A single-center case series. Clin Case Rep 2020; 8:1693-1697. [PMID: 32983479 PMCID: PMC7495816 DOI: 10.1002/ccr3.2972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/25/2020] [Accepted: 05/05/2020] [Indexed: 11/12/2022] Open
Abstract
Intracardiac thrombosis and distant thromboembolic events are rare complications of patients diagnosed with any type of cardiomyopathies. The low prevalence of this entity makes it challenging and unfortunate for the patients and their families. This review aims to add to the current limited available data describing similar clinical entities.
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Affiliation(s)
- Abdulrahman Bendahmash
- Department of pediatric cardiology, Heart CenterKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
| | - Saeed Almanie
- Department of pediatric cardiology, Heart CenterKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
| | - Abdullah Alwadai
- Department of pediatric cardiology, Heart CenterKing Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
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6
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Feingold B, Mahle WT, Auerbach S, Clemens P, Domenighetti AA, Jefferies JL, Judge DP, Lal AK, Markham LW, Parks WJ, Tsuda T, Wang PJ, Yoo SJ. Management of Cardiac Involvement Associated With Neuromuscular Diseases: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e200-e231. [DOI: 10.1161/cir.0000000000000526] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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Abstract
Due to progressive advances in surgical techniques, immunosuppressive therapies, and supportive care, outcomes from both solid organ transplantation and hematopoietic stem cell transplantation continue to improve. Thrombosis remains a challenging management issue in this context, with implications for both graft survival and long-term quality of life. Unfortunately, there remains a general paucity of pediatric-specific data regarding thrombosis incidence, risk stratification, and the safety or efficacy of preventative strategies with which to guide treatment algorithms. This review summarizes the available evidence and rationale underlying the spectrum of current practices aimed at preventing thrombosis in the transplant recipient, with a particular focus on risk factors, pathophysiology, and described antithrombotic regimens.
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Affiliation(s)
- J D Robertson
- Haematology Service, Division of Medicine, Lady Cilento Children's Hospital, Brisbane, Qld, Australia
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Gulsen S. Successful Heart Transplantation Following Decompressive Craniectomy in a Patient with Restrictive Cardiomyopathy and Extensive Stroke in the Region of the Right Middle Cerebral Artery. Open Access Maced J Med Sci 2014. [DOI: 10.3889/oamjms.2014.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Restrictive cardiomyopathy (RCM) in children is associated with a greater risk of embolic stroke than are other congenital heart diseases. After diagnosis, 50% of children with RCM die within 2 years without heart transplantation. As such, all RCM patients are placed on the heart transplantation list and must wait for an appropriate heart for transplantation. Every type of embolic stroke can occur while waiting for a donor heart; therefore, the cardiovascular team must initiate antithrombotic therapy at time RCM is diagnosed. Some pediatric RCM patients experience embolic stroke (50% are the cerebral type) despite antithrombotic therapy, including acetylsalicylic acid, warfarin, and heparine. Neurosurgeons working in hospitals that perform organ transplantation expect to see RCM cases with restrictive large cerebral infarct. We think that decompressive craniectomy should be performed as soon as possible after determining the clinical condition of any patient with RCM and a large right middle cerebral artery (MCA) infarct.
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10
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Anticoagulation of cardiomyopathy in children. Thromb Res 2014; 134:255-8. [DOI: 10.1016/j.thromres.2014.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 04/08/2014] [Accepted: 05/06/2014] [Indexed: 11/20/2022]
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Freud LR, Koenig PR, Russell HM, Patel A. Left ventricular thrombus formation after repair of anomalous left coronary artery from the pulmonary artery. World J Pediatr Congenit Heart Surg 2014; 5:342-4. [PMID: 24668990 DOI: 10.1177/2150135113510185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although thrombus formation following myocardial infarction in adults is well known, intracardiac thrombosis in children is uncommon. We report the case of a large left ventricular thrombus in an infant with ischemic cardiomyopathy secondary to anomalous origin of the left coronary artery from the pulmonary artery. Given its mobility and protrusion across the aortic valve, the patient underwent urgent thrombus removal through a transaortic approach. There were no embolic or neurologic complications. This case highlights that thrombectomy may be performed safely and successfully in critically ill pediatric patients.
