Intracardiac thrombi complicating central total parenteral nutrition: Resolution without surgery or thrombolysis

Mendoza, G; Soto, Alberto Pérez del; Brown, Edwin G.; Dolgin, Stephen E.; Steinfeld, Leonard; Sweet, Avron Y.

doi:10.1016/s0022-3476(86)80849-6

Cited by 25 publications

(14 citation statements)

References 10 publications

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“…The large and dense thrombus requires more prolonged therapy as a rule [3]. In our series, we have demonstrated a statistically significant (P = .027 and r = 0.5) correlation between the size and the complete resolution time.…”

Section: Discussionsupporting

confidence: 50%

“…Hereditary or acquired risk factors, such as prematurity, cyanosis, bacteremia, malignancy, nephrotic syndrome, indwelling (umblical or central venous) catheters and acquired or genetic thrombophilia (protein C/S deficiency, factor V Leiden or prothrombin gene mutations) have been clearly defined as the most common etiologies to date [1,2,3]. However, treatment of these cases has some controversies because of the potential complications, such as hemorrhage and embolization.…”

Section: Introductionmentioning

confidence: 99%

“…However, treatment of these cases has some controversies because of the potential complications, such as hemorrhage and embolization. The treatment approaches were thrombolytics [tissue plasminogen activator (t-PA), streptokinase, urokinase] and/or anticoagulants (classical/low molecular weight (LMW) heparin, warfarin) or rarely surgical thrombectomy [3,[4][5][6][7]. However, better approach or an algorithm has not yet been defined for these cases.…”

Section: Introductionmentioning

confidence: 99%

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Intracardiac Thrombus in Children: The Fine Equilibrium Between the Risk and the Benefit

Çetin¹,

Ekici²,

Ünal

et al. 2014

Pediatric Hematology and Oncology

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The medical records of 16 patients diagnosed as intracardiac thrombus were searched. The size, location and outcome of thrombus together with demographic data of patients were assessed. The median age of the patients was 2.2 years. Six patients were newborn and two patients were infant. The median size of thrombus was 9 mm. The localization was right atrium in seven, right ventricle in five, left ventricle in one, pulmonary artery in one, and superior vena cava in two patients. There was prematurity in five, ciyanotic congenital heart disease in one, blood culture positivity in three, malignancy in four, nephrotic syndrome in one, indwelling catheters in 10, and acquired or genetic thrombophilia in six patients as risk factors. In the treatment, the first choice was tissue plasminogen activator in two patients, heparin infusion in one patient and low molecular weight heparin in remaining 12 patients. In nine patients, therapy included parenteral antimicrobials together with anticoagulants. The result was complete resolution in 15 patients and in one patient thrombus was surgically removed. The median time was 16 (2-70) days for 50% resolution and 26 (3-93) days for complete resolution. There was a statistically significant (P = .027 and r = 0.5) correlation between the size and the complete resolution time. There was no anticoagulant therapy related major complication. In patients with intracardiac thrombus, selection of anticoagulant therapy may decrease the risk of complications. Surgery is rarely required and thrombolytics are not usually necessary for resolution of thrombus.

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Section: Discussionsupporting

confidence: 50%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Intracardiac Thrombus in Children: The Fine Equilibrium Between the Risk and the Benefit

Çetin¹,

Ekici²,

Ünal

et al. 2014

Pediatric Hematology and Oncology

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“…[10,11,32,34,56,57] In the presence of one of the above-mentioned clinical signs of thrombosis, Doppler ultrasound including 2D-echocardiography examination has to be undertaken, although such recommendations are based on case reports alone. [32,34,58] While 2D-echocardiographic and Doppler imaging with flow studies are the first examination of choice, occasionally a definitive diagnosis cannot be made using these methods. In such cases contrast angiography and/or computer tomography (CT) are sometimes needed but their use should be restricted because of the various risks associated with the injection of iodinated contrast media or with the transport of a sick preterm infant to CT.…”

Section: Diagnosis and Screeningmentioning

confidence: 99%

“…In asymptomatic infants, regular screening for catheter-related thrombosis has been advocated by some authors [10,16,26,34,41] and discouraged by others. [11] …”

Section: Diagnosis and Screeningmentioning

confidence: 99%

Management of Preterm Infants with Intracardiac Thrombi

2001

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Improvement in neonatal care has led to improvements in survival and patient outcome in preterm infants; however, this improved survival has been associated with the development of secondary complications, such as catheter-associated intravascular and intracardiac thrombus formation with a non-negligible morbidity and mortality. The sick preterm infant is at high risk of catheter-related thrombus formation because of the combination of a high prothrombotic activity, low levels of natural anticoagulants, and various imbalances in the fibrinolytic systems. Based on clinical experience in adults and children, and several neonatal case reports demonstrating the efficacy and tolerability of specific thrombolytic treatment, this approach should be recommended as a first choice treatment in the premature infant with intracardiac or intravascular thrombosis. The thrombolytic agents of choice are urokinase or tissue plasminogen activator (tPA); however, none of them have proven to be superior to the other in terms of efficacy or tolerability, either in adult patients or premature infants. In the past, it has been suggested that newborn infants may require higher doses of thrombolytic agents than adults for effective systemic thrombolysis; however, based on more recent in vitro studies, it seems unlikely that this is true. Nevertheless, systemic (high dose) fibrinolysis is of concern as premature neonates present an increased risk of cerebral haemorrhage during the first weeks of life; therefore, low dose treatment has been proposed with, if possible, direct infusion of the fibrinolytic agent into, or close to, the thrombus. This approach has proven to be efficient and well tolerated in several small case series of newborn and preterm infants. Recommended doses are 1000 to 3000 U/kg/h for urokinase or 0.01 to 0.05 mg/kg/h for tPA. A systemic proteolytic state will not be induced by this low dose; however, specific monitoring of fibrinogen plasma levels has to be recommended. Fibrinogen levels should remain above 100 mg/dL during low dose treatment. Lower levels of fibrinogen will indicate the presence of an unwanted systemic fibrinolytic state. After successful thrombolysis, a follow-up treatment, preferentially with low-molecular-weight heparin for neonates at adjusted doses, should be instituted for at least 6 weeks in the absence of any persisting thrombophilic factor. A longer course (3 to 6 months) of anticoagulation therapy is recommended when thrombophilic factors (i.e. hereditary thrombophilia or central venous catheter still in place) are present. Furthermore, it is recommended that any neonate with thrombosis should be evaluated for hereditary thrombophilia later in life.

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Right atrial thrombosis associated with central venous catheters in children with cancer

Wacker

Oberhänsli

Didier

et al. 1994

Med. Pediatr. Oncol.

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Intracardiac thrombi complicating central total parenteral nutrition: Resolution without surgery or thrombolysis

Cited by 25 publications

References 10 publications

Intracardiac Thrombus in Children: The Fine Equilibrium Between the Risk and the Benefit

Intracardiac Thrombus in Children: The Fine Equilibrium Between the Risk and the Benefit

Management of Preterm Infants with Intracardiac Thrombi

Right atrial thrombosis associated with central venous catheters in children with cancer

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