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Sunada T, Takeshita J, Tachibana K. New intra-conduit thrombus detected using transesophageal echocardiography immediately after weaning from cardiopulmonary bypass during the Fontan procedure: a case report. J Anesth 2023; 37:482-486. [PMID: 37085673 DOI: 10.1007/s00540-023-03195-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/13/2023] [Indexed: 04/23/2023]
Abstract
This study reports a case wherein a new thrombus was detected by transesophageal echocardiography in the conduit during extracardiac conduit Fontan procedure. Immediately after weaning from the cardiopulmonary bypass and administration of protamine, a thrombus was noted in the conduit by transesophageal echocardiography. Since the patient was hemodynamically stable, anticoagulation therapy was initiated after admission to the intensive care unit. One week post-surgery, imaging results showed residual thrombus, but the patient was safely discharged. Even during Fontan procedure, careful observation with transesophageal echocardiography is important because of the possibility of thrombus formation in the conduit.
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Affiliation(s)
- Taiga Sunada
- Osaka Women's and Children's Hospital, 840 Murodocho, Izumi, Osaka, Japan.
- Kobe City Medical Center General Hospital, Kobe, Japan.
| | - Jun Takeshita
- Osaka Women's and Children's Hospital, 840 Murodocho, Izumi, Osaka, Japan
| | - Kazuya Tachibana
- Osaka Women's and Children's Hospital, 840 Murodocho, Izumi, Osaka, Japan
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Doi Y, Kim SH, Ishigaki M, Sato K, Yoshimoto J, Mitsushita N, Nii M, Ikai A, Sakamoto K, Tanaka Y. Catheter Intervention for Flow Regulatory Clips on Palliative Shunts and Conduits in Patients with Congenital Heart Disease. Pediatr Cardiol 2023; 44:210-217. [PMID: 35857080 DOI: 10.1007/s00246-022-02967-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/01/2022] [Indexed: 02/06/2023]
Abstract
Catheter intervention (CI) for a Blalock-Taussig shunt (BTS) or a ventricle-to-pulmonary artery conduit (VPC) is often required after a palliative surgery for congenital heart disease. Flow regulatory clips help improve interstage mortality; their use necessitates CIs to prevent cyanosis. To study the CI outcomes in patients who underwent palliative surgery with either BTSs or VPCs with flow regulatory clips. This single-center retrospective study evaluated demographic characteristics and interventional outcomes of 49 consecutive pediatric patients who required CI for BTS (BTS group) or VPC (VPC group) between January 2008 and September 2018. Overall, 34 and 18 procedures were performed in the BTS and VPC groups, respectively. Moreover, 19/32 (59.3%) and 12/17 (70.1%) patients from the BTS and VPC groups had flow regulatory clips, respectively. All clips were unclipped successfully; one patient in each group underwent staged unclipping. A higher proportion of "clipped patients" underwent CI due to desaturation [clipped vs. non-clipped: BTS, 10/20 (50.0%) vs. 3/14 (21.4%), p = 0.092; VPC, 9/13 (69.2%) vs. 1/5 (20.0%), p = 0.060]. Most clipped patients successfully progressed to the next stage [BTS, 19/20 (95.0%); VPC, 12/13 (92.3%)]. Severe adverse events (SAEs) were more frequent in the VPC group than in the BTS group [3/13 (23.1%) vs. 0/20 (0%), p = 0.024]. Two patients developed an atrioventricular block (requiring an atropine infusion), while one died due to pulmonary overcirculation. While the indication of CI was cyanosis for a higher proportion of clipped patients, all clips were unclipped successfully. The incidence of CI-related SAEs was higher in the VPC group than in the BTS group.
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Affiliation(s)
- Yuji Doi
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan.
- Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, Japan.
| | - Sung-Hae Kim
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Mizuhiko Ishigaki
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Keisuke Sato
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Jun Yoshimoto
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Norie Mitsushita
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Masaki Nii
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Akio Ikai
- Department of Cardiovascular Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Kisaburo Sakamoto
- Department of Cardiovascular Surgery, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Yasuhiko Tanaka
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka, Japan
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Samarai D, Lindstedt S, Isma N, Hlebowicz J. Rate and risk factors for thromboembolism and major bleeding in adults with congenital heart disease taking vitamin K antagonist therapy. THROMBOSIS UPDATE 2022. [DOI: 10.1016/j.tru.2022.100122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Ban JE. Non-vitamin K antagonist oral anticoagulants in adults with congenital heart disease. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2022. [DOI: 10.1186/s42444-022-00071-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractDespite an improved survival rate, cardiovascular accidents including thromboembolic events are a common cause of death in adults with congenital heart disease (CHD). Therefore, many adult patients with CHD require long-term oral anticoagulants depending on disease complexity, atrial tachyarrhythmia, residual intracardiac shunt, ventricular dysfunction, and the presence of a prosthetic valve. Although prevention of stroke and pulmonary embolism has traditionally been managed with vitamin K antagonists (VKA), recent guidelines suggest the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with adult CHD presenting with atrial fibrillation (AF), stroke, or pulmonary embolism. NOACs are an efficient alternative to VKA with reduced bleeding propensity, relatively low dietary and drug interactions, and the potential to eliminate the need for international normalized ratio monitoring in patients with nonvalvular AF. Recently, several multicenter studies reported the indication for thromboprophylaxis and the potential role of NOACs in adult CHD patients. In this review, we aim to assess the efficacy and safety of NOACs in adult CHD patients and to pursue adequate anticoagulation strategies in this special population.
