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Semin Thromb Hemost 2011; 37(7): 826-833
DOI: 10.1055/s-0031-1297174
© Thieme Medical Publishers

Anticoagulation in Children Undergoing Cardiac Surgery

Katharina E. Thom1 , Andreas Hanslik1 , Christoph Male1
  • 1Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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Publikationsdatum:
20. Dezember 2011 (online)

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ABSTRACT

Advances in medical and surgical care have resulted in improved survival of patients with congenital heart disease (CHD). Parallel to these progresses, an increasing number of immediate and long-term complications have been recognized. One important complication in CHD is the development of thrombosis. Children with a single functional cardiac ventricle usually require sequential steps of surgery: the initial Blalock-Taussig shunts (BTS) during the neonatal period, followed by the Glenn shunt, and finally, the Fontan shunt, the “definitive palliative” procedure. Surgery mostly involves cardiopulmonary bypass (CPB), which also affects the coagulation system and causes an inflammatory response. This article will review surgical procedures, such as BTS, Glenn shunt, and Fontan shunt, prosthetic mechanical valves, and CPB, and their risk of thrombotic complications. There is insufficient evidence and no consensus for optimal anticoagulant prophylaxis or treatment in children with CHD. Current recommendations are mostly based on adult data.

KEYWORDS

Pediatric cardiology - cardiac surgery - thrombosis - thromboprophylaxis - anticoagulation

