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VanderPluym C, Kobayashi R. Leveling the playing field: The role of level-based dosing in pediatric anticoagulation management. Pediatr Blood Cancer 2024; 71:e31136. [PMID: 38967607 DOI: 10.1002/pbc.31136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 07/06/2024]
Affiliation(s)
- Christina VanderPluym
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan Kobayashi
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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2
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Duran S, Gerber C, Bilsky S, Plummer S, Bocks M. Use of Rivaroxaban in Children with Congenital Heart Disease: A Single-Center Case Series. Pediatr Cardiol 2024; 45:1295-1300. [PMID: 36681724 DOI: 10.1007/s00246-022-03094-6] [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: 10/17/2022] [Accepted: 12/28/2022] [Indexed: 01/22/2023]
Abstract
Rivaroxaban is a direct oral anticoagulant approved for therapeutic and prophylactic anticoagulation in both adults and children. Studies on rivaroxaban use in pediatric patients with congenital heart disease (CHD) are limited. Currently, warfarin (oral) and enoxaparin (injection) are the primary options for pediatric outpatient anticoagulation. Rivaroxaban may be a less burdensome alternative, but its use has not been well described in the pediatric CHD population. We describe our single-center experience. From May 2020-July 2022, we identified all pediatric CHD patients started on rivaroxaban. Dosing was based on recommendations reported in the EINSTEIN-Jr (Male et al. in Lancet Haematol 7:e18-e27, 2020) and UNIVERSE study (McCrindle et al. in J Am Heart Assoc 10:e021765, 2021) protocols. Qualitative outcomes on safety and efficacy are reported. There were 27 patients studied with an age range of 4 months-15 years at time of medication initiation. Single ventricle heart disease was present in 70% (19/27) of patients. Of the 27 patients initiated on rivaroxaban, 15 (56%) were started for VTE prophylaxis and 12 (44%) were started for VTE treatment. No patients started on rivaroxaban for prophylaxis developed a VTE. There was resolution or lack of propagation in 10 of the 12 patients started for treatment. There were two clinically relevant bleeding episodes. Our single-center case series describes the experience with rivaroxaban for VTE prophylaxis and treatment in pediatric congenital heart disease. Larger studies are required to further investigate safety, efficacy, and use indications.
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Affiliation(s)
- Silvestre Duran
- University Hospitals Rainbow Babies and Children's Hospital Pediatric Cardiology, Cleveland, OH, USA.
| | - Christina Gerber
- University Hospitals Rainbow Babies and Children's Hospital Pediatric Cardiology, Cleveland, OH, USA
| | - Shannon Bilsky
- University Hospitals Rainbow Babies and Children's Hospital Pediatric Cardiology, Cleveland, OH, USA
| | - Sarah Plummer
- University Hospitals Rainbow Babies and Children's Hospital Pediatric Cardiology, Cleveland, OH, USA
| | - Martin Bocks
- University Hospitals Rainbow Babies and Children's Hospital Pediatric Cardiology, Cleveland, OH, USA
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3
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Sullivan PM, Ing FF. Systemic Central Venous Rehabilitation in Congenital Heart Disease. Interv Cardiol Clin 2024; 13:439-450. [PMID: 38839176 DOI: 10.1016/j.iccl.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Chronic venous obstructions resulting from indwelling lines, surgery and instrumentation, and congenital anomalies are increasingly common in patients with congenital heart disease (CHD) and other chronic illnesses. Venous obstruction results in threatened long-term vascular access and congestive symptoms. Endovascular therapies are safe and can be effective at rehabilitating obstructed and even occluded veins. The risk of recurrent obstruction is high, however. Post-rehabilitation monitoring and anticoagulation therapy are important, and reinterventions are common. Here, the authors describe techniques to address a variety of venous obstruction lesions that may be encountered in CHD patients and provide illustrative cases.
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Affiliation(s)
- Patrick M Sullivan
- USC Keck School of Medicine, Los Angeles, CA, USA; Children's Hospital Los Angeles Heart Institute, 4650 Sunset Boulevard #34, Los Angeles, CA 90027, USA.
| | - Frank F Ing
- UC Davis School of Medicine, Pediatric Heart Center, UC Davis Children's Hospital, 2516 Stockton Boulevard TICON II, Sacramento, CA 95817, USA
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Shen H, He Q, Li W, Zhu G, Wang X, Liu J, Zhang Y, Li S, Zhou Z. Thrombocytopenia developed in intensive care unit for congenital heart disease: incidence, risk factors, and outcomes. J Thromb Haemost 2024:S1538-7836(24)00361-1. [PMID: 38908831 DOI: 10.1016/j.jtha.2024.05.036] [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: 03/25/2024] [Revised: 05/23/2024] [Accepted: 05/29/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND Thrombocytopenia is common for patients in the intensive care unit (ICU) and is associated with adverse outcomes. ICU thrombocytopenia in pediatric patients who underwent cardiac surgeries with cardiopulmonary bypass (CPB) is inadequately studied. OBJECTIVES We aimed to investigate the incidence, risk factors, and prognostic role of ICU thrombocytopenia after congenital cardiac surgeries with CPB. METHODS A retrospective study involving 11 761 patients was conducted. Patients were categorized into 4 groups of thrombocytopenia based on platelet counts tested during ICU: non (>150 × 109/L), mild (100-150 × 109/L), moderate (50-100 × 109/L), and severe (<50 × 109/L). Logistic and Cox regression analyses were utilized to explore the risk factors of thrombocytopenia and the association of ICU thrombocytopenia with 30-day mortality. RESULTS ICU thrombocytopenia was observed in 4007 patients (34.1%), with mild, moderate, and severe thrombocytopenia occurring in 2773 (23.6%), 987 (8.4%), and 247 (2.1%) patients, respectively. Younger age, cyanotic congenital heart disease, CPB duration, and preoperative laboratory findings (red blood cell, thrombocytopenia, red cell distribution width, hematocrit, and coagulation disorder) were identified as independent risk factors of ICU thrombocytopenia. Patients with moderate (hazard ratio [95% CI]: 11.38 [3.02-42.87]; P < .001) and severe thrombocytopenia (hazard ratio [95% CI]: 49.54 [13.11-187.14]; P < .001) had a significantly higher risk of 30-day mortality. Furthermore, with the increase in the severity of ICU thrombocytopenia, there was an incremental increase in the incidence of postoperative critical bleeding and thrombosis, perioperative blood transfusions, length of ICU stays, and duration of mechanical ventilation. CONCLUSION ICU thrombocytopenia occurred in one-third of children after congenital cardiac surgery with CPB, and it was associated with multiple adverse outcomes.
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Affiliation(s)
- Huayan Shen
- Center of Laboratory Medicine, State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Qiyu He
- Pediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Wenke Li
- Center of Laboratory Medicine, State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Guoyan Zhu
- Center of Laboratory Medicine, State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Xu Wang
- Pediatric Intensive Care Unit, Pediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Pediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China
| | - Yang Zhang
- Center of Laboratory Medicine, State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China.
| | - Shoujun Li
- Pediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China.
| | - Zhou Zhou
- Center of Laboratory Medicine, State Key Laboratory of Cardiovascular Disease, Beijing Key Laboratory for Molecular Diagnostics of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College/National Center for Cardiovascular Diseases, Beijing, China.
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5
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Elias MD, Brothers JA, Hogarty AN, Martino J, O'Byrne ML, Patel C, Stephens P, Tingo J, Vetter VL, Ravishankar C, Giglia TM. Outcomes Associated with Giant Coronary Artery Aneurysms after Kawasaki Disease: A Single-Center United States Experience. J Pediatr 2024; 274:114145. [PMID: 38878963 DOI: 10.1016/j.jpeds.2024.114145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/13/2024] [Accepted: 06/11/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES To determine the long-term outcomes among a cohort of patients with Kawasaki disease (KD) and a history of giant coronary artery aneurysms (CAAs) at a single US center. STUDY DESIGN Medical records for all patients with KD and giant CAAs at a pediatric academic institution were reviewed. Primary outcomes included major adverse cardiovascular events (MACE) and normalization of CA luminal diameter, using Kaplan-Meier analyses. RESULTS There were 60 patients with KD and giant CAAs identified between 1989 and 2023. The majority of patients were male (71.7%) with a median age at diagnosis of 0.9 years (range, 0.2-13.3 years). Patients were followed for a median of 11 years, up to 34.5 years. MACE occurred in 13 patients (21.7%) at a median of 1.4 years (range, 0.04-22.6 years) after KD diagnosis. The 10-, 20-, and 30-year MACE-free rates were 75%, 75%, and 60%. Patients with maximal CA z scores of ≥20 or bilateral CAA were more likely to have MACE. During follow-up, 26.7% of CAA regressed to a normal luminal diameter at a median of 3.6 years (range, 0.6-12.0 years). The 10-, 20- and 30-year likelihood of CA regression to normal luminal diameter was 36%, 46%, and 46%. CONCLUSIONS Over 30 years, MACE occurred in nearly 22% of patients, more often in those with bilateral CAA or CA z scores of ≥20. Despite regression to a normal luminal diameter in >25% of CAAs, patients with a history of KD-associated giant CAA require ongoing surveillance for cardiac complications, even years after the initial disease.
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Affiliation(s)
- Matthew D Elias
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Julie A Brothers
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alexa N Hogarty
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jordy Martino
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Michael L O'Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Chandni Patel
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Paul Stephens
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer Tingo
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Victoria L Vetter
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Therese M Giglia
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
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Kulp BE, Khan MN, Gazit AZ, Eghtesady P, Scheel JN, Said AS, Rabinowitz EJ. Single Ventricular Assist Device Care and Outcomes for Failed Stage I Palliation: A Single-Center Decade of Experience. ASAIO J 2024; 70:517-526. [PMID: 38346282 DOI: 10.1097/mat.0000000000002149] [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: 02/15/2024] Open
Abstract
Single ventricular assist device (SVAD) use before and after stage I palliation (S1P) is increasing with limited data on outcomes. To address this knowledge gap, we conducted a single-center retrospective review to assess pre- and post-SVAD clinical status, complications, and outcomes. We leveraged a granular, longitudinal, local database that captures end-organ support, procedural interventions, hematologic events, laboratory data, and antithrombotic strategy. We identified 25 patients between 2013 and 2023 implanted at median age of 53 days (interquartile range [IQR] = 16-130); 80% had systemic right ventricles and underwent S1P. Median SVAD days were 54 (IQR = 29-86), and 40% were implanted directly from ECMO. Compared to preimplant, there was a significant reduction in inotrope use ( p = 0.013) and improved weight gain ( p = 0.008) post-SVAD. Complications were frequent including bleeding (80%), stroke (40%), acute kidney injury (AKI) (40%), infection (36%), and unanticipated catheterization (56%). Patients with in-hospital mortality had significantly more bleeding complications ( p = 0.02) and were more likely to have had Blalock-Thomas-Taussig shunts pre-SVAD ( p = 0.028). Survival to 1 year postexplant was 40% and included three recovered and explanted patients. At 1 year posttransplant, all survivors have technology dependence or neurologic injury. This study highlights the clinical outcomes and ongoing support required for successful SVAD use in failed single-ventricle physiology before or after S1P.
