A Method for Anticoagulation of Children on Mechanical Circulatory Support

Abstract

Anticoagulation of children on mechanical circulatory support presents a challenge. We implanted 28 devices in children and infants using a consistent anticoagulation protocol. We performed a retrospective review of all children implanted in our program with mechanical assist devices since 1997. Heparin, dipyridamole, and aspirin were used for anticoagulation and antiaggregation. Coagulation monitoring included thromboelastography (TEG), platelet aggregration studies, international normalized ratio, partial thromboplastin time, and platelet count. Twenty-eight children, ages 1 month to 16 years (mean 5.3; median 2.4 years), were implanted for 3-107 days (mean 27; median 17). Eighteen received left ventricular assist devices, seven received biventricular assist devices, and three received total artificial hearts. Adverse events during the 720 days of device support included the following: six (21%) reoperations for bleeding; seven strokes (25%): two fatal, two with a mild residual deficit, and three without deficit; and three (11%) visceral emboli: two fatal and one nonfatal. There were eight deaths (29%). Causes of death were embolic (four), graft failure post-transplantation (one), preimplant anoxic brain damage (two), and postexplant heart failure (one). 24/28 (86%) survived to transplantation or weaning from device and 20/28 (71%) were discharged from the hospital, 10 after transplantation and 10 after native heart recovery. All 20 early survivors survived long term. We describe an anticoagulation protocol based upon TEG and platelet aggregation studies and using heparin, aspirin, and dipyridamole. Adequate anticoagulation is more difficult in children. However, 71% of the patients in our study survived long term.

Thrombolytics in VAD management — A single-center experience

“…Despite a fairly rigid regimen of anticoagulation and antiplatelet measures, pump thrombosis still occurs and has devastating consequences [23], [24], [25], [26], [27]. In addition to the existing routinely used regimens, other anticoagulants/antiplatelet agents reported in the literature include dipyridamole, pentoxifylline, dextran, and fluindione [28], [29], [30], [31].…”

In vitro anti-platelet potency of ticagrelor in blood samples from infants and children

“…after implantation of systemic-to-pulmonary shunts, [1] prosthetic heart valves [2] and ventricular assist devices. [3] The most widely used antiplatelet drug for paediatric patients is acetylsalicylic acid (ASA), [4] sometimes in combination with clopidogrel, a prodrug and irreversibly binding P2Y 12 antagonist. [5] Ticagrelor is a direct acting reversibly binding P2Y 12 antagonist that provides a higher and more consistent inhibition of ADP-induced platelet aggregation than clopidogrel [6,7], has a faster on-set and off-set of the pharmacodynamic effects [8],…”

Aspirin in childhood acute ischemic stroke: The evidence for treatment and efficacy testing

“…Stroke risk is substantial, regardless of the device used, though device‐specific pharmacologic recommendations may differ. In a study of 28 children with left‐sided or biventricular assist devices or total artificial hearts, stroke incidence was 25% despite therapeutic monitoring and dose‐adjusted ASA, along with anticoagulation and dipyramidole without clopidogrel . However, aggressive antiplatelet therapy appears to be beneficial.…”