REFERENCES

  • 1 Boris J R, Harris M A. The use of anticoagulation in pediatric cardiac disease.  Images Pediatr Cardiol. 2003;  16 1-35
    Suche in Google Scholar
  • 2 Monagle P. Thrombosis in children with BT shunts, Glenns and Fontans.  Prog Pediatr Cardiol. 2005;  21 17-21
    Suche in Google Scholar
  • 3 Monagle P, Adams M, Mahoney M et al.. Outcome of pediatric thromboembolic disease: a report from the Canadian Childhood Thrombophilia Registry.  Pediatr Res. 2000;  47 (6) 763-766
    Suche in Google Scholar
  • 4 Blalock A. Physiopathology and surgical treatment of congenital cardiovascular defects.  Harvey Lect. 1945–1946;  41 90-116
    Suche in Google Scholar
  • 5 Glenn W W. Circulatory bypass of the right side of the heart. IV. Shunt between superior vena cava and distal right pulmonary artery; report of clinical application.  N Engl J Med. 1958;  259 (3) 117-120
    Suche in Google Scholar
  • 6 Fontan F, Baudet E. Surgical repair of tricuspid atresia.  Thorax. 1971;  26 (3) 240-248
    Suche in Google Scholar
  • 7 Monagle P, Cochrane A, Roberts R et al.. A multicentre randomized trial comparing heparin/warfarin and aspirin as primary thromboprophylaxis for two years after fontan procedure in children.  J Am Coll Cardiol. 2011;  58 645-651
    Suche in Google Scholar
  • 8 Caldarone C A, Raghuveer G, Hills C B et al.. Long-term survival after mitral valve replacement in children aged <5 years: a multi-institutional study.  Circulation. 2001;  104 (12, Suppl 1) I143-I147
    Suche in Google Scholar
  • 9 Khitin L M, Sade R M, Bradley S M, Crawford Jr F A, Widener C E, Stroud M R. Prevention of thrombosis and embolism in children and adolescents with mechanical valve prostheses: warfarin versus antiplatelet agents.  J Heart Valve Dis. 2006;  15 (3) 394-399 discussion 399
    Suche in Google Scholar
  • 10 Tamisier D, Vouhé P R, Vernant F, Lecá F, Massot C, Neveux J Y. Modified Blalock-Taussig shunts: results in infants less than 3 months of age.  Ann Thorac Surg. 1990;  49 (5) 797-801
    Suche in Google Scholar
  • 11 Karpawich P P, Bush C P, Antillon J R, Amato J J, Marbey M L, Agarwal K C. Modified Blalock-Taussig shunt in infants and young children. Clinical and catheterization assessment.  J Thorac Cardiovasc Surg. 1985;  89 (2) 275-279
    Suche in Google Scholar
  • 12 Ahmad U, Fatimi S H, Naqvi I et al.. Modified Blalock-Taussig shunt: immediate and short-term follow-up results in neonates.  Heart Lung Circ. 2008;  17 (1) 54-58
    Suche in Google Scholar
  • 13 Norwood W I, Lang P, Hansen D D. Physiologic repair of aortic atresia-hypoplastic left heart syndrome.  N Engl J Med. 1983;  308 (1) 23-26
    Suche in Google Scholar
  • 14 Al Jubair K A, Al Fagih M R, Al Jarallah A S et al.. Results of 546 Blalock-Taussig shunts performed in 478 patients.  Cardiol Young. 1998;  8 (4) 486-490
    Suche in Google Scholar
  • 15 Tsai K T, Chang C H, Lin P J. Modified Blalock-Taussig shunt: statistical analysis of potential factors influencing shunt outcome.  J Cardiovasc Surg (Torino). 1996;  37 (2) 149-152
    Suche in Google Scholar
  • 16 Wells W J, Yu R J, Batra A S, Monforte H, Sintek C, Starnes V A. Obstruction in modified Blalock shunts: a quantitative analysis with clinical correlation.  Ann Thorac Surg. 2005;  79 (6) 2072-2076
    Suche in Google Scholar
  • 17 Moulton A L, Brenner J I, Ringel R et al.. Classic versus modified Blalock-Taussig shunts in neonates and infants.  Circulation. 1985;  72 (3 Pt 2) II35-II44
    Suche in Google Scholar
  • 18 Gladman G, McCrindle B W, Williams W G, Freedom R M, Benson L N. The modified Blalock-Taussig shunt: clinical impact and morbidity in Fallot's tetralogy in the current era.  J Thorac Cardiovasc Surg. 1997;  114 (1) 25-30
    Suche in Google Scholar
  • 19 Karakurt C, Koçak G, Ozgen U. Recanalization of occluded modified Blalock-Taussig shunt with balloon angioplasty and intraarterial streptokinase.  Anadolu Kardiyol Derg. 2008;  8 (1) 76-78
    Suche in Google Scholar
  • 20 Monagle P, Chalmers E, Chan A American College of Chest Physicians et al. Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).  Chest. 2008;  133 (6, Suppl) 887S-968S
    Suche in Google Scholar
  • 21 LeBlanc J, Albus R, Williams W G et al.. Serous fluid leakage: a complication following the modified Blalock-Taussig shunt.  J Thorac Cardiovasc Surg. 1984;  88 (2) 259-262
    Suche in Google Scholar
  • 22 Mullen J C, Lemermeyer G, Bentley M J. Modified Blalock-Taussig shunts: to heparinize or not to heparinize?.  Can J Cardiol. 1996;  12 (7) 645-647
    Suche in Google Scholar
  • 23 Fenton K N, Siewers R D, Rebovich B, Pigula F A. Interim mortality in infants with systemic-to-pulmonary artery shunts.  Ann Thorac Surg. 2003;  76 (1) 152-156 discussion 156-157
    Suche in Google Scholar
  • 24 Motz R, Wessel A, Ruschewski W, Bürsch J. Reduced frequency of occlusion of aorto-pulmonary shunts in infants receiving aspirin.  Cardiol Young. 1999;  9 (5) 474-477
