Anticoagulation Therapy Trends in Children Supported by Ventricular Assist Devices

Abstract

Ventricular assist device (VAD) use in children has increased dramatically. There are currently few data regarding trends in anticoagulation management for pediatric VADs. A retrospective cohort study was conducted for patients with an International Classification of Diseases, Ninth Revision (ICD-9) code for VAD implantation from 2000 to 2011 from the Pediatric Health Information System database. Patient demographics, use of extracorporeal membrane oxygenation, orthotopic heart transplantation (OHT), disease states, and medications pertinent to the management of VAD anticoagulation were queried. Patients were grouped into 3 year time periods to evaluate trends in medication use over time. Four hundred sixty-six patients were identified with a median length of VAD therapy of 21 days (range 1-362 days). In-hospital mortality was 31.9%, and 54.5% underwent OHT. Length of VAD therapy and patients undergoing OHT increased, while mortality decreased. Patients received a median of two anticoagulant medications (range 0-6), one (range 0-4) antiplatelet medications, three (range 0-5) procoagulant medications, and one (range 0-3) antifibrinolytics. Patients received greater mean numbers of anticoagulant, procoagulant, antifibrinolytic, and antiplatelet agents, and the use of oral medications increased more than twofold over time. There is wide variability for in-hospital pediatric VAD anticoagulation management, with a significant increase in the use of oral agents in more recent years.

The Use of Ventricular Assist Device Support in Children: The State of the Art

“…One‐third of patients in the Pediatric Heart Transplant Study assist device multiinstitutional study and up to 50% of those in the Berlin Heart trial had major bleeding requiring reoperation . A study examining trends in anticoagulation therapy in pediatric patients with assist devices revealed wide variability of in‐hospital anticoagulation management . Nearly all patients received unfractionated heparin.…”

Mechanical circulatory support: balancing bleeding and clotting in high-risk patients

“…34 Antiplatelet medication use over time increased to 67% of children, with aspirin being the most common (52%), followed by dipyridamole (32%), pentoxifylline (2%), omega 3 fatty acids (1%), and abciximab (0.2%). 34 Pediatric and device specific antithrombotic guidelines (Table 3) were developed and prospectively studied during the EXCOR trial. 37,38 AT supplementation was recommended if the level was Ͻ70%, 37 but no dosing guidance was given.…”

“…31 In children, physiologic AT levels are lower than adults, resulting in the administration of AT concentrate by some centers during ECMO, despite the lack of safety and efficacy data. 30,34 Challenges with UFH exist including development of heparin induced thrombocytopenia and an inability to achieve therapeutic anticoagulation. In both clinical scenarios, alternate anticoagulant agents are required.…”

“…Moffet et al reported an increase in use of procoagulant and antifibrinolytic agents over time in children with VAD associated hemorrhage. 34 Recombinant FVIIa was administered in 23% of children compared to factor VIII (0.2%) and factor IX (4.7%). Aminocaproic acid and tranexamic acid were used in 34% and 13% of children, respectively, but the safety and efficacy of anti-fibrinolytic therapy has not been systematically studied.…”

Anticoagulation Therapy in Children

“…period of time, there was an increased use of ventricularassist devices, extracorporeal membrane oxygenation, and endovascular procedures in children. [9][10][11] The increased incidence of pediatric VTE, as well as the more frequent use of extracorporeal circuits, has resulted in an expanded use of anticoagulants.…”