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The Fontan circulation: from ideal to failing hemodynamics and drug therapies for optimization. Can J Cardiol 2022; 38:1059-1071. [DOI: 10.1016/j.cjca.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 12/19/2022] Open
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Stalikas N, Doundoulakis I, Karagiannidis E, Bouras E, Kartas A, Frogoudaki A, Karvounis H, Dimopoulos K, Giannakoulas G. Non-Vitamin K Oral Anticoagulants in Adults with Congenital Heart Disease: A Systematic Review. J Clin Med 2020; 9:jcm9061794. [PMID: 32526897 PMCID: PMC7356004 DOI: 10.3390/jcm9061794] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/30/2020] [Accepted: 06/04/2020] [Indexed: 01/10/2023] Open
Abstract
Adults with congenital heart disease (ACHD) experience more thromboembolic complications than the general population. We systematically searched and critically appraised all studies on the safety and efficacy of non-vitamin-K oral anticoagulants (NOACs) in adult patients with various forms of congenital heart disease. PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) were used, with duplicate extraction of data and risk of bias assessment. The Newcastle-Ottawa quality assessment scale was used to assess study quality. Three studies fulfilled the inclusion criteria and were analyzed. The total number of participants was 766, with a total follow-up of 923 patient-years. The majority of patients (77%) received a NOAC for atrial arrhythmias, while the remainder were prescribed NOACs for secondary (19%) or primary (4%) thromboprophylaxis. The annual rate of thromboembolic and major bleeding events was low: 0.98% (95% CI: 0.51–1.86) and 1.74% (95% CI: 0.86–3.49) respectively. In Fontan patients, the annual rate of thromboembolic and major bleeding events was 3.13% (95% CI: 1.18–8.03) and 3.17% (95% CI: 0.15–41.39) respectively. NOACs appear safe and effective in ACHD without mechanical prostheses. Additional studies are, however, needed to confirm their efficacy in complex ACHD, especially those with a Fontan-type circulation.
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Affiliation(s)
- Nikolaos Stalikas
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
- Department of Internal Medicine, General Hospital of Edessa, 582 00 Proastio, Greece
| | - Ioannis Doundoulakis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
- Department of Cardiology, 424 General Military Training Hospital, 54 124 Thessaloniki, Greece
| | - Efstratios Karagiannidis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
| | - Emmanouil Bouras
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, 54 124 Thessaloniki, Greece;
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
| | - Alexandra Frogoudaki
- Second Department of Cardiology, Attikon University Hospital, University of Athens, 124 62 Athens, Greece;
| | - Haralambos Karvounis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital and Imperial College, London SW3 6NP, UK;
| | - George Giannakoulas
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
- Correspondence: ; Tel.: +302313303587
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McVea S, McGettrick A. Fifteen-minute consultation: Assessing the child with a Blalock-Taussig shunt who is unwell in a district general hospital. Arch Dis Child Educ Pract Ed 2020; 105:142-146. [PMID: 31278077 DOI: 10.1136/archdischild-2018-315875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 06/20/2019] [Accepted: 06/22/2019] [Indexed: 12/28/2022]
Abstract
Univentricular heart disease accounts for ~1.25% of all congenital heart disease. Such cases remain among the most challenging to manage, typically requiring a three-staged palliation. The first stage involves placement of a systemic to pulmonary shunt. While a variety of shunt types, including ductal stenting, can be used to manage univentricular conditions, the archetype remains the Blalock-Taussig (BT) shunt. While waiting future palliative intervention at home, intercurrent illness may necessitate presentation to a district general hospital where subspecialist advice and assessment is remote. This review aims to present the general paediatrician with a straightforward BT shunt physiology overview highlighting unique complications which may complicate intercurrent illness.