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Affiliation(s)
- Lindsay R Freud
- Department of Pediatrics, Division of Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Ponniah U, Overholt E. Severe reversible dilated cardiomyopathy associated with a large left ventricular thrombus in a young child with middle aortic syndrome. IMAGES IN PAEDIATRIC CARDIOLOGY 2014; 16:7-13. [PMID: 26236372 PMCID: PMC4521336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report a case of a seven-year girl who presented with severe dilated cardiomyopathy (DCM) associated with a large thrombus in the left ventricle (LV). She had a long segment stenosis of the lower thoracic descending aorta, possibly due to non-specific aortitis and underwent successful stent angioplasty. The LV thrombus resolved after heparin without sequelae.
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Affiliation(s)
- U Ponniah
- Department of Pediatrics, Division of Pediatric Cardiology, Oklahoma University Health Sciences Center.,Umakumaran Ponniah: M.D. Division of Pediatric Cardiology, NP2350, Suite 850 Everett, Tower, Oklahoma City, Oklahoma-73003(405) 271-4411(405) 271-5055
| | - E Overholt
- Department of Pediatrics, Division of Pediatric Cardiology, Oklahoma University Health Sciences Center
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Giglia TM, Massicotte MP, Tweddell JS, Barst RJ, Bauman M, Erickson CC, Feltes TF, Foster E, Hinoki K, Ichord RN, Kreutzer J, McCrindle BW, Newburger JW, Tabbutt S, Todd JL, Webb CL. Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease. Circulation 2013; 128:2622-703. [DOI: 10.1161/01.cir.0000436140.77832.7a] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Dechant MJ, Siepe M, Stiller B, Grohmann J. Surgical thrombectomy of two left ventricular thrombi in a child with acute myocarditis. Pediatrics 2013; 131:e1303-7. [PMID: 23460683 DOI: 10.1542/peds.2012-1185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Myocarditis is a potentially life-threatening disease. Although ventricular thrombus formation in myocarditis is rare, it carries the risk of serious complications. We report on a 10-year-old previously healthy girl presenting with 2 large left ventricular thrombi in acute lymphocytic acute myocarditis. No coagulation disorder was found. Her clinical course and mobile thrombi characteristics prompted us to carry out an urgent surgical thrombectomy rather than primary anticoagulation therapy. The patient has recovered well without clinical signs of thromboembolism.
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Affiliation(s)
- Markus-Johann Dechant
- Department of Congenital Heart Disease and Pediatric Cardiology, Heart Center, Freiburg University, Mathildenstrasse 1, 79106 Freiburg, Germany.
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Clinically significant thrombosis in pediatric heart transplant recipients during their waiting period. Pediatr Cardiol 2013; 34:334-40. [PMID: 22878808 DOI: 10.1007/s00246-012-0451-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 07/10/2012] [Indexed: 10/28/2022]
Abstract
Thrombosis is a serious complication of heart failure for which available data on pediatric patients are scarce. This report describes the frequency and risk factors of clinically significant thrombosis (CST) for children awaiting transplantation. A retrospective study analyzed a cohort of heart recipients with CST, defined by the presence of intracardiac thrombus by imaging, explant pathology, or symptomatic clinical event. Among the 123 patients in the study, 56 % were male and 44 % had congenital heart disease. The median age at transplantation was 6.6 years (range 0-30 years). The prevalence of CST was 12.2 % (15/123), and its incidence was 32.7 events per 100 patient-years. The thromboembolic event frequencies were 2.4 % and 6.5 events per 100 patient-years. The median interval from listing to CST was eight days (range 0-113 days). The median wait-list duration was 31 days (range 8-169 days) in the CST group versus 51 days (range 0-1,743 days) in the non-CST group. Inpatient status was statistically associated with CST (14 of 15 subjects were inpatients, p = 0.03). Inotropic support (p = 0.068) and United Network for Organ Sharing (UNOS) status 1 (p = 0.061) approached significance. Clinically significant thrombosis was common in this end-stage heart failure population. Until randomized clinical trial data are available, it may be reasonable to consider anticoagulation for children admitted with decompensated heart failure and listed as UNOS status 1.