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Affiliation(s)
- Blaire E Kulp
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
| | - Marium N Khan
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Pediatric Critical Care Medicine, St Louis, MO
| | - Avihu Z Gazit
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Pediatric Critical Care Medicine, St Louis, MO
- Division of Pediatric Cardiology, St Louis, MO
| | - Pirooz Eghtesady
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Cardiothoracic Surgery, St Louis, MO
| | - Janet N Scheel
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Pediatric Cardiology, St Louis, MO
| | - Ahmed S Said
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Pediatric Critical Care Medicine, St Louis, MO
| | - Edon J Rabinowitz
- From the Washington University School of Medicine in St Louis Department of Pediatrics and St Louis Children's Hospital, St Louis, MO
- Division of Pediatric Critical Care Medicine, St Louis, MO
- Division of Pediatric Cardiology, St Louis, MO
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Zhang T, Gao C, Chen W, Ma H, Tao L. Patent Foramen Ovale in Children: A Review of Recent Progress. Pediatr Cardiol 2024:10.1007/s00246-024-03526-5. [PMID: 38822852 DOI: 10.1007/s00246-024-03526-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/14/2024] [Indexed: 06/03/2024]
Abstract
The support has been provided by clinical trials and guidelines for managing patent foramen ovale (PFO) in adults; however, the optimal approach is still unclear for treating PFO in pediatric patients. PFO and its associated clinical syndromes, imaging diagnosis, and management in pediatric patients were analyzed by a comprehensive analysis. Extensive research was performed using electronic databases, including PubMed, Cochrane, Web of Science, and EMBASE. This review includes the studies published until February 1st, 2024. A total of 583 articles were obtained, of which 54 were included in the comprehensive review. Numerous evidences have indicated that a right-to-left shunt through a PFO may be involved in cryptogenic stroke in children, although the connection between migraine and aura has not been substantiated by robust evidence. Children with sickle cell disease and a PFO were at higher risks of paradoxical embolization, rare syndromes caused by PFO could also occur in children such as platypnea-orthodeoxia syndrome, myocardial infarction, and decompression sickness. Contrast transthoracic echocardiography was deemed the most appropriate examination for children due to its favorable transthoracic windows, eliminating the need for anesthesia. This review suggested that the additional treatment was not needed as no evidence was provided for potential future complications linked to isolated PFO in children. For children facing unique circumstances related to PFO, a customized interdisciplinary consultation is essential prior to considering medical interventions.
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Affiliation(s)
- Tingting Zhang
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Changle West Road, Xi'an, 710032, China
| | - Chao Gao
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Changle West Road, Xi'an, 710032, China
| | - Wei Chen
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Changle West Road, Xi'an, 710032, China
| | - Hui Ma
- Department of Ultrasound Diagnostics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ling Tao
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Changle West Road, Xi'an, 710032, China.
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8
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Hong H, Zhu W, Xie Z. Effect of non-vitamin K oral anticoagulants for thrombosis prophylaxis in pediatric heart diseases. Eur J Intern Med 2024; 124:138-140. [PMID: 38443264 DOI: 10.1016/j.ejim.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Hong Hong
- Department of Pediatrics,The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Wengen Zhu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China.
| | - Zhongli Xie
- Department of Pediatrics,The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China.
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Regan IE, Cox D, Kelleher ST, McMahon CJ. The Effects of Aspirin dose in Children with Congenital and Acquired Heart Disease. Results from the Paediatric Study of Aspirin Efficacy using Diagnostic and Monitoring Tools (PAED-M). Pediatr Cardiol 2024:10.1007/s00246-024-03509-6. [PMID: 38755451 DOI: 10.1007/s00246-024-03509-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 04/23/2024] [Indexed: 05/18/2024]
Abstract
The optimal dose of aspirin required in children with congenital and acquired heart disease is not known. The primary aim of this prospective observational study was to evaluate the effects of aspirin dose on platelet inhibition. The secondary aim was to determine the prevalence and clinical predictors of aspirin non-responsiveness. Measurements were by Thromboelastography with Platelet Mapping (TEGPM) only in children less than 2 years (y) of age with particular emphasis on the parameter known as maximum amplitude with arachidonic acid (MAAA) and using both TEGPM, and light transmission aggregometry (LTA) in children greater than 2 y. We prospectively studied 101 patients with congenital and acquired cardiac disease who were receiving empirical doses of aspirin for a minimum of 4 weeks but no other antiplatelet agents. Patients were stratified according to dose concentration and age. There was a trend toward lower age in patients with no response or semi-response to aspirin. All patients were considered responsive to aspirin in the higher-dose quartile (Q4) with a median dose of 4.72 (4.18-6.05) mg/kg/day suggesting that patients in this age group may require 5 mg/kg/day as an empirical dose. In children > 2 y, there was no significant difference in inhibition found in patients dosed at higher doses in Q3 versus Q4 suggesting that patients in this cohort are responsive with 3 mg/kg/day dose. The current practices may lead to reduced platelet inhibition in some children due to under-dosing or overdosing in others. In conclusion, younger children require higher doses of aspirin. Laboratory assessment is warranted in this population to mitigate against under and overdosing.
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Affiliation(s)
- Irene E Regan
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- National Children's Research Centre, Children's Health Ireland, Dublin, Ireland
| | - Dermot Cox
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons Ireland, Dublin, Ireland
| | - Sean T Kelleher
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland.
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
- School of Health Professions Education (SHE), Maastricht University, Maastricht, Netherlands.
- National Children's Research Centre, Children's Health Ireland, Dublin, Ireland.
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10
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Palmieri V, Yijin X, Fischbach P, Whitehill R. Safety of same-day discharge without anticoagulation for left-sided radiofrequency catheter ablations in pediatrics. Heart Rhythm 2024; 21:592-599. [PMID: 38215810 DOI: 10.1016/j.hrthm.2024.01.004] [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: 06/04/2023] [Revised: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND For left-sided radiofrequency catheter ablation (LCA) in pediatrics, significant practice variability exists regarding anticoagulation and discharge practices. Given the lack of data in pediatric patients, the risks and benefits of these practices are not well defined. OBJECTIVE The purpose of this study was to evaluate the safety of same-day discharge and use of aspirin (ASA) in pediatric patients following LCA. METHODS We performed a retrospective cohort study of pediatric patients who underwent LCA from 2010 to 2020 at our institution. Discharge timing and ASA usage were based on operator preference. The primary outcome was incidence of postablation anticoagulation complications reported within 1 month of the procedure. RESULTS Three hundred seventy-six patients underwent LCA and met inclusion criteria. Median [25th, 75th percentiles] age was 13.9 [10.5, 16.2] years; 18 (4.7%) had a history of structural heart disease. The most common substrates for ablation were Wolff-Parkinson-White syndrome (183 patients [48.7%]), concealed accessory pathway (159 patients [42.3%]), and ectopic atrial tachycardia (10 patients [2.7%]). Three hundred thirty-eight patients (89.9%) were discharged on the day of LCA. Seventy-six patients (20.2%) were prescribed ASA at discharge. Of those who underwent follow-up (273 patients [72.6%]), 7 (2.7%) reported an anticoagulation complication (5 with hematoma, 2 with headache). One of these patients was prescribed ASA; none required readmission. There was no correlation between anticoagulation complications and same-day discharge or with ASA usage. CONCLUSION Given the rare incidence of anticoagulation complications in pediatric patients undergoing LCAs, same-day discharge from the electrophysiology laboratory without anticoagulation should be considered.
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Affiliation(s)
- Vincent Palmieri
- Children's Healthcare of Atlanta Cardiology, Atlanta, Georgia; Emory University School of Medicine, Atlanta, Georgia.
| | - Xiang Yijin
- Emory University School of Medicine, Atlanta, Georgia
| | - Peter Fischbach
- Children's Healthcare of Atlanta Cardiology, Atlanta, Georgia; Emory University School of Medicine, Atlanta, Georgia
| | - Robert Whitehill
- Children's Healthcare of Atlanta Cardiology, Atlanta, Georgia; Emory University School of Medicine, Atlanta, Georgia
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11
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McGetrick ME, Riviello JJ. Neurological injury in pediatric heart disease: A review of developmental and acquired risk factors and management considerations. Semin Pediatr Neurol 2024; 49:101115. [PMID: 38677794 DOI: 10.1016/j.spen.2024.101115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/29/2024]
Abstract
Medical and surgical advancements have improved survival in children with acquired and congenital heart disease (CHD), but the burden of neurological morbidity is high. Brain disorders associated with CHD include white matter injury, stroke, seizure, and neurodevelopmental delays. While genetics and disease-specific factors play a substantial role in early brain injury, therapeutic management of the heart disease intensifies the risk. There is a growing interest in understanding how to reduce brain injury and improve neurodevelopmental outcomes in cardiac diseases. Pediatric neurologists serve a vital role in care teams managing these complex patients, providing interpretation of neuromonitoring and imaging, managing neurologic emergencies, assisting with neuro prognostication, and identifying future research aims.
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Affiliation(s)
- Molly E McGetrick
- Division of Cardiology and Critical Care, Department of Pediatrics, the University of Texas Southwestern, Children's Medical Center, Dallas, Texas, USA.
| | - James J Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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12
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Newland DM, Palmer MM, Knorr LR, Pak JL, Albers EL, Friedland-Little JM, Hong BJ, Law YM, Spencer KL, Kemna MS. Analysis of Platelet Function Testing in Children Receiving Aspirin for Antiplatelet Effects. Pediatr Cardiol 2024; 45:614-622. [PMID: 38153548 DOI: 10.1007/s00246-023-03377-6] [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: 07/23/2023] [Accepted: 12/06/2023] [Indexed: 12/29/2023]
Abstract
Aspirin (ASA) remains the most common antiplatelet agent used in children. VerifyNow Aspirin Test® (VN) assesses platelet response to ASA, with therapeutic effect defined by the manufacturer as ≤ 549 aspirin reaction units (ARU). Single-center, observational, analysis of 195 children (< 18 years-old) who underwent first VN between 2015 and 2020. Primary outcome was proportion of patients with ASA biochemical resistance (> 549 ARU). Secondary outcomes included incidence of new clinical thrombotic and bleeding events during ≤ 6 months from VN in those who received ASA monotherapy (n = 113). Median age was 1.8 years. Common indications for ASA included cardiac anomalies or dysfunction (74.8%) and ischemic stroke (22.6%). Median ASA dose before VN was 4.6 mg/kg/day. Mean VN was 471 ARU. ASA biochemical resistance was detected in 14.4% (n = 28). Of 113 patients receiving ASA monotherapy, 14 (12.4%) had a thrombotic event and 2 (1.8%) had a bleeding event. Mean VN was significantly higher at initial testing in patients experiencing thrombotic event compared to those without thrombosis (516 vs 465 ARU, [95% CI: 9.8, 92.2], p = 0.02). Multivariable analysis identified initial VN ASA result ≥ 500 ARU at initial testing as the only significant independent risk factor for thrombosis (p < 0.01). VN testing identifies ASA biochemical resistance in 14.4% of children. VN ASA ≥ 500 ARU rather than ≥ 550 ARU at initial testing was independently associated with increased odds of thrombosis. Designated cut-off of 550 ARU for detecting platelet dysfunction by ASA may need reconsideration in children.
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Affiliation(s)
- David M Newland
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA.
