Thrombotic Complications and Thromboprophylaxis Across All Three Stages of Single Ventricle Heart Palliation

Manlhiot, Cedric; Brandão, Leonardo R.; Kwok, Jason M; Kegel, Stefan; Menjak, Ines B.; Carew, Caitlin L.; Chan, Anthony; Schwartz, Steven M.; Sivarajan, V. Ben; Caldarone, Christopher A.; Arsdell, Glen S. Van; McCrindle, Brian W.

doi:10.1016/j.jpeds.2012.03.004

Cited by 74 publications

(74 citation statements)

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“…The majority of the studies were observational studies (n=49), 16 studies were RCTs, and 3 were meta‐analyses (Tables 1 and 2). 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84 Of the 16 RCTs identified,1...…”

Section: Resultsmentioning

confidence: 99%

“…Because cardiac surgical patients are also prothrombotic postsurgery (up to 30 days),6, 7, 8, 9 use of low‐dose antiplatelet agents alone would not be sufficient in preventing VTE during this high‐risk period if the patients have multiple risk factors for VTE (Table 3). We noted that fatal PE after cardiac surgery still occurred within the last decade despite advances in cardiac surgical care, including routine use of low‐dose aspirin post‐CABG 23, 26, 71, 73, 77. Fatal PE accounted for approximately 11% to 20% of all unexplained deaths after cardiac surgery, with at least 50% not diagnosed before death 57, 58.…”

Section: Discussionmentioning

confidence: 99%

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Incidence of Venous Thromboembolism and Benefits and Risks of Thromboprophylaxis After Cardiac Surgery: A Systematic Review and Meta‐Analysis

Bham

Pavey

2015

JAHA

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BackgroundOptimal thromboprophylaxis after cardiac surgery is uncertain. This systematic review aimed to define the incidence and risk factors for deep vein thrombosis (DVT), fatal and nonfatal pulmonary embolism (PE), and assess whether venous thromboembolism (VTE) prophylaxis was effective in reducing VTE without complications after cardiac surgery.Methods and ResultsTwo reviewers independently searched and assessed the quality and outcomes of randomized, controlled trials (RCTs) and observational studies on VTE after cardiac surgery in the MEDLINE, EMBASE, and Cochrane controlled trial register (1966 to December 2014). Sixty‐eight studies provided data on VTE outcomes or complications related to thromboprophylaxis after cardiac surgery. The majority of the studies were observational studies (n=49), 16 studies were RCTs, and 3 were meta‐analyses. VTE prophylaxis was associated with a reduced risk of PE (relative risk [RR], 0.45; 95% confidence interval [CI], 0.28–0.72; P=0.0008) or symptomatic VTE (RR, 0.44; 95% CI, 0.28–0.71; P=0.0006) compared to the control without significant heterogeneity. Median incidence (interquartile range) of symptomatic DVT, PE, and fatal PE were 3.2% (0.6–8.1), 0.6% (0.3–2.9), and 0.3% (0.08–1.7), respectively. Previous history of VTE, obesity, left or right ventricular failure, and prolonged bed rest, mechanical ventilation, or use of a central venous catheter were common risk factors for VTE. Bleeding or cardiac tamponade requiring reoperation owing to pharmacological VTE prophylaxis alone, without systemic anticoagulation, was not observed.ConclusionsUnless proven otherwise by adequately powered RCTs, initiating pharmacological VTE prophylaxis as soon as possible after cardiac surgery for patients who have no active bleeding is highly recommended.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Incidence of Venous Thromboembolism and Benefits and Risks of Thromboprophylaxis After Cardiac Surgery: A Systematic Review and Meta‐Analysis

Bham

Pavey

2015

JAHA

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“…[1][2][3] Finally, blood circulation for many types of congenital heart lesions is dependent on shunts that are prone to thrombotic and/or stenotic occlusions. 4,5 Clinical Perspective on p 1519…”

