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Yang Y, Lv J, Li Y, Gan C, Ji P. Intracardiac thrombosis after congenital heart disease surgeries in neonates: a report of two cases. BMC Pediatr 2023; 23:277. [PMID: 37268877 DOI: 10.1186/s12887-023-04069-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/10/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Intracardiac thrombosis (ICT) is a rare complication after the cardiopulmonary surgery for interrupted aortic arch (IAA) or total anomalous pulmonary venous connection (TAPVC) without previous records. There are still no general guidelines regarding as the mechanism or management of postoperative ICT in neonates and younger infants. CASE PRESENTATION We reported the conservative and surgical therapies in two neonates with intra-ventricular and intra-atrial thrombosis after the anatomical repair for IAA and TAPVC, respectively. There were no risk factors for ICT in both patients, except for the use of blood product and prothrombin complex concentrate. The surgery was indicated after TAPVC correction due to the worsening respiratory status and rapidly decreased mixed venous saturation. Anticoagulation combined with antiplatelet therapies was adopted in another patient. These two were both finally recovered, and three-month, six-month, and one-year follow-up echocardiography revealed no abnormality. CONCLUSIONS ICT is uncommon in pediatric population after the surgery for congenital heart disease. Single ventricle palliation, heart transplantation, longer central line use, post-extracorporeal membrane oxygenation, and massive blood product use are major risk factors for postcardiotomy thrombosis. The causes of postoperative ICT are multifactorial, and the immaturity of thrombolytic and fibrinolytic system in neonates may serve as a prothrombotic factor. However, no consensus reached regarding as the therapies for postoperative ICT, and the large-scale prospective cohort study or randomized clinical trial is needed.
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Affiliation(s)
- Yanlin Yang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Wuhou District 610041, Chengdu, Sichuan Province, China
| | - Jing Lv
- Anesthesia Operation Center, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yajiao Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Changping Gan
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Wuhou District 610041, Chengdu, Sichuan Province, China.
| | - Peng Ji
- Department of Critical Care Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Wuhou District 610041, Chengdu, Sichuan Province, China.
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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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Mesher AL, Hermsen JL, Rubio AE, Chen JM, McMullan DM. Neoaortic thrombus after Norwood procedure: complication of extracorporeal life support? Ann Thorac Surg 2015; 99:709-10. [PMID: 25639418 DOI: 10.1016/j.athoracsur.2014.03.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/10/2014] [Accepted: 03/19/2014] [Indexed: 10/24/2022]
Abstract
Hypoplastic left heart syndrome is the most common diagnosis among infants requiring cardiac extracorporeal life support (ECLS) in the neonatal period, with more than half of patients experiencing an ECLS-related complication. We present a case of nearly obstructing neoaortic thrombus during ECLS occurring in the early postoperative period after modified Norwood palliation of hypoplastic left heart syndrome. Stasis within the neoaortic root due to the increased ventricular afterload associated with venoarterial ECLS may have potentiated this complication. Echocardiographic monitoring and early cardiac catheterization while on ECLS enabled prompt diagnosis and timely surgical correction.
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Affiliation(s)
- Andrew L Mesher
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Joshua L Hermsen
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington
| | - Agustin E Rubio
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - Jonathan M Chen
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington
| | - David Michael McMullan
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington; Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington.
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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: 964] [Impact Index Per Article: 80.3] [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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