- School of Pharmacy, University of Washington, Seattle, WA, USA.
| | - Michelle M Palmer
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Lisa R Knorr
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Jennifer L Pak
- Department of Pharmacy, Seattle Children's Hospital, 4800 Sandpoint Way NE, Mailstop MB.5.420, Seattle, WA, 98105, USA
- School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Erin L Albers
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Joshua M Friedland-Little
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Borah J Hong
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Yuk M Law
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | - Mariska S Kemna
- Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
- School of Medicine, University of Washington, Seattle, WA, USA
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13
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O'Neil MJ, Garr BN, Faircloth JM, Ciambarella JA, Lubert AM, Nelson NL, Cooper DS. Utility of a pharmacist-managed Anticoagulation Program in patients with congenital heart disease. Cardiol Young 2024; 34:628-633. [PMID: 37681464 DOI: 10.1017/s1047951123003268] [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] [Indexed: 09/09/2023]
Abstract
BACKGROUND Warfarin remains the preferred anticoagulant for many patients with CHD. The complexity of management led our centre to shift from a nurse-physician-managed model with many providers to a pharmacist-managed model with a centralized anticoagulation team. We aim to describe the patient cohort managed by our Anticoagulation Program and evaluate the impact of implementation of this consistent, pharmacist-managed model on time in therapeutic range, an evidence-based marker for clinical outcomes. METHODS A single-centre retrospective cohort study was conducted to evaluate the impact of the transition to a pharmacist-managed model to improve anticoagulation management at a tertiary pediatric heart centre. The percent time in therapeutic range for a cohort managed by both models was compared using a paired t-test. Patient characteristics and time in therapeutic range of the program were also described. RESULTS After implementing the pharmacist-managed model, the time in therapeutic range for a cohort of 58 patients increased from 65.7 to 80.2% (p < .001), and our Anticoagulation Program consistently maintained this improvement from 2013 to 2022. The cohort of patients managed by the Anticoagulation Program in 2022 included 119 patients with a median age of 24 years (range 19 months-69 years) with the most common indication for warfarin being mechanical valve replacement (n = 81, 68%). CONCLUSIONS Through a practice change incorporating a collaborative, centralized, pharmacist-managed model, this cohort of CHD patients on warfarin had a fifteen percent increase in time in therapeutic range, which was sustained for nine years.
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Affiliation(s)
- Meredith J O'Neil
- Division of Pharmacy, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - BreAnn N Garr
- Division of Pharmacy, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Julie A Ciambarella
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Adam M Lubert
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nicole L Nelson
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David S Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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14
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Bhansali S, Antonchak M, Cecchin F, Tan RB. Thromboembolism prophylaxis practices of pediatric and congenital electrophysiologists during invasive electrophysiology studies: A PACES survey. Pacing Clin Electrophysiol 2024; 47:365-372. [PMID: 38240348 DOI: 10.1111/pace.14928] [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: 06/24/2023] [Revised: 12/03/2023] [Accepted: 01/04/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Thromboembolic events related to invasive electrophysiology studies, while rare, can have devastating consequences. Use of systemic anticoagulation for a pediatric or adult-congenital invasive electrophysiology study is recommended, however there is no established standard of practice in this population. OBJECTIVE To report on procedural practices for thromboembolism prophylaxis during invasive electrophysiology studies for pediatric patients and adults with congenital heart disease. METHODS An anonymous web-based survey was sent to the members of the Pediatric and Congenital Electrophysiology Society. The survey focused on pre-procedural, intra-procedural, and post-procedural thromboembolism prophylaxis practices during invasive electrophysiology studies. Significant practice variation was defined as <90% concordance among respondents. RESULTS Survey was completed by 73 members; 52 (71%) practicing in the United States, 65 (89%) practicing in an academic institution, and 14 (19%) in an institution that performs more than 200 invasive electrophysiology procedures annually. Responses showed significant variation in practice. Prior to an invasive electrophysiology procedure, 25% discontinue aspirin while 47% discontinue anticoagulants. Heparin is given for all procedures by 32%. When heparin is administered, the first dose is given by 32% after sheaths are placed, 42% after crossing into the systemic atrium, and 26% just prior to systemic-side ablation. Most target an activated clotting time between 200-300 seconds. Post systemic-side ablation, 58% do not initiate a heparin infusion. Post-procedural oral agents were initiated on day of procedure by 34% of respondents and on post-procedure day 1 by 53%. If treating with aspirin, 74% use low-dose (3-5 mg/kg or 81 mg daily), and 68% treat for 4-6 weeks. CONCLUSION There is significant variation in thromboembolism prophylaxis for invasive EP studies among pediatric and congenital electrophysiologists. Further studies are needed to optimize the management of thromboembolism prophylaxis in this population.
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Affiliation(s)
- Suneet Bhansali
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael Antonchak
- Division of Pediatric Cardiology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York, USA
| | - Frank Cecchin
- Division of Pediatric Cardiology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York, USA
| | - Reina Bianca Tan
- Division of Pediatric Cardiology, Department of Pediatrics, NYU Grossman School of Medicine, New York, New York, USA
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15
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Watanabe H, Nagano N, Tsuji Y, Noto N, Ayusawa M, Morioka I. Challenges of pediatric pharmacotherapy: A narrative review of pharmacokinetics, pharmacodynamics, and pharmacogenetics. Eur J Clin Pharmacol 2024; 80:203-221. [PMID: 38078929 DOI: 10.1007/s00228-023-03598-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/20/2023] [Indexed: 02/07/2024]
Abstract
PURPOSE Personalized pharmacotherapy, including for the pediatric population, provides optimal treatment and has emerged as a major trend owing to advanced drug therapeutics and diversified drug selection. However, it is essential to understand the growth and developmental characteristics of this population to provide appropriate drug therapy. In recent years, clinical pharmacogenetics has accumulated knowledge in pediatric pharmacotherapy, and guidelines from professional organizations, such as the Clinical Pharmacogenetics Implementation Consortium, can be consulted to determine the efficacy of specific drugs and the risk of adverse effects. However, the existence of a large knowledge gap hinders the use of these findings in clinical practice. METHODS We provide a narrative review of the knowledge gaps in pharmacokinetics (PK) and pharmacodynamics (PD) in the pediatric population, focusing on the differences from the perspective of growth and developmental characteristics. In addition, we explored PK/PD in relation to pediatric clinical pharmacogenetics. RESULTS The lack of direct and indirect biomarkers for more accurate assessment of the effects of drug administration limits the current knowledge of PD. In addition, incorporating pharmacogenetic insights as pivotal covariates is indispensable in this comprehensive synthesis for precision therapy; therefore, we have provided recommendations regarding the current status and challenges of personalized pediatric pharmacotherapy. The integration of clinical pharmacogenetics with the health care system and institution of educational programs for health care providers is necessary for its safe and effective implementation. A comprehensive understanding of the physiological and genetic complexities of the pediatric population will facilitate the development of effective and personalized pharmacotherapeutic strategies.
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Affiliation(s)
- Hirofumi Watanabe
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1 Kami-cho Ooyaguchi, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Nobuhiko Nagano
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1 Kami-cho Ooyaguchi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuhiro Tsuji
- Laboratory of Clinical Pharmacometrics, School of Pharmacy, Nihon University, Chiba, Japan
| | - Nobutaka Noto
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1 Kami-cho Ooyaguchi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Mamoru Ayusawa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1 Kami-cho Ooyaguchi, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1 Kami-cho Ooyaguchi, Itabashi-ku, Tokyo, 173-8610, Japan
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16
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Benvenuto V, Hartje-Dunn C, Vo L, Hellinger A, Esteso P, Fynn-Thompson F, VanderPluym C. Use of apixaban in children awaiting heart transplantation. Pediatr Transplant 2024; 28:e14632. [PMID: 37897124 DOI: 10.1111/petr.14632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/27/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND The use of apixaban in the pediatric cardiac population is expanding. We describe our apixaban dosing and monitoring strategy in children and young adults awaiting heart transplantation, along with outcomes related to bleeding and thrombosis during wait-list and early post-transplant periods. METHODS This study is a retrospective, single-center analysis of all patients receiving apixaban while awaiting cardiac transplantation. Weight-based dosing was monitored with peak drug-specific anti-Xa chromogenic analysis. Significant post-operative bleeding defined by chest tube output or need for surgical intervention. RESULTS From September 2020 to December 2022, 19 patients, median age 13.5 years (6.1, 15.8 years), weighing 48.9 kg (15.4, 67.6) received apixaban while awaiting transplant. Indication for apixaban was prophylaxis (n = 18, 3 with ventricular assist devices) and treatment of thrombus (n = 1). There were no clinically relevant non-major or major bleeding, nor thrombotic events while awaiting transplant. The median time from last apixaban dose to arrival in the operating room was 23.2 h (15.6-33.8), with median random apixaban level of 37 ng/mL (28.3, 59), 6.3 h (4.8, 8.4) prior to arrival in the operating room. In this study, 32% of patients had significant post-operative bleeding based on chest tube output post-transplant or need for intervention. No patients meeting criteria for significant post-operative bleeding were thought to be attributable to apixaban. CONCLUSIONS Careful use of apixaban can be safe and effective while awaiting heart transplant. There was no appreciable increase in peri-operative bleeding. The use of apixaban is promising in providing safe, predictable and efficacious anticoagulation while avoiding additional patient stressors.
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Affiliation(s)
- Victor Benvenuto
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Linda Vo
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amy Hellinger
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Paul Esteso
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Di Biase L, Lakkireddy DJ, Marazzato J, Velasco A, Diaz JC, Navara R, Chrispin J, Rajagopalan B, Natale A, Mohanty S, Zhang X, Della Rocca D, Dalal A, Park K, Wiley J, Batchelor W, Cheung JW, Dangas G, Mehran R, Romero J. Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:82-108. [PMID: 38171713 DOI: 10.1016/j.jacc.2023.09.831] [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: 02/22/2023] [Revised: 08/24/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024]
Abstract
Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.
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Affiliation(s)
- Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA.
| | | | - Jacopo Marazzato
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alejandro Velasco
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Juan Carlos Diaz
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rachita Navara
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | | | - Xiaodong Zhang
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Aarti Dalal
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ki Park
- Department of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Jose Wiley
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Wayne Batchelor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - George Dangas
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jorge Romero
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
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18
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Guan C, Guo L, Liang S. Systematic Review of Randomized Clinical Trials on Direct Oral Anticoagulants in Pediatric Heart Diseases. Clin Appl Thromb Hemost 2024; 30:10760296241271974. [PMID: 39099474 DOI: 10.1177/10760296241271974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have been widely applied in adults for thrombosis prophylaxis. However, the effect of DOACs in pediatric patients with congenital or acquired heart diseases who need anticoagulation therapy remains unclear. METHODS We systematically searched the databases of PubMed, Embase, and the Cochrane Library, as well as the ClinicalTrials.gov registry and the World Health Organization's International Clinical Trials Registry Platform until June 2024 to identify relevant randomized clinical trials (RCTs). If the number of included studies was less than 5, we performed a narrative review to assess the effect of DOACs in pediatric patients. RESULTS Four studies were included. In the UNIVERSE study, thrombotic events occurred in 2% of the rivaroxaban group and 9% of the aspirin group, with bleeding events in 36% and 41%, respectively. The ENNOBLE-ATE study showed no thromboembolic events in the edoxaban group and 1.7% in the SOC group (rate difference: -0.07%, 95% CI: -0.22 to 0.07%). Major bleeding rates were similar (rate difference: -0.03%, 95% CI: -0.18 to 0.12%). The SAXOPHONE trial showed no thromboembolic events in either group and similar major bleeding rates (-0.8%, 95% CI: -8.1 to 3.3%). In the DIVERSITY trial, 81% of dabigatran patients achieved the primary outcome versus 59.3% in the SOC group (Odds ratio: 0.342, 95% CI: 0.081-1.229). No major bleeding occurred in either group. CONCLUSION Existing studies suggest that the use of DOACs hold promise as an effective and safe alternative for preventing and treating thromboembolism in pediatric patients with heart conditions.