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confidence: 99%

Risk, Clinical Features, and Outcomes of Thrombosis Associated With Pediatric Cardiac Surgery

et al. 2011

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Background— Thrombosis, usually considered a serious but rare complication of pediatric cardiac surgery, has not been a major clinical and/or research focus in the past. Methods and Results— We noted 444 thrombi (66% occlusive, 60% symptomatic) in 171 of 1542 surgeries (11%). Factors associated with increased odds of thrombosis were age <31 days (odds ratio [OR], 2.0; P =0.002), baseline oxygen saturation <85% (OR, 2.0; P =0.001), previous thrombosis (OR, 2.6; P =0.001), heart transplantation (OR, 4.1; P <0.001), use of deep hypothermic circulatory arrest (OR, 1.9 P =0.01), longer cumulative time with central lines (OR, 1.2 per 5-day equivalent; P <0.001), and postoperative use of extracorporeal support (OR, 5.2; P <0.001). Serious complications of thrombosis occurred with 64 of 444 thrombi (14%) in 47 of 171 patients (28%), and were associated with thrombus location (intrathoracic, 45%; extrathoracic arterial, 19%; extrathoracic venous, 8%; P <0.001), symptomatic thrombi (OR, 8.0; P =0.02), and partially/fully occluding thrombi (OR, 14.3; P =0.001); indwelling access line in vessel (versus no access line) was associated with lower risk of serious complications (OR, 0.4; P =0.05). Thrombosis was associated with longer intensive care unit (+10.0 days; P <0.001) and hospital stay (+15.2 days; P <0.001); higher odds of cardiac arrest (OR, 4.9; P <0.001), catheter reintervention (OR, 3.3; P =0.002), and reoperation (OR, 2.5; P =0.003); and increased mortality (OR, 5.1; P <0.001). Long-term outcome assessment was possible for 316 thrombi in 129 patients. Of those, 197 (62%) had resolved at the last follow-up. Factors associated with increased odds of thrombus resolution were location (intrathoracic, 75%; extrathoracic arterial, 89%; extrathoracic venous, 60%; P <0.001), nonocclusive thrombi (OR, 2.2; P =0.01), older age at surgery (OR, 1.2 per year; P =0.04), higher white blood cell count (OR, 1.1/10 9 cells per 1 mL; P =0.002), and lower fibrinogen (OR, 1.4/g/L; P =0.02) after surgery. Conclusions— Thrombosis affects a high proportion of children undergoing cardiac surgery and is associated with suboptimal outcomes. Increased awareness and effective prevention and detection strategies are needed.

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“…3 Cyanosis is associated with ongoing inflammation and congestive hepatopathy. It lowers the threshold for platelet activation and aggregation, 13 consequently resulting in a hypercoagulable environment.…”

Section: Unique Hemodynamic Factors and Presence Of Thrombogenic Matementioning

confidence: 99%

“…3 In both scenarios, clinically-evident thrombosis was associated with increased morbidity and mortality. 3,53 Hence, recognizing thrombosis immediately and instituting effective treatment is pivotal in preventing thrombosis-related conditions.…”

Section: Interventional Studies -Acute Treatment Of Thrombotic Complimentioning

confidence: 99%

Challenges and Priorities for Research

McCrindle

Manlhiot

et al. 2014

Circulation

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Thrombotic Complications and Thromboprophylaxis Across All Three Stages of Single Ventricle Heart Palliation

Cited by 74 publications

References 27 publications

Incidence of Venous Thromboembolism and Benefits and Risks of Thromboprophylaxis After Cardiac Surgery: A Systematic Review and Meta‐Analysis

Incidence of Venous Thromboembolism and Benefits and Risks of Thromboprophylaxis After Cardiac Surgery: A Systematic Review and Meta‐Analysis

Risk, Clinical Features, and Outcomes of Thrombosis Associated With Pediatric Cardiac Surgery

Challenges and Priorities for Research

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