    Suche in Google Scholar
  • 25 Li J S, Yow E, Berezny K Y et al.. Clinical outcomes of palliative surgery including a systemic-to-pulmonary artery shunt in infants with cyanotic congenital heart disease: does aspirin make a difference?.  Circulation. 2007;  116 (3) 293-297
    Suche in Google Scholar
  • 26 Wessel D L, Berger F, Li J S, Fontecave S, Rakhit A, Newburger J W. for the CLARINET Investigators . A randomized trial of clopidogrel to reduce mortality and shunt-related morbidity in infants palliated with systemic to pulmonary artery shunt.  Circulation. 2010;  122 A19459
    Suche in Google Scholar
  • 27 Tanoue Y, Kado H, Boku N et al.. Three hundred and thirty-three experiences with the bidirectional Glenn procedure in a single institute.  Interact Cardiovasc Thorac Surg. 2007;  6 (1) 97-101
    Suche in Google Scholar
  • 28 Gewillig M. The Fontan circulation.  Heart. 2005;  91 (6) 839-846
    Suche in Google Scholar
  • 29 Pennington D G, Nouri S, Ho J et al.. Glenn shunt: long-term results and current role in congenital heart operations.  Ann Thorac Surg. 1981;  31 (6) 532-539
    Suche in Google Scholar
  • 30 Kopf G S, Laks H, Stansel H C, Hellenbrand W E, Kleinman C S, Talner N S. Thirty-year follow-up of superior vena cava-pulmonary artery (Glenn) shunts.  J Thorac Cardiovasc Surg. 1990;  100 (5) 662-670 discussion 670-671
    Suche in Google Scholar
  • 31 Koutlas T C, Harrison J K, Bashore T M, O'Laughlin M P, Tripp M E, Gaynor J W. Late conduit occlusion after modified Fontan procedure with classic Glenn shunt.  Ann Thorac Surg. 1996;  62 (1) 258-261 discussion 261-262
    Suche in Google Scholar
  • 32 Kuroczynski W. [Development of the Fontan procedure as therapeutic concept for children with complex congenital heart disease].  Herz. 2007;  32 (3) 241-247
    Suche in Google Scholar
  • 33 Kaulitz R, Ziemer G, Luhmer I, Kallfelz H C. Modified Fontan operation in functionally univentricular hearts: preoperative risk factors and intermediate results.  J Thorac Cardiovasc Surg. 1996;  112 (3) 658-664
    Suche in Google Scholar
  • 34 Lemler M S, Scott W A, Leonard S R, Stromberg D, Ramaciotti C. Fenestration improves clinical outcome of the fontan procedure: a prospective, randomized study.  Circulation. 2002;  105 (2) 207-212
    Suche in Google Scholar
  • 35 Kaulitz R, Ziemer G, Rauch R et al.. Prophylaxis of thromboembolic complications after the Fontan operation (total cavopulmonary anastomosis).  J Thorac Cardiovasc Surg. 2005;  129 (3) 569-575
    Suche in Google Scholar
  • 36 Cromme-Dijkhuis A H, Henkens C M, Bijleveld C M, Hillege H L, Bom V J, van der Meer J. Coagulation factor abnormalities as possible thrombotic risk factors after Fontan operations.  Lancet. 1990;  336 (8723) 1087-1090
    Suche in Google Scholar
  • 37 Cromme-Dijkhuis A H, Hess J, Hählen K et al.. Specific sequelae after Fontan operation at mid- and long-term follow-up. Arrhythmia, liver dysfunction, and coagulation disorders.  J Thorac Cardiovasc Surg. 1993;  106 (6) 1126-1132
    Suche in Google Scholar
  • 38 Balling G, Vogt M, Kaemmerer H, Eicken A, Meisner H, Hess J. Intracardiac thrombus formation after the Fontan operation.  J Thorac Cardiovasc Surg. 2000;  119 (4 Pt 1) 745-752
    Suche in Google Scholar
  • 39 Coon P D, Rychik J, Novello R T, Ro P S, Gaynor J W, Spray T L. Thrombus formation after the Fontan operation.  Ann Thorac Surg. 2001;  71 (6) 1990-1994
    Suche in Google Scholar
  • 40 Seipelt R G, Franke A, Vazquez-Jimenez J F et al.. Thromboembolic complications after Fontan procedures: comparison of different therapeutic approaches.  Ann Thorac Surg. 2002;  74 (2) 556-562
    Suche in Google Scholar
  • 41 Chun D S, Schamberger M S, Flaspohler T et al.. Incidence, outcome, and risk factors for stroke after the Fontan procedure.  Am J Cardiol. 2004;  93 (1) 117-119
    Suche in Google Scholar
  • 42 Stümper O, Sutherland G R, Geuskens R, Roelandt J R, Bos E, Hess J. Transesophageal echocardiography in evaluation and management after a Fontan procedure.  J Am Coll Cardiol. 1991;  17 (5) 1152-1160
    Suche in Google Scholar
  • 43 Fyfe D A, Kline C H, Sade R M, Gillette P C. Transesophageal echocardiography detects thrombus formation not identified by transthoracic echocardiography after the Fontan operation.  J Am Coll Cardiol. 1991;  18 (7) 1733-1737
    Suche in Google Scholar
  • 44 Heying R, van Oeveren W, Wilhelm S et al.. Children undergoing cardiac surgery for complex cardiac defects show imbalance between pro- and anti-thrombotic activity.  Crit Care. 2006;  10 (6) R165
    Suche in Google Scholar
  • 45 Iyer G K, Van Arsdell G S, Dicke F P, McCrindle B W, Coles J G, Williams W G. Are bilateral superior vena cavae a risk factor for single ventricle palliation?.  Ann Thorac Surg. 2000;  70 (3) 711-716