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Affiliation(s)
- Chaokun Guan
- Department of Cardiology, Wuhan Third Hospital & Tongren Hospital of Wuhan University, Wuhan, Hubei, China
| | - Linjuan Guo
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - Shucheng Liang
- Faculty of Medicine, Macau University of Science and Technology, Macau SAR, China
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Payne RM, Burns KM, Glatz AC, Male C, Donti A, Brandão LR, Balling G, VanderPluym CJ, Bu'Lock F, Kochilas LK, Stiller B, Cnota JF, Rahkonen O, Khan A, Adorisio R, Stoica S, May L, Burns JC, Saraiva JFK, McHugh KE, Kim JS, Rubio A, Chía-Vazquez NG, Meador MR, Dyme JL, Reedy AM, Ajavon-Hartmann T, Jarugula P, Carlson-Taneja LE, Mills D, Wheaton O, Monagle P. Apixaban for Prevention of Thromboembolism in Pediatric Heart Disease. J Am Coll Cardiol 2023; 82:2296-2309. [PMID: 38057072 DOI: 10.1016/j.jacc.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Children with heart disease frequently require anticoagulation for thromboprophylaxis. Current standard of care (SOC), vitamin K antagonists or low-molecular-weight heparin, has significant disadvantages. OBJECTIVES The authors sought to describe safety, pharmacokinetics (PK), pharmacodynamics, and efficacy of apixaban, an oral, direct factor Xa inhibitor, for prevention of thromboembolism in children with congenital or acquired heart disease. METHODS Phase 2, open-label trial in children (ages, 28 days to <18 years) with heart disease requiring thromboprophylaxis. Randomization 2:1 apixaban or SOC for 1 year with intention-to-treat analysis. PRIMARY ENDPOINT a composite of adjudicated major or clinically relevant nonmajor bleeding. Secondary endpoints: PK, pharmacodynamics, quality of life, and exploration of efficacy. RESULTS From 2017 to 2021, 192 participants were randomized, 129 apixaban and 63 SOC. Diagnoses included single ventricle (74%), Kawasaki disease (14%), and other heart disease (12%). One apixaban participant (0.8%) and 3 with SOC (4.8%) had major or clinically relevant nonmajor bleeding (% difference -4.0 [95% CI: -12.8 to 0.8]). Apixaban incidence rate for all bleeding events was nearly twice the rate of SOC (100.0 vs 58.2 per 100 person-years), driven by 12 participants with ≥4 minor bleeding events. No thromboembolic events or deaths occurred in either arm. Apixaban pediatric PK steady-state exposures were consistent with adult levels. CONCLUSIONS In this pediatric multinational, randomized trial, bleeding and thromboembolism were infrequent on apixaban and SOC. Apixaban PK data correlated well with adult trials that demonstrated efficacy. These results support the use of apixaban as an alternative to SOC for thromboprophylaxis in pediatric heart disease. (A Study of the Safety and Pharmacokinetics of Apixaban Versus Vitamin K Antagonist [VKA] or Low Molecular Weight Heparin [LMWH] in Pediatric Subjects With Congenital or Acquired Heart Disease Requiring Anticoagulation; NCT02981472).
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Affiliation(s)
- R Mark Payne
- Riley Hospital for Children, Wells Center for Pediatric Research, Department of Pediatrics, Division of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA.
| | - Kristin M Burns
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Andrea Donti
- IRCCS- Azienda Ospedaliera-Universitaria, Ospedale di S. Orsola, Bologna, Italy
| | - Leonardo R Brandão
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada; Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Gunter Balling
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Christina J VanderPluym
- Heart Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frances Bu'Lock
- East Midlands Congenital Heart Centre and University of Leicester, University Hospitals of Leicester NHS Trust, Leicester, England
| | - Lazaros K Kochilas
- Children's Healthcare of Atlanta and the Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology, University Heart Centre, Medical Center-University of Freiburg, Freiburg, Germany
| | - James F Cnota
- Heart Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Otto Rahkonen
- New Children's Hospital, Helsinki University Central Hospital, Department of Pediatric Cardiology, Helsinki, Finland
| | - Asra Khan
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Rachele Adorisio
- Heart Failure, Transplant and Mechanical Assist Devices, Bambino Gesù Hospital and Research Institute, Rome, Italy
| | - Serban Stoica
- Bristol Children's Hospital and the Heart Institute, Bristol, United Kingdom
| | - Lindsay May
- University of Utah: Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Jane C Burns
- Rady Children's Hospital San Diego, University of California-San Diego, La Jolla, California, USA
| | | | - Kimberly E McHugh
- Division of Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John S Kim
- Division of Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Agustin Rubio
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - Nadia G Chía-Vazquez
- Pediatric Cardiology Department, Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Marcie R Meador
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Joshua L Dyme
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | - Alison M Reedy
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | | | | | | | - Donna Mills
- Bristol Myers Squibb, Inc, Lawrence Township, New Jersey, USA
| | | | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia; Haematology Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Haematology, Royal Children's Hospital, Melbourne, Victoria, Australia; Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
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20
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AkbariRad M, Dehghani M, Sadeghi M, Torshizian A, Saeedi N, Sarabi M, Sahebi M, Shakeri MT. The Effect of Telenursing on Disease Outcomes in People with Type 2 Diabetes Mellitus: A Narrative Review. J Diabetes Res 2023; 2023:4729430. [PMID: 38098964 PMCID: PMC10721346 DOI: 10.1155/2023/4729430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 10/27/2023] [Accepted: 11/21/2023] [Indexed: 12/17/2023] Open
Abstract
Method A comprehensive search of online databases, including PubMed, Scopus, Cochrane Library, and Google Scholar, was performed using the following MeSH keywords: telenursing, telephone follow-up, diabetes mellitus, disease management, glycemic, self-care, treatment adherence, and quality of life, up to September 2023. Two reviewers independently screened pertinent studies based on the prespecified outcomes (treatment adherence, self-care, glycemic control, and quality of life) and extracted data from all eligible studies. Results Of all retrieved records, 23 studies including 5 quasiexperimental (21%) and 18 randomized controlled trials (RCTs) (79%) from five continents met the inclusion criteria. Both male and female patients were considered in the included studies, with mean age of 56.2 years old and a follow-up range of 12 weeks to 18 months. Findings showed that telenursing or nurse telephone follow-up significantly increased mean self-care efficacy score, improved adherence to the treatment regimen, decreased glycosylated hemoglobin and plasma glucose levels (but not lipid profile and body mass index), and improved quality of life compared to the routine care in people with T2DM. Conclusion Telenursing can effectively supplement healthcare professionals to manage PWT2D. Increasing patients' knowledge about their drugs, insulin administration, and diabetes complications improves self-care behaviors and medical adherence. Consistently, improved self-care and regular use of treatment result in improved metabolic indicators and decreased rate of complications, which is associated with a better quality of life.
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Affiliation(s)
- Mina AkbariRad
- Department of Internal Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohsen Dehghani
- Department of Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Masoumeh Sadeghi
- Department of Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ashkan Torshizian
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nikoo Saeedi
- Islamic Azad University, Mashhad Branch, Mashhad, Iran
| | - Mehrdad Sarabi
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahdieh Sahebi
- Department of Epidemiology, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Taghi Shakeri
- Department of Biostatistics, Faculty of Health, Mashhad University of Medical Sciences, Mashhad, Iran
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21
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Sherwin ED, Shah MJ. Leadless Pacemakers in Patients with Congenital Heart Disease. Card Electrophysiol Clin 2023; 15:421-432. [PMID: 37865516 DOI: 10.1016/j.ccep.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Transcatheter leadless pacemakers have benefits in congenital heart disease because they eliminate the risks of lead malfunction, venous occlusions, and pocket complications. This newest pacemaker's utility in this population has been limited by the large sheath and delivery system, need for atrioventricular synchronous pacing, lack of explantation options, and possible lack of adequate access to the subpulmonary ventricle. With careful planning, leadless pacing can be successfully performed in these patients. Consideration of nonfemoral access, alternative implant sites to avoid myocardial scar or prosthetic material, anticoagulation for patients with persistent intracardiac shunts or systemic ventricular implantation, and operator experience are critical.
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Affiliation(s)
- Elizabeth D Sherwin
- Division of Pediatric Cardiology, Children's National Hospital, Division of Cardiology Washington, 111 Michigan Avenue, NW, Washington, DC 20010, USA
| | - Maully J Shah
- Cardiac Electrophysiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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22
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Hosoi M, Ohbayashi M, Miyahara Y, Fujii T, Kise H, Kogo M. Risk Factors for Thromboembolic and Bleeding Events in Patients After the Fontan Operation (Insights from the National Database of Health Insurance Claims of Japan). Am J Cardiol 2023; 207:399-406. [PMID: 37782971 DOI: 10.1016/j.amjcard.2023.08.153] [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: 05/02/2023] [Revised: 08/23/2023] [Accepted: 08/23/2023] [Indexed: 10/04/2023]
Abstract
Risk stratification of thromboembolic events (TEs) and bleeding events is important for the appropriate selection of thromboprophylaxis in patients after the Fontan operation. Therefore, we clarified the risk factors for TEs and bleeding events in patients after the Fontan operation using the National Database of Health Insurance Claims and Specific Health Checkups of Japan. We conducted a retrospective cohort study including 2,515 patients who underwent the Fontan operation between June 2011 and September 2019. The end points were TEs and bleeding events within 1 year of the Fontan operation analysis. We analyzed the risk factors for these end points using a multivariate analysis. In total, 1,903 patients were included in the analysis. The median age at the time of the Fontan operation was 3 (1 to 22) years, and 1,067 patients (56%) were male. The incidence rates of TEs and bleeding events were 12% and 11%, respectively. Age (odds ratio [OR] 1.1 per 1 year older, p <0.05) was an independent risk factor for TEs. Thromboprophylaxis with aspirin after the Fontan operation significantly reduced TEs (OR 0.3, p <0.05). A history of postoperative hemorrhage (OR 1.5, p <0.05) and the use of a potassium channel blocker (OR 2.1, p <0.05) were independent risk factors for bleeding events. In conclusion, aspirin was found to reduce the risk of TEs within 1 year of the Fontan operation. The results of this study will be useful in selecting effective and safe thromboprophylaxis in patients after the Fontan operation.