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Lee GH, Kim YH. Cerebral Ischemic Stroke in an Infant with Acute Myocarditis - A Case Report -. Korean J Crit Care Med 2013. [DOI: 10.4266/kjccm.2013.28.2.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ga Hyun Lee
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Yeo Hyang Kim
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
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Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S-e801S. [PMID: 22315277 DOI: 10.1378/chest.11-2308] [Citation(s) in RCA: 950] [Impact Index Per Article: 79.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children. METHODS The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C). CONCLUSIONS The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.
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Affiliation(s)
- Paul Monagle
- Haematology Department, The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Neil A Goldenberg
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO
| | - Rebecca N Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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Abstract
PURPOSE OF REVIEW American and European guidelines for treatment of adult heart failure have been recently revised. This review will reconcile those guidelines to recent studies and experience in the treatment of pediatric dilated cardiomyopathy. RECENT FINDINGS Therapy for pediatric dilated cardiomyopathy includes establishing a diagnosis for diagnostic-specific therapies as well as preventive strategies for anthracycline toxicity and muscular dystrophy. Pediatric studies demonstrate safety and efficacy for use of angiotensin-converting enzyme inhibition and beta-blockers in dilated cardiomyopathy. Cardiac resynchronization and mitral annuloplasty represent potential nonpharmacologic therapies. Implantable defibrillator therapy may be of less import in children as compared with adults. Ventricular assist devices (VADs) are now available for all ages, which can improve survival and potentially can lead to recovery. SUMMARY The robust development of new therapies for adult heart failure has been successfully applied to children with dilated cardiomyopathy. Therapies for severe, intractable heart failure have been more widely utilized than therapies for mild-to-moderate heart failure.
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Choi SH, Jeong SI, Yang JH, Kang IS, Jun TG, Lee HJ, Huh J. A single-center experience with intracardiac thrombosis in children with dilated cardiomyopathy. Pediatr Cardiol 2010; 31:264-9. [PMID: 19937007 DOI: 10.1007/s00246-009-9602-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Accepted: 11/06/2009] [Indexed: 11/24/2022]
Abstract
Intracardiac thrombosis in patients with a dilated cardiomyopathy can be life threatening. This study investigated the incidence, risk factors, and outcome of intracardiac thrombosis in children with dilated cardiomyopathy. A retrospective review of the clinical records was performed in 83 children with dilated cardiomyopathy diagnosed from January 1995 to December 2008. Intracardiac thrombi were detected in 5 patients (6.0%). The intracardiac thrombi were found mainly in the left ventricle (n = 3). One patient had a thrombus in the left atrium at the time of diagnosis, and a right ventricular thrombus was found in 1 patient with unrepaired ventricular septal defect complicated by pulmonary hypertension. Intracardiac thrombosis developed during rapid deterioration of ventricular function, and all patients had a poor ejection fraction of the left ventricle. All patients were treated with heparinization, and thrombectomy was performed in 1 patient. Three patients achieved complete resolution of the thrombus without further embolic complications. Careful evaluation and aggressive anticoagulation are necessary for the prevention of intracardiac thrombosis in children with poor ventricular function, especially during rapid deterioration of ventricular function.
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Affiliation(s)
- Soo-Han Choi
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
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Tigen K, Cevik C, Bitigen A, Tanalp C, Mutlu B. Anticoagulation in severe heart failure. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2007; 13:297-298. [PMID: 17917499 DOI: 10.1111/j.1527-5299.2007.06524.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Kursat Tigen
- Cardiology Division, Kosuyolu Heart and Research Hospital, Istanbul, Kartal, Turkey.
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