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Affiliation(s)
- Steven McVea
- Paediatric Intensive Care, Royal Hospital for Children Glasgow, Glasgow, UK
| | - Anne McGettrick
- Paediatric Critical Care, Royal Hospital for Children Glasgow, Glasgow, UK
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Karsenty C, Zhao A, Marijon E, Ladouceur M. Risk of thromboembolic complications in adult congenital heart disease: A literature review. Arch Cardiovasc Dis 2018; 111:613-620. [PMID: 29859704 DOI: 10.1016/j.acvd.2018.04.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 04/02/2018] [Accepted: 04/04/2018] [Indexed: 12/13/2022]
Abstract
Adult congenital heart disease (ACHD) is a constantly expanding population with challenging issues. Initial medical and surgical treatments are seldom curative, and the majority of patients still experience late sequelae and complications, especially thromboembolic events. These common and potentially life-threating adverse events are probably dramatically underdiagnosed. Better identification and understanding of thromboembolic risk factors are essential to prevent long-term related morbidities. In addition to specific situations associated with a high risk of thromboembolic events (Fontan circulation, cyanotic congenital heart disease), atrial arrhythmia has been recognized as an important risk factor for thromboembolic events in ACHD. Unlike in patients without ACHD, thromboembolic risk stratification scores, such as the CHA2DS2-VASc score, may not be applicable in ACHD. Overall, after a review of the scientific data published so far, it is clear that the complexity of the underlying congenital heart disease represents a major risk factor for thromboembolic events. As a consequence, prophylactic anticoagulation is indicated in patients with complex congenital heart disease and atrial arrhythmia, regardless of the other risk factors, as opposed to simple heart defects. The landscape of ACHD is an ongoing evolving process, and specific thromboembolic risk scores are needed, especially in the setting of simple heart defects; these should be coupled with specific trials or long-term follow-up of multicentre cohorts.
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Affiliation(s)
- Clement Karsenty
- Adult Congenital Heart Disease Unit, Centre de Référence des Malformations Cardiaques Congénitales Complexes (M3C), 75015 Paris, France; Cardiology Department, Hôpital Européen Georges-Pompidou, 75015 Paris, France; Paris Descartes University, 75006 Paris, France; Inserm UMR 1048, Institut des Maladies Métaboliques et Cardiovasculaires, 31432 Toulouse, France.
| | - Alexandre Zhao
- Cardiology Department, Hôpital Européen Georges-Pompidou, 75015 Paris, France; Paris Descartes University, 75006 Paris, France
| | - Eloi Marijon
- Adult Congenital Heart Disease Unit, Centre de Référence des Malformations Cardiaques Congénitales Complexes (M3C), 75015 Paris, France; Cardiology Department, Hôpital Européen Georges-Pompidou, 75015 Paris, France; Paris Descartes University, 75006 Paris, France; Inserm U970, Paris Centre de Recherche Cardiovasculaire, 75015 Paris, France
| | - Magalie Ladouceur
- Adult Congenital Heart Disease Unit, Centre de Référence des Malformations Cardiaques Congénitales Complexes (M3C), 75015 Paris, France; Cardiology Department, Hôpital Européen Georges-Pompidou, 75015 Paris, France; Paris Descartes University, 75006 Paris, France; Inserm U970, Paris Centre de Recherche Cardiovasculaire, 75015 Paris, France
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Ligon RA, Ooi YK, Kim DW, Vincent RN, Petit CJ. Intervention on Surgical Systemic-to-Pulmonary Artery Shunts: Carotid Versus Femoral Access. JACC Cardiovasc Interv 2017; 10:1738-1744. [PMID: 28823774 DOI: 10.1016/j.jcin.2017.05.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The purpose of this study was to compare results between the femoral arterial (FA) and carotid arterial (CA) approaches in catheter-based interventions on Blalock-Taussig shunts (BTS). BACKGROUND Transcatheter intervention on BTS is often performed in shunt-dependent, hypoxemic infants. The approach to BTS intervention likely has an impact on timeliness and overall success. METHODS The authors reviewed all cases of catheter intervention for BTS obstruction between 2012 and 2017 for their institution. They sought to compare procedural success rates and time, sheath time, time to arterial access, and time from access to stent implantation between FA and CA approaches. RESULTS There were 42 BTS interventions between 34 patients. BTS intervention was more successful from the CA approach (p = 0.035). Among the FA cohort, BTS intervention was unsuccessful in 8 cases (25%), 5 of which were converted to CA with subsequent success. The CA cohort had lower procedure time (62 min vs. 104 min; p = 0.01) and anesthesia time (119 min vs. 151 min; p = 0.01). Additionally, CA access was associated with shorter time to arterial access (4.0 min vs. 9.3 min; p < 0.01), time to placement of the guidewire through the BTS (6.5 min vs. 13 min; p < 0.01), and time from the final sheath to BTS stent implantation (9 min vs. 20 min; p < 0.01). CONCLUSIONS Operators should consider the route of access to the BTS deliberately. The authors' approach has been the carotid artery as an alternative access site-associated with greater procedural success, shorter procedural time, and shorter time to stent implantation.
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Affiliation(s)
- R Allen Ligon
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Yinn K Ooi
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Dennis W Kim
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Robert N Vincent
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Christopher J Petit
- Children's Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.
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