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Affiliation(s)
- Masayoshi Hosoi
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, School of Pharmacy, Showa University, Tokyo, Japan; Pfizer Japan Inc., Tokyo, Japan.
| | - Masayuki Ohbayashi
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, School of Pharmacy, Showa University, Tokyo, Japan
| | - Yoshinori Miyahara
- Pediatric Heart Disease and Adult Congenital Heart Disease Center, Showa University Hospital, Tokyo, Japan
| | - Takanari Fujii
- Pediatric Heart Disease and Adult Congenital Heart Disease Center, Showa University Hospital, Tokyo, Japan
| | - Hiroaki Kise
- Pediatric Heart Disease and Adult Congenital Heart Disease Center, Showa University Hospital, Tokyo, Japan
| | - Mari Kogo
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, School of Pharmacy, Showa University, Tokyo, Japan
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23
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Visser C, Yousefi A, Nierman MC, Huisman MV, Gulpen AJW, van Ommen CH, Kruip MJHA. The effect of COVID-19 vaccination on anticoagulation stability in adolescents and young adults using vitamin K antagonists. Thromb Res 2023; 228:121-127. [PMID: 37321159 PMCID: PMC10258126 DOI: 10.1016/j.thromres.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/21/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION The European Medicine Agency has authorized COVID-19 vaccination in adolescents and young adults (AYAs) from 12 years onwards. In elderly vitamin K antagonist (VKA) users, COVID-19 vaccination has been associated with an increased risk of supra- and subtherapeutic INRs. Whether this association is also observed in AYAs using VKA is unknown. Our aim was to describe the stability of anticoagulation after COVID-19 vaccination in AYA VKA users. MATERIALS AND METHODS A case-crossover study was performed in a cohort of AYAs (12-30 years) using VKAs. The most recent INR results before vaccination, the reference period, were compared with the most recent INR after the first and, if applicable, second vaccination. Several sensitivity analyses were performed in which we restricted our analysis to stable patients and patients without interacting events. RESULTS 101 AYAs were included, with a median age [IQR] of 25 [7] years, of whom 51.5 % were male and 68.3 % used acenocoumarol. We observed a decrease of 20.8 % in INRs within range after the first vaccination, due to an increase of 16.8 % in supratherapeutic INRs. These results were verified in our sensitivity analyses. No differences were observed after the second vaccination compared to before and after the first vaccination. Complications after vaccination occurred less often than before vaccination (9.0 vs 3.0 bleedings) and were non-severe. CONCLUSIONS the stability of anticoagulation after COVID-19 vaccination was decreased in AYA VKA users. However, the decrease might not be clinically relevant as no increase of complications nor significant dose adjustments were observed.
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Affiliation(s)
- Chantal Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Arjen Yousefi
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostics Centers, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Anouk J W Gulpen
- Department of Internal Medicine, The Elkerliek Hospital, Helmond, the Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands; Thrombosis Service Star-shl, Rotterdam, the Netherlands.
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24
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Cohen CT, Zobeck M, Han H, Spinner JA, Powers JM, Lee-Kim Y, Sartain SE. Bleeding outcomes and management of supratherapeutic episodes secondary to warfarin in children: A single center 10-year experience. Thromb Res 2023; 228:148-150. [PMID: 37329724 PMCID: PMC10699501 DOI: 10.1016/j.thromres.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Clay T Cohen
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA.
| | - Mark Zobeck
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
| | - HyoJeong Han
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
| | - Joseph A Spinner
- Division of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jacquelyn M Powers
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
| | - YoungNa Lee-Kim
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
| | - Sarah E Sartain
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, TX, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to review recent findings regarding stroke epidemiology, etiologies, and treatment in children and young adults. RECENT FINDINGS Incidence in young adults is increasing, and incidence, recurrence, and survival is worse in patients with cryptogenic stroke and in developing countries. Careful consideration of patent foramen ovale closure is now recommended in young adults with cryptogenic stroke. Thrombectomy has recently been extended to carefully selected children with acute ischemic stroke, and two recent publications strongly suggest that it can be beneficial for children. Sickle cell is also an important global contributor to stroke burden, but hydroxyurea can be a cost effective medication for stroke prevention in children. Recent advances in genetic testing and treatments may improve outcomes for patients with monogenic causes of stroke, such as deficiency of adenosine deaminase 2, hemophilia, and Fabry's disease. SUMMARY Stroke in children and young adults is a morbid disease responsible for enormous indirect societal costs and a high burden of years with disability per affected patient. Recent advances have improved access to care for children with large vessel occlusion and adults with rare causes of stroke. Future research may bring effective treatments for other monogenic causes of stroke as well as increasing access to hyperacute therapies for young stroke patients.
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Affiliation(s)
- Stuart Fraser
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center Houston, Houston, Texas
| | - Lisa Pabst
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Fiona Smith
- Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, Texas and Houston Methodist Sugar Land Hospital, Sugar Land, Texas
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26
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Fox C. Pediatric Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:566-583. [PMID: 37039410 DOI: 10.1212/con.0000000000001239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Pediatric cerebrovascular disease is one of the leading causes of death and disability in children. Survivors of childhood stroke and their families are often left to cope with long-lasting sequelae, such as barriers to school reentry and long-term challenges in attaining independence as adults. Because childhood stroke is rare and providers may not be familiar with the disorder, this article reviews the risk factors, acute management, and sequelae of ischemic stroke in children. LATEST DEVELOPMENTS High-quality evidence has resulted in an organized approach to emergent treatment of ischemic stroke in adults, but most front-line providers are less prepared for emergent stroke management in children. The level of evidence for reperfusion therapies in children remains low but is growing. Thrombolysis and thrombectomy are sometimes considered for hyperacute treatment of stroke in children. Readiness for pediatric stroke at regional centers should include an organized approach to pediatric stroke triage and management based on extrapolation from adult stroke trials, expert consensus, and emerging pediatric studies. ESSENTIAL POINTS This review provides up-to-date information about ischemic stroke risk factors and management in children. Preparation for rapid stroke diagnosis and management in children may improve outcomes.
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Grapsy J, Hoang A, Lee Y, Zia A. Potential drug-drug interaction between warfarin and norethindrone in adolescent females: A case series. Am J Health Syst Pharm 2023; 80:124-129. [PMID: 36264703 DOI: 10.1093/ajhp/zxac303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Indexed: 01/26/2023] Open
Abstract
PURPOSE In the pediatric population, warfarin remains the recommended oral anticoagulant for valvular heart disease. Warfarin carries a risk of bleeding complications that can manifest as heavy menstrual bleeding (HMB) in postmenarchal adolescent females. As a result, these patients may be started on hormonal therapies, such as norethindrone, to suppress menstruation. SUMMARY This case series describes a potential drug interaction between warfarin and norethindrone in 3 adolescent females with a history of mechanical mitral valve replacement who developed HMB. These patients were on stable warfarin regimens before the initiation of norethindrone and subsequently experienced increases in their international normalized ratio (INR). In response, they required an up to 50% reduction in their weekly warfarin dose over 5 to 12 weeks. CONCLUSION These observations suggest that use of norethindrone for the management of HMB may significantly potentiate the anticoagulant effect of warfarin. Close INR monitoring and aggressive dose adjustments during initiation and discontinuation of norethindrone are recommended in patients on warfarin.
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Affiliation(s)
- Jillian Grapsy
- Department of Pharmacy, Children's Health Medical Center Dallas, Dallas, TX, USA
| | - Anh Hoang
- Department of Pharmacy, Children's Health Medical Center Dallas, Dallas, TX, USA
| | - Ying Lee
- Department of Pharmacy, Children's Health Medical Center Dallas, Dallas, TX, USA
| | - Ayesha Zia
- Department of Pediatrics-Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX, USA
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28
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Special Considerations in Critical Care of the Congenital Heart Disease Patient. Can J Cardiol 2023; 39:544-557. [PMID: 36682483 DOI: 10.1016/j.cjca.2023.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Outcomes of congenital heart disease have improved markedly over the past 20 years, with survival to adulthood now close to 90%. The mean age of admission to an intensive care unit (ICU) is 40 years. The incidence of hospital and critical care admissions have increased significantly as a consequence of this improved survival. Intensivists are now confronted with the management not only of complex adult congenital heart disease (ACHD) lesions from a cardiac perspective, but also of extracardiac organ consequences of years of abnormal circulation after surgical or palliative correction. Kidney and liver dysfunction and respiratory and hematologic abnormalities are very common in this population. ACHD patients can present to the ICU for a vast number of reasons, classified in this review as medical noncardiac, medical cardiac, and surgical. Community/hospital-acquired infections, cerebrovascular accidents, and respiratory failure, alongside arrhythmias and heart failure, are responsible for medical admissions. Surgical admissions include postoperative management after correction or palliation, but also medical optimisation and work-up for advanced therapies. ICU management of this large heterogeneous group requires a thorough understanding of the pathophysiology in order to apply conventional adult critical care modalities; left ventricular or right ventricular dysfunction, pulmonary hypertension, intracardiac, extracardiac, and palliative surgical shunts can be present and require additional consideration. This review focuses on the pathophysiology, long-term sequelae, and different treatment modalities to supply a framework for the ICU physician caring for these patients. Successful outcome, especially in complex lesions, depends on early involvement of specialised ACHD centres.
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29
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Pérez-Pérez A, Vigil-Vázquez S, Gutiérrez-Vélez A, Solís-García G, López-Blázquez M, Zunzunegui Martínez JL, Medrano López C, Gil-Jaurena JM, de Agustín-Asensio JC, Sánchez-Luna M. Chylothorax in newborns after cardiac surgery: a rare complication? Eur J Pediatr 2023; 182:1569-1578. [PMID: 36646910 DOI: 10.1007/s00431-023-04808-5] [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: 11/27/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/18/2023]
Abstract
UNLABELLED The aim of this study was to analyze patients diagnosed with chylothorax after congenital heart disease surgery among a cohort of neonatal patients, comparing the evolution, complications, and prognosis after surgery of patients who were and were not diagnosed with chylothorax, and to analyze possible risk factors that may predict the appearance of chylothorax in this population. Retrospective and observational study included all neonates (less than 30 days since birth) who underwent congenital heart disease surgery in a level III neonatal intensive care department. We included infants born between January 2014 and December 2019. We excluded those infants who were born before 34 weeks of gestational age or whose birth weight was less than 1800 g. We also excluded catheter lab procedures and patent ductus arteriosus closure surgeries. Included patients were divided into two groups depending on whether they were diagnosed with chylothorax or not after surgery, and both groups were compared in terms of perinatal-obstetrical information, surgical data, and NICU course after surgery. We included 149 neonates with congenital heart disease surgery. Thirty-one patients (20.8%) developed chylothorax, and in ten patients (32.3%), it was considered large volume chylothorax. Regarding the evolution of these patients, 22 infants responded to general dietetic measures, a catheter procedure was performed in 9, and 5 of them finally required pleurodesis. Cardiopulmonary bypass, median sternotomy, and delayed sternal closure were the surgical variables associated with higher risks of chylothorax. Patients with chylothorax had a longer duration of inotropic support and mechanical ventilation and took longer to reach full enteral feeds. As complications, they had higher rates of cholestasis, catheter-related sepsis, and venous thrombosis. Although there were no differences in neonatal mortality, patients with chylothorax had a higher rate of mortality after the neonatal period. In a multiple linear regression model, thrombosis and cardiopulmonary bypass multiplied by 10.0 and 5.1, respectively, the risk of chylothorax and have an umbilical vein catheter decreases risk. CONCLUSION We have found a high incidence of chylothorax after neonatal cardiac surgery, which prolongs the average stay and causes significant morbidity and mortality. We suggested that chylothorax could be an underestimated complication of congenital heart disease surgery during the neonatal period. WHAT IS KNOWN • Acquired chylothorax in the neonatal period usually appears as a complication of congenital heart disease surgery, being the incidence quite variable among the different patient series (2.5-16.8%). The appearance of chylothorax as a complication of a cardiac surgery increases both mortality and morbidity in these patients, which makes it a quality improvement target in the postsurgical management of this population. WHAT IS NEW •Most of the published studies include pediatric patients of all ages, from newborns to teenagers, and there is a lack of studies focusing on neonatal populations. The main strength of our study is that it reports, to the best of our knowledge, one of the largest series of neonatal patients receiving surgery for congenital heart disease in the first 30 days after birth. We have found a high incidence of chylothorax after cardiac surgery during the neonatal period compared to other studies. We suggested that chylothorax could be an underestimated complication of congenital heart disease surgery during this period of life.