    Suche in Google Scholar
  • 46 Bando K, Turrentine M W, Park H J, Sharp T G, Scavo V, Brown J W. Evolution of the Fontan procedure in a single center.  Ann Thorac Surg. 2000;  69 (6) 1873-1879
    Suche in Google Scholar
  • 47 Mair D D, Puga F J, Danielson G K. The Fontan procedure for tricuspid atresia: early and late results of a 25-year experience with 216 patients.  J Am Coll Cardiol. 2001;  37 (3) 933-939
    Suche in Google Scholar
  • 48 Petrossian E, Reddy V M, McElhinney D B et al.. Early results of the extracardiac conduit Fontan operation.  J Thorac Cardiovasc Surg. 1999;  117 (4) 688-696
    Suche in Google Scholar
  • 49 Giannico S, Santoro G, Marino B, Cicini M P, Marcelletti C. Bidirectional cavopulmonary anastomosis in congenital heart disease. Functional and clinical outcome.  Herz. 1992;  17 (4) 234-241
    Suche in Google Scholar
  • 50 Shirai L K, Rosenthal D N, Reitz B A, Robbins R C, Dubin A M. Arrhythmias and thromboembolic complications after the extracardiac Fontan operation.  J Thorac Cardiovasc Surg. 1998;  115 (3) 499-505
    Suche in Google Scholar
  • 51 Konstantinov I E, Puga F J, Alexi-Meskishvili V V. Thrombosis of intracardiac or extracardiac conduits after modified Fontan operation in patients with azygous continuation of the inferior vena cava.  Ann Thorac Surg. 2001;  72 (5) 1641-1644
    Suche in Google Scholar
  • 52 Abid F, Abid A, Fekih M, Zaouali R M, Ben Ismail M. Aortic valve replacement in children under 16 years of age with congenital or rheumatic valvular disease. A study of 64 cases.  J Cardiovasc Surg (Torino). 1992;  33 (3) 265-271
    Suche in Google Scholar
  • 53 Robbins R C, Bowman Jr F O, Malm J R. Cardiac valve replacement in children: a twenty-year series.  Ann Thorac Surg. 1988;  45 (1) 56-61
    Suche in Google Scholar
  • 54 Eaton M P, Iannoli E M. Coagulation considerations for infants and children undergoing cardiopulmonary bypass.  Paediatr Anaesth. 2011;  21 (1) 31-42
    Suche in Google Scholar
  • 55 Despotis G J, Avidan M S, Hogue Jr C W. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation.  Ann Thorac Surg. 2001;  72 (5) S1821-S1831
    Suche in Google Scholar
  • 56 Mojcik C F, Levy J H. Aprotinin and the systemic inflammatory response after cardiopulmonary bypass.  Ann Thorac Surg. 2001;  71 (2) 745-754
    Suche in Google Scholar
  • 57 Guzzetta N A, Miller B E, Todd K, Szlam F, Moore R H, Tosone S R. An evaluation of the effects of a standard heparin dose on thrombin inhibition during cardiopulmonary bypass in neonates.  Anesth Analg. 2005;  100 (5) 1276-1282,table of contents
    Suche in Google Scholar
  • 58 Koster A, Fischer T, Praus M et al.. Hemostatic activation and inflammatory response during cardiopulmonary bypass: impact of heparin management.  Anesthesiology. 2002;  97 (4) 837-841
    Suche in Google Scholar
  • 59 Freed M D, Keane J F, Rosenthal A. The use of heparinization to prevent arterial thrombosis after percutaneous cardiac catheterization in children.  Circulation. 1974;  50 (3) 565-569
    Suche in Google Scholar
  • 60 Saxena A, Gupta R, Kumar R K, Kothari S S, Wasir H S. Predictors of arterial thrombosis after diagnostic cardiac catheterization in infants and children randomized to two heparin dosages.  Cathet Cardiovasc Diagn. 1997;  41 (4) 400-403
    Suche in Google Scholar
  • 61 Bulbul Z R, Galal M O, Mahmoud E et al.. Arterial complications following cardiac catheterization in children less than 10 kg.  Asian Cardiovasc Thorac Ann. 2002;  10 (2) 129-132
    Suche in Google Scholar
  • 62 Grady R M, Eisenberg P R, Bridges N D. Rational approach to use of heparin during cardiac catheterization in children.  J Am Coll Cardiol. 1995;  25 (3) 725-729
    Suche in Google Scholar
  • 63 Girod D A, Hurwitz R A, Caldwell R L. Heparinization for prevention of thrombosis following pediatric percutaneous arterial catheterization.  Pediatr Cardiol. 1982;  3 (2) 175-180
    Suche in Google Scholar
  • 64 Laurin S, Lundström N R. Venous thrombosis after cardiac catheterization in infants.  Acta Radiol. 1987;  28 (3) 241-246
    Suche in Google Scholar
  • 65 Miga D E, McKellar L F, Denslow S, Wiles H B, Case C L, Gillette P C. Incidence of femoral vein occlusion after catheter ablation in children: evaluation with magnetic resonance angiography.  Pediatr Cardiol. 1997;  18 (3) 204-207
    Suche in Google Scholar
  • 66 Hanslik A, Kitzmüller E, Thom K, Salzer-Muhar U, Michel-Behnke I, Male C. Comparison of high-dose vs low-dose heparinization protocols for prophylaxis of thrombotic complications during cardiac catheterization in children, HEARTCAT Study.  J Thromb Hemost. 2011;  in press
    Suche in Google Scholar

Katharina E. ThomM.D. 

Department for Pediatric Cardiology, University Hospital for Children and Adolescent Medicine

Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria

eMail: katharina.thom@meduniwien.ac.at