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Affiliation(s)
- Alba Pérez-Pérez
- Neonatology Department, Hospital General Universitario Gregorio Marañón, O'Donnell 48, Madrid, 28009, Spain.
| | - Sara Vigil-Vázquez
- Neonatology Department, Hospital General Universitario Gregorio Marañón, O'Donnell 48, Madrid, 28009, Spain
| | - Ana Gutiérrez-Vélez
- Neonatology Department, Hospital General Universitario Gregorio Marañón, O'Donnell 48, Madrid, 28009, Spain
| | | | - María López-Blázquez
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Juan Miguel Gil-Jaurena
- Pediatric Cardiac Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Manuel Sánchez-Luna
- Neonatology Department, Hospital General Universitario Gregorio Marañón, O'Donnell 48, Madrid, 28009, Spain
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30
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Tan RBM, Giglia TM, Cecchin F. Time to Move Forward on Pediatric Atrial Standstill. JACC Clin Electrophysiol 2023; 9:70-72. [PMID: 36697202 DOI: 10.1016/j.jacep.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/20/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Reina Bianca M Tan
- Division of Cardiology, Hassenfeld Children's Hospital, NYU Langone Health, New York, New York USA
| | - Therese M Giglia
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Frank Cecchin
- Division of Cardiology, Hassenfeld Children's Hospital, NYU Langone Health, New York, New York USA.
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31
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de Lange C, Möller T, Hebelka H. Fontan-associated liver disease: Diagnosis, surveillance, and management. Front Pediatr 2023; 11:1100514. [PMID: 36937979 PMCID: PMC10020358 DOI: 10.3389/fped.2023.1100514] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
The Fontan operation is a lifesaving procedure for patients with functional single-ventricle congenital heart disease, where hypoplastic left heart syndrome is the most frequent anomaly. Hemodynamic changes following Fontan circulation creation are now increasingly recognized to cause multiorgan affection, where the development of a chronic liver disease, Fontan-associated liver disease (FALD), is one of the most important morbidities. Virtually, all patients with a Fontan circulation develop liver congestion, resulting in fibrosis and cirrhosis, and most patients experience childhood onset. FALD is a distinctive type of congestive hepatopathy, and its pathogenesis is thought to be a multifactorial process driven by increased nonpulsatile central venous pressure and decreased cardiac output, both of which are inherent in the Fontan circulation. In the advanced stage of liver injury, complications of portal hypertension often occur, and there is a risk of developing secondary liver cancer, reported at young age. However, FALD develops with few clinical symptoms, a surprisingly variable degree of severity in liver disease, and with little relation to poor cardiac function. The disease mechanisms and modifying factors of its development are still not fully understood. As one of the more important noncardiac complications of the Fontan circulation, FALD needs to be diagnosed in a timely manner with a structured monitoring scheme of disease development, early detection of malignancy, and determination of the optimal time point for transplantation. There is also a clear need for consensus on the best surveillance strategy for FALD. In this regard, imaging plays an important role together with clinical scoring systems, biochemical workups, and histology. Patients operated on with a Fontan circulation are generally followed up in cardiology units. Ultimately, the resulting multiorgan affection requires a multidisciplinary team of healthcare personnel to address the different organ complications. This article discusses the current concepts, diagnosis, and management of FALD, with special emphasis on the role of different imaging techniques in the diagnosis and monitoring of disease progression, as well as current recommendations for liver disease surveillance.
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Affiliation(s)
- Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas Möller
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hanna Hebelka
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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32
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Rawanduzy CA, Earl E, Mayer G, Lucke-Wold B. Pediatric Stroke: A Review of Common Etiologies and Management Strategies. Biomedicines 2022; 11:biomedicines11010002. [PMID: 36672510 PMCID: PMC9856134 DOI: 10.3390/biomedicines11010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Pediatric stroke is an important cause of mortality and morbidity in children. There is a paucity of clinical trials pertaining to pediatric stroke management, and solidified universal guidelines are not established for children the way they are for the adult population. Diagnosis of pediatric stroke can be challenging, and it is often delayed or mischaracterized, which can result in worse outcomes. Understanding risks and appropriate therapy is paramount to improving care.
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Affiliation(s)
| | - Emma Earl
- School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Greg Mayer
- School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
- Correspondence:
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33
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Choueiter NF. Advancing Anticoagulation for Children With Cardiac Disease. J Am Coll Cardiol 2022; 80:2311-2313. [PMID: 36480973 DOI: 10.1016/j.jacc.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/06/2022] [Accepted: 10/06/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Nadine F Choueiter
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA.
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34
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Edoxaban for Thromboembolism Prevention in Pediatric Patients With Cardiac Disease. J Am Coll Cardiol 2022; 80:2301-2310. [PMID: 36328157 DOI: 10.1016/j.jacc.2022.09.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/23/2022] [Accepted: 09/28/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Standard of care (SOC) anticoagulation for thromboembolism (TE) prevention in children with cardiac disease includes low molecular weight heparins or vitamin K antagonists. Limited data exists for alternate use of direct oral anticoagulants in children. OBJECTIVES The investigators aimed to obtain safety and efficacy data for edoxaban in children. METHODS We performed a phase 3, multinational, prospective, randomized, open-label, blinded-endpoint trial in patients <18 years of age with cardiac disease (ENNOBLE-ATE [Edoxaban for Prevention of Blood Vessels Being Blocked by Clots (Thrombotic Events) in Children at Risk Because of Cardiac Disease] trial). Patients were randomized 2:1 to age- and weight-based oral edoxaban once daily vs SOC for 3 months (main study period), stratified by cardiac diagnosis. Both groups could continue in an open-label edoxaban extension arm through 1 year. The primary endpoint was adjudicated clinically relevant bleeding (CRB). The main secondary endpoint was symptomatic TE or asymptomatic intracardiac thrombosis. RESULTS The modified intention-to-treat cohort included 167 children. One patient per group experienced a nonmajor CRB in the main period. Treatment-emergent adverse events occurred in 46.8% (51 of 109) with edoxaban and 41.4% (24 of 58) with SOC. One SOC patient experienced 2 TE events (DVT with PE). Among 147 children in the extension, 1 CRB event (0.7%) and 4 TEs occurred (2.8%; 2 strokes and 2 of 33 Kawasaki disease patients with coronary artery thromboses and/or myocardial infarctions). CONCLUSIONS Edoxaban is a potential alternative mode of thromboprophylaxis in children with cardiac disease showing low rates of CRB and TEs with advantages of once daily dosing and infrequent monitoring requirement. (ENNOBLE-ATE [Edoxaban for Prevention of Blood Vessels Being Blocked by Clots] (Thrombotic Events) in Children at Risk Because of Cardiac Disease trial; NCT03395639).
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35
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Long F, Zhu S, Wang Z, Zhang S, He J, Ge X, Ning J. Update on the treatment of multisystem inflammatory syndrome in children associated with COVID-19. Future Virol 2022:10.2217/fvl-2022-0048. [PMID: 36699562 PMCID: PMC9853872 DOI: 10.2217/fvl-2022-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 12/05/2022] [Indexed: 01/21/2023]
Abstract
In late 2019, SARS-CoV-2 was detected in China and spread worldwide. In rare cases, children who were infected with COVID-19 may develop multisystem inflammatory syndrome (MIS-C), which could have higher mortality than COVID-19 itself. Therefore, diagnosis and management are critical for treatment. Specifically, most of the initial treatment options of MIS-C choose intravenous immunoglobulin (IVIG) and steroids as the first-line treatment for patients. Moreover, antagonists of some cytokines are used as potential future therapeutics. Of note, therapeutic plasmapheresis can be used as a treatment for refractory severe MIS-C. We believe that each patient, especially those with comorbid conditions, should have individualized treatment based on both multidisciplinary consensus approach and expert opinion.
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Affiliation(s)
- Fangyuan Long
- 1Department of Physiology, Jining Medical University, 133 Hehua Rd, Jining, 272067, China
| | - Shiheng Zhu
- 1Department of Physiology, Jining Medical University, 133 Hehua Rd, Jining, 272067, China
| | - Zeguang Wang
- 1Department of Physiology, Jining Medical University, 133 Hehua Rd, Jining, 272067, China
| | - Shungeng Zhang
- 1Department of Physiology, Jining Medical University, 133 Hehua Rd, Jining, 272067, China
| | - Jinlong He
- 1Department of Physiology, Jining Medical University, 133 Hehua Rd, Jining, 272067, China
| | - Xinbin Ge
- 1Department of Physiology, Jining Medical University, 133 Hehua Rd, Jining, 272067, China
| | - Jun Ning
- 2Department of Paediatrics, Affiliated Hospital of Jining Medical University, Jining, Shandong, 272029, China,Author for correspondence:
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Anton-Martin P, Matherne E, Kramer J, Joseph N, Rayburn M. Cangrelor Dosing and Monitoring for Prevention of Acute Systemic-to-Pulmonary Artery Shunt Thrombosis in Neonates. J Pediatr Pharmacol Ther 2022; 27:707-714. [DOI: 10.5863/1551-6776-27.8.707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 01/13/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE
Systemic-to-pulmonary artery shunts are amongst the most common palliative procedures performed in neonates with congenital heart defects. These procedures require immediate postoperative thromboprophylaxis to prevent life-threatening shunt thrombosis. The novel use of intravenous P2Y12 platelet receptor antagonists has led to a need for dosing recommendations and monitoring. This study aims to determine cangrelor dosing in neonates through laboratory assessment of P2Y12 receptor reactivity and adverse events.
METHODS
Observational retrospective cohort study on the use of cangrelor for thromboprophylaxis in the immediate postoperative period of neonates undergoing placement of systemic-to-pulmonary artery shunts in a tertiary children's hospital from March 2020 to March 2021.
RESULTS
Ten neonates receiving cangrelor post systemic-to-pulmonary artery shunt placement were included in the study. Median age and weight were 4 days (IQR, 2.75–5.25) and 3.49 kg (IQR, 3.1–3.75), respectively. Five (50%) patients received a 3.5-mm shunt, while the remaining patients received a 4-mm shunt. For thrombin inhibition, 5 (50%) patients received heparin and 5 (50%) received bivalirudin. Median cangrelor dose was 0.1 mcg/kg/min (IQR, 0.1–0.1). Median achieved P2Y12 reaction units (PRU) at this cangrelor dose was 127.5 (IQR, 72.5–173.75). No shunt thrombosis occurred in these patients; however, there was 1 minor hemorrhagic event.
CONCLUSIONS
Our study suggests that a cangrelor dose of 0.1 mcg/kg/min is associated with therapeutic PRU and prevents shunt thrombosis in neonates post systemic-to-pulmonary artery shunt, with minimal hemorrhagic complications.
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Affiliation(s)
- Pilar Anton-Martin
- Department of Pediatrics, Division of Cardiology (PAM, JK), University of Tennessee Health Science Center/Le Bonheur Children's Hospital, Memphis, TN
| | - Emma Matherne
- Department of Clinical Pharmacy and Translational Science (EM, MR), University of Tennessee Health Science Center/Le Bonheur Children's Hospital, Memphis, TN
| | - Jennifer Kramer
- Department of Pediatrics, Division of Cardiology (PAM, JK), University of Tennessee Health Science Center/Le Bonheur Children's Hospital, Memphis, TN
| | - Noel Joseph
- Department of Pediatrics, Division of Critical Care Medicine (JN), University of Tennessee Health Science Center/Le Bonheur Children's Hospital, Memphis, TN
| | - Mark Rayburn
- Department of Clinical Pharmacy and Translational Science (EM, MR), University of Tennessee Health Science Center/Le Bonheur Children's Hospital, Memphis, TN
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Management of Multisystem Inflammatory Syndrome in Children: Decision-Making Regarding a New Condition in the Absence of Clinical Trial Data. Can J Cardiol 2022:S0828-282X(22)01048-0. [PMID: 36455760 PMCID: PMC9705008 DOI: 10.1016/j.cjca.2022.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a new illness that evolved during the COVID-19 pandemic with initial reports of severe disease including use of extracorporeal membrane oxygenation and death. Institutions rapidly assembled task forces to develop treatment algorithms. At the national/international levels, collaboratives and associations assembled consensus writing groups to draft guidelines. These guidelines and algorithms were initially on the basis of expert opinion and small case series. Some groups used the Delphi approach, and the resultant guidelines often mimicked those for other conditions that resembled MIS-C, like Kawasaki disease (KD). For instance, intravenous immunoglobulin (IVIG), a known effective treatment for KD, was recommended for MIS-C. Early in the pandemic many favoured IVIG over steroids as first-line therapy. As evidence evolved so did some guidelines, which now endorse the dual use of IVIG with steroids as first-line therapy. In contrast, withholding immunotherapy became an option for some MIS-C patients with mild symptoms. Herein, we review guidelines and discuss the evidence informing early recommendations, how this has evolved, the role and limitations of expert opinion and observational data, and the importance of leveraging existing research infrastructures, such as the intensive care unit collaborative (Overcoming COVID-19 surveillance registry), and the International Kawasaki Disease Registry. Finally, we discuss strategies to rapidly develop, deploy, and adapt clinical trials evaluating the treatment of such rare conditions in children, which might include alternatives to conventional clinical trial design. The emergence of MIS-C during the COVID-19 pandemic has highlighted unmet needs regarding research of a new condition.
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Cooper DS, Hill KD, Krishnamurthy G, Sen S, Costello JM, Lehenbauer D, Twite M, James L, Mah KE, Taylor C, McBride ME. Acute Cardiac Care for Neonatal Heart Disease. Pediatrics 2022; 150:189882. [PMID: 36317971 DOI: 10.1542/peds.2022-056415j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/07/2022] Open
Abstract
This manuscript is one component of a larger series of articles produced by the Neonatal Cardiac Care Collaborative that are published in this supplement of Pediatrics. In this review article, we summarize the contemporary physiologic principles, evaluation, and management of acute care issues for neonates with complex congenital heart disease. A multidisciplinary team of authors was created by the Collaborative's Executive Committee. The authors developed a detailed outline of the manuscript, and small teams of authors were assigned to draft specific sections. The authors reviewed the literature, with a focus on original manuscripts published in the last decade, and drafted preliminary content and recommendations. All authors subsequently reviewed and edited the entire manuscript until a consensus was achieved. Topics addressed include cardiopulmonary interactions, the pathophysiology of and strategies to minimize the development of ventilator-induced low cardiac output syndrome, common postoperative physiologies, perioperative bleeding and coagulation, and common postoperative complications.
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Affiliation(s)
- David S Cooper
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kevin D Hill
- Division of Cardiology, Duke Children's Hospital, Durham, North Carolina
| | - Ganga Krishnamurthy
- Division of Neonatology, Columbia University Medical Center, New York, New York
| | - Shawn Sen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John M Costello
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - David Lehenbauer
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark Twite
- Department of Anesthesia, Colorado Children's Hospital, Aurora, Colorado
| | - Lorraine James
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, California
| | - Kenneth E Mah
- Department of Pediatrics, University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Carmen Taylor
- Department of Pediatric Cardiothoracic Surgery, The Children's Hospital, Oklahoma City, Oklahoma
| | - Mary E McBride
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Management of Patients With MAC: Percutaneous Therapies for the Rescue of Failing Surgery. JACC Case Rep 2022; 4:1274-1276. [PMID: 36406908 PMCID: PMC9666920 DOI: 10.1016/j.jaccas.2022.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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40
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Srivastava R, Mailo J, Dunbar M. Perinatal Stroke in Fetuses, Preterm and Term Infants. Semin Pediatr Neurol 2022; 43:100988. [PMID: 36344024 DOI: 10.1016/j.spen.2022.100988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/06/2022] [Accepted: 07/29/2022] [Indexed: 12/14/2022]
Abstract
Perinatal stroke is a well-defined heterogenous group of disorders involving a focal disruption of cerebral blood flow between 20 weeks gestation and 28 days of postnatal life. The most focused lifetime risk for stroke occurs during the first week after birth. The morbidity of perinatal stroke is high, as it is the most common cause of hemiparetic cerebral palsy which results in lifelong disability that becomes more apparent throughout childhood. Perinatal strokes can be classified by the timing of diagnosis (acute or retrospective), vessel involved (arterial or venous), and underlying cause (hemorrhagic or ischemic). Perinatal stroke has primarily been reported as a disorder of term infants; however, the preterm brain possesses different vulnerabilities that predispose an infant to stroke injury both in utero and after birth. Accurate diagnosis of perinatal stroke syndromes has important implications for investigations, management, and prognosis. The classification of perinatal stroke by age at presentation (fetal, preterm neonatal, term neonatal, and infancy/childhood) is summarized in this review, and includes detailed descriptions of risk factors, diagnosis, treatment, outcomes, controversies, and resources for family support.
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Affiliation(s)
- R Srivastava
- Division of Pediatric Neurology, Department of Pediatrics, University of Albertam, AB, Canada
| | - J Mailo
- Division of Pediatric Neurology, Department of Pediatrics, University of Albertam, AB, Canada
| | - M Dunbar
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, AB, Canada; Alberta Children's Hospital Research Institute (ACHRI), Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, AB, Canada.
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41
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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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Jin Y, Cui Y, Zhang Y, Zhang P, Bai L, Li Y, Gao P, Wang W, Wang X, Liu J, Hu J. Hemostatic complications and systemic heparinization in pediatric post-cardiotomy veno-arterial extracorporeal membrane oxygenation failed to wean from cardiopulmonary bypass. Transl Pediatr 2022; 11:1458-1469. [PMID: 36247891 PMCID: PMC9561514 DOI: 10.21037/tp-22-104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/08/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Hemostatic complications and the need for large amounts of blood products are major obstacles during veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Additionally, the occurrence of coagulopathy after cardiopulmonary bypass (CPB) affects systemic heparinization in pediatric post-cardiotomy patients. This study compares hemostatic complications in pediatric post-cardiotomy VA-ECMO patients for failure to wean from CPB with those who received post-cardiotomy VA-ECMO for other indications, while also exploring the relationship between different stages-hemostatic complications and the timing of systemic heparinization. METHODS We retrospectively analyzed 146 pediatric patients who received post-cardiotomy VA-ECMO support (CPB-ECMO, n=96 vs. non-CPB-ECMO, n=50) from January 2005 to June 2020. Patients were divided into survivors (n=46) and non-survivors (n=50) according to in-hospital mortality in the CPB-ECMO group. We compared clinical outcomes between the groups, then examined the associations between the timing of systemic heparinization after ECMO implantation and different stages-hemostatic complications, in the CPB-ECMO group. RESULTS We found that the risk of early bleeding was significantly increased in patients who failed to wean from CPB. The presence of early bleeding was accompanied by the higher demand for blood products transfusion in the CPB-ECMO group, and for treatment the patients received a longer delayed continuous heparin infusion. As a result of using delayed systemic heparinization to avoid early bleeding, early hemolysis increased in the CPB-ECMO group. A delayed systemic heparinization of 9.5 hours showed the best Youden index results and the overall greatest accuracy in predicting early hemolysis. CONCLUSIONS A direct transition from CPB to ECMO in pediatric post-cardiotomy patients significantly increases early bleeding. Delayed systemic heparinization to reduce early bleeding has good discrimination for predicting early hemolysis in the CPB-ECMO group. Coagulopathy is complex in pediatric post-cardiotomy VA-ECMO patients who failed to wean from CPB, and, as such, it is extremely important to monitor coagulation-related indicators in multiple dimensions to determine the timing of systemic heparinization.
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Affiliation(s)
- Yu Jin
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongli Cui
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peiyao Zhang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liting Bai
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yixuan Li
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Gao
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenting Wang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Wang
- Department of Pediatric Intensive Care Unit, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinxiao Hu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Willmann S, Ince I, Ahsman M, Coboeken K, Zhang Y, Thelen K, Kubitza D, Zannikos P, Zhou W, Pina LM, Post T, Lippert J. Model‐informed bridging of rivaroxaban doses for thromboprophylaxis in pediatric patients aged 9 years and older with congenital heart disease. CPT Pharmacometrics Syst Pharmacol 2022; 11:1111-1121. [PMID: 35665486 PMCID: PMC9381895 DOI: 10.1002/psp4.12830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/09/2022] [Accepted: 05/23/2022] [Indexed: 12/04/2022] Open
Abstract
Rivaroxaban is approved in various regions for the treatment of acute venous thromboembolism (VTE) in children aged between 0 and 18 years and was recently investigated for thromboprophylaxis in children aged between 2 and 8 years (with body weights <30 kg) with congenital heart disease who had undergone the Fontan procedure. In the absence of clinical data, rivaroxaban doses for thromboprophylaxis in post‐Fontan children aged 9 years and older or ≥30 kg were derived by a bridging approach that used physiologically‐based pharmacokinetic (PBPK) and population pharmacokinetic (popPK) models based on pharmacokinetic (PK) data from 588 pediatric patients and from adult patients who received 10 mg once daily for thromboprophylaxis after major orthopedic surgeries as a reference. Both models showed a tendency toward underestimating rivaroxaban exposure in post‐Fontan patients aged between 2 and 5 years but accurately described rivaroxaban PK in post‐Fontan patients aged between 5 and 8 years. Under the assumption that hepatic function is not impaired in post‐Fontan patients, PBPK and popPK simulations indicated that half of the rivaroxaban doses for the same body weight given to pediatric patients treated for acute VTE would yield in pediatric post‐Fontan patients exposures similar to the exposure observed in adult patients receiving 10 mg rivaroxaban once daily for thromboprophylaxis. Simulation‐derived doses (7.5 mg rivaroxaban once daily for body weights 30–<50 kg and 10 mg once daily for body weights ≥50 kg) were therefore included in the recent US label of rivaroxaban for thromboprophylaxis in children aged 2 years and older with congenital heart disease who have undergone the Fontan procedure.
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Affiliation(s)
- Stefan Willmann
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Ibrahim Ince
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Maurice Ahsman
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics Leiden The Netherlands
| | - Katrin Coboeken
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Yang Zhang
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Kirstin Thelen
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Dagmar Kubitza
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Peter Zannikos
- Janssen Research & Development, LLC Raritan New Jersey USA
| | - Wangda Zhou
- Janssen Research & Development, LLC Raritan New Jersey USA
| | | | - Teun Post
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics Leiden The Netherlands
| | - Jörg Lippert
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
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Majiyagbe OO, Akinsete AM, Adeyemo TA, Salako AO, Ekure EN, Okoromah CAN. Coagulation abnormalities in children with uncorrected congenital heart defects seen at a teaching hospital in a developing country. PLoS One 2022; 17:e0263948. [PMID: 35901057 PMCID: PMC9333323 DOI: 10.1371/journal.pone.0263948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 04/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background Coagulation abnormality is a significant complication and cause of mortality in children with uncorrected congenital heart defects (CHD). The aim of this study was to determine the prevalence of coagulation abnormalities and the associated factors in children with uncorrected CHD. Method A cross sectional study conducted to determine the prevalence of coagulation abnormalities among 70 children with uncorrected CHD aged six months to 17 years and 70 age and sex matched apparently healthy controls. Coagulation abnormalities was determined using complete blood count, prothrombin time, activated partial thromboplastin time and D-dimer assay. Results The prevalence of coagulation abnormalities among children with CHD and controls was 37.1% and 7.1% respectively. Children with Cyanotic CHD had a significantly higher prevalence of coagulation abnormalities compared to children with Acyanotic CHD (57.1% versus 17.1%). Haematocrit and oxygen saturation levels were significantly associated with coagulation abnormalities. Conclusion This study affirms that coagulation abnormalities are frequent in children with uncorrected CHD. Oxygen saturation and haematocrit are risk factors of coagulation abnormalities. Routine coagulation screen is recommended especially in children with cyanotic congenital heart defects to improve their quality of life and reduce morbidity and mortality while awaiting definitive surgeries.
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Affiliation(s)
- Omotola O. Majiyagbe
- Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
- Department of Paediatrics, Massey Street Children’s Hospital, Lagos Island, Lagos, Nigeria
- * E-mail:
| | - Adeseye M. Akinsete
- Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
- Department of Paediatrics, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Titilope A. Adeyemo
- Department of Pathology, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Abideen O. Salako
- Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria
| | - Ekanem N. Ekure
- Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
- Department of Paediatrics, College of Medicine of the University of Lagos, Lagos, Nigeria
| | - Christy A. N. Okoromah
- Department of Paediatrics, Lagos University Teaching Hospital, Lagos, Nigeria
- Department of Paediatrics, College of Medicine of the University of Lagos, Lagos, Nigeria
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Broberg MCG, Cheifetz IM, Plummer ST. Current evidence for pharmacologic therapy following stage 1 palliation for single ventricle congenital heart disease. Expert Rev Cardiovasc Ther 2022; 20:627-636. [PMID: 35848073 DOI: 10.1080/14779072.2022.2103542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Infants with single ventricle congenital heart disease are vulnerable to complications between stage 1 and stage 2 of palliation. Pharmaceutical treatment during this period is varied and often dependent on institutional practices as there is little evidence supporting a particular treatment path. AREAS COVERED This review focuses on medical management of patients following stage I palliation. We performed a scoping review of the current literature regarding angiotensin converting enzyme inhibitors and digoxin treatment in the interstage period. In addition, we discuss other medication classes frequently used in these patients. EXPERT OPINION Due to significant heterogeneity of anatomy, rarity of disease, and other confounding factors, there is limited evidence to support most commonly used medications within the interstage period. Digoxin is associated with improved mortality within the interstage period and should be considered; however, no large randomized controlled trial exists supporting its use. Prevention of thrombotic complication with aspirin is also associated with improved outcomes and should be considered unless a contraindication exists. The addition of other prescriptions in this patient population should be considered only after an evaluation of the risks and benefits of each medication, recognizing the burden and risk of polypharmacy in this fragile patient population.
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Affiliation(s)
- Meredith C G Broberg
- Department of Pediatrics, Division of Pediatric Cardiac Critical Care, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ira M Cheifetz
- Department of Pediatrics, Division of Pediatric Cardiac Critical Care, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.,Department of Pediatrics, Division of Pediatric Cardiology, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sarah T Plummer
- Department of Pediatrics, Division of Pediatric Cardiology, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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46
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Wang YJ, Lei L, Huang Y. Factors associated with venous thromboembolism in the paediatric intensive care unit: A systematic review and meta‐analysis. Nurs Crit Care 2022. [DOI: 10.1111/nicc.12813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ya Jing Wang
- West China School of Nursing, Sichuan University/Nursing Department, West China Second University Hospital Sichuan University Chengdu China
- Nursing Department West China Second University Hospital, Sichuan University Chengdu China
| | - Lei Lei
- Nursing Department West China Second University Hospital, Sichuan University Chengdu China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education Chengdu China
| | - Yan Huang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education Chengdu China
- Department of pediatric Intensive Care Unit, Nursing Department, West China second University Sichuan University Chengdu China
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47
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Eun Pak M, Kim YJ, Jin Park Y, Go Y, Soo Shin C, Yoon JW, Jeon SM, Song YH, Kim K. Human milk oligosaccharide, 2′-Fucosyllactose, attenuates platelet activation in arterial thrombosis. J Funct Foods 2022. [DOI: 10.1016/j.jff.2022.105138] [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
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48
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Heidendael JF, Engele LJ, Bouma BJ, Dipchand AI, Thorne SA, McCrindle BW, Mulder BJM. Coagulation and Anticoagulation in Fontan Patients. Can J Cardiol 2022; 38:1024-1035. [PMID: 35122939 DOI: 10.1016/j.cjca.2022.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/17/2022] [Accepted: 01/27/2022] [Indexed: 01/22/2023] Open
Abstract
Patients with a Fontan circulation for single-ventricle physiology are at increased risk of developing thromboembolic events. Thromboembolic events can lead to failure of the Fontan circulation, chronic sequelae in case of stroke, and early mortality. Controversies exist regarding the substrates, risk factors, and optimal detection methods for thromboembolic events. Despite the major clinical implications, there is currently no consensus regarding the optimal antithrombotic therapy to prevent or treat thromboembolic events after the Fontan procedure. In this review we aimed to untangle the available literature regarding antithrombotic prophylaxis and treatment for pediatric and adult Fontan patients. A decision-tree algorithm for thromboprophylaxis in Fontan patients is proposed. Additionally, the current state of knowledge is reviewed with respect to the epidemiology, pathophysiology, and detection of thromboembolic events in Fontan patients, and important evidence gaps are highlighted.
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Affiliation(s)
- Josephine F Heidendael
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Leo J Engele
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Anne I Dipchand
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sara A Thorne
- Department of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Bauman M, Hellinger A, Pluym CV, Bhat R, Simpson E, Mehegan M, Knox P, Massicotte M. Online KidClot education for patients and families initiating warfarin therapy: The eKITE study. Thromb Res 2022; 215:14-18. [PMID: 35594736 PMCID: PMC9755220 DOI: 10.1016/j.thromres.2022.05.003] [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: 03/27/2022] [Revised: 04/22/2022] [Accepted: 05/03/2022] [Indexed: 01/12/2023]
Abstract
Anticoagulation with Vitamin K antagonists (VKA) has always posed challenges in terms of monitoring requirements. These challenges were further exacerbated in the setting of the COVID-19 pandemic, with limited access to and/or avoidance of laboratory testing. The importance of utilizing point of care (POC) health technology for individualized patient management is salient. The foundation of effective home INR monitoring is establishing patient knowledge about their therapy and INR testing proficiency. The eKITE series was developed to support patients in establishing foundational knowledge required for VKA (warfarin) management and INR monitoring. The primary objectives were to evaluate eKITE, a patient-oriented innovative online education program for warfarin therapy, participant learning stress, and patient preference for online learning. This multi-center prospective study provided patients access to warfarin online education. Participants were required to complete written quizzes assessing warfarin knowledge of key concepts proficiency and identifying knowledge deficits. Patient preference, evaluating calm (lack of anxiety) while learning, and an INR on a home meter was completed. Participants performed INR tests at home and reported INRs by telephone. The analysis included 144 children and caregivers enrolled at five US and CDN sites. Most indications for anticoagulation were cardiac (congenital or acquired heart disease) with varied INR target ranges. Mean knowledge scores for warfarin and INR self-testing modules were 97%, with low anxiety with TTR of 84%. Patient preferred online learning. eKITE is an effective teaching modality for warfarin/home INR monitoring with safe INR testing and warfarin management that is appropriate for pediatrics and adults alike. PROLOGUE: The whir in the hallways is deafening. Lights bright, alarms are ringing in a chorus of unsynchronized beeps and screeches. It has been more than a week since I have slept. Snuggled beside me is my precious child, whining and equally irritated with the asynchronous symphony, further compounded by anxiety, procedures, and pain. The sun has broken. The staff smiles are welcoming and incessant, as one after one, they approach hurried, urgent, assiduous, their need to coach me for our upcoming departure to the warmth of home. Each provides essential information that I will require to keep my child, my treasure, safe and healthy. Yet, my eyes are heavy, blurred, and my brain foggy, trapped in a dark heavy cloud. How am I to follow? Comprehend? and retain anything? As they instruct, my precious child yearns for loving arms, compassion and love, whining, crying in disquiet. Overwhelmed does not adequately describe my ineffable exhaustion. Amidst this, how am I to learn about warfarin? Such a challenging medication, with so much to know. Concentrate, I tell myself, focus; now is my only opportunity to learn. I must be alert. It seems to be nonsensical.
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Affiliation(s)
- M.E. Bauman
- Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada,Corresponding author at: KidClot Pediatric Thrombosis Program, University of Alberta, Stollery Children's Hospital, 3-585 ECHA, 11405-87 Ave NW, Edmonton, Alberta T6G 1C9, Canada
| | | | | | - R. Bhat
- Division of Hematology/Oncology/Stem Cell Transplant, Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - E. Simpson
- Children's Hospital of Eastern Ontario, ON, Canada
| | | | - P. Knox
- Alberta Children's Hospital, Canada
| | - M.P. Massicotte
- Stollery Children's Hospital, University of Alberta, Edmonton, AB, Canada
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Boucher AA, Heneghan JA, Jang S, Spillane KA, Abarbanell AM, Steiner ME, Meyer AD. A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease. Front Surg 2022; 9:907782. [PMID: 35774388 PMCID: PMC9237365 DOI: 10.3389/fsurg.2022.907782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/26/2022] [Indexed: 11/18/2022] Open
Abstract
Congenital heart disease encompasses a range of cardiac birth defects. Some defects require early and complex surgical intervention and post-operative thromboprophylaxis primarily for valve, conduit, and shunt patency. Antiplatelet and anticoagulant management strategies vary considerably and may or may not align with recognized consensus practice guidelines. In addition, newer anticoagulant agents are being increasingly used in children, but these medications are not addressed in most consensus statements. This narrative review evaluated the literature from 2011 through 2021 on the topic of postoperative thromboprophylaxis after congenital heart disease operations. The search was focused on the descriptions and results of pediatric studies for replacement and/or repair of heart valves, shunts, conduits, and other congenital heart disease operations. Wide variability in practice exists and, as was true a decade ago, few randomized controlled trials have been conducted. Aspirin, warfarin, and perioperative heparin remain the most commonly used agents with varying dosing, duration, and monitoring strategies, making comparisons difficult. Only recently have data on direct oral anticoagulants been published in children, suggesting evolving paradigms of care. Our findings highlight the need for more research to strengthen the evidence for standardized thromboprophylaxis strategies.
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Affiliation(s)
- Alexander A. Boucher
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Correspondence: Alexander A. Boucher Julia A. Heneghan
| | - Julia A. Heneghan
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Correspondence: Alexander A. Boucher Julia A. Heneghan
| | - Subin Jang
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Kaitlyn A. Spillane
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
| | - Aaron M. Abarbanell
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
| | - Marie E. Steiner
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Andrew D. Meyer
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
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