Comparative trial of the use of antiplatelet and oral anticoagulant in thrombosis prophylaxis in patients undergoing total cavopulmonary operation with extracardiac conduit: echocardiographic, tomographic, scintigraphic, clinical and laboratory analysis

Abstract

ObjectiveTo compare the efficacy of aspirin and warfarin for prophylaxis of thrombosis in patients undergoing total cavopulmonary anastomosis. Evaluate whether coagulation factors (VII, VIII and protein C), clinical data, fenestration or hemodynamic factors, interfere with postoperative thrombosis.MethodsA prospective, randomized study of 30 patients, randomized into Group I (Warfarin) and Group II (AAS), underwent total cavopulmonary shunt with extracardiac conduit, between 2008 and 2011, with follow-up by clinical visits to evaluate side effects and adhesion. Performed transesophageal echocardiography in post operatory time, 3, 6,12 and 24 months; angiotomography at 6, 12 and 24 months to evaluate changes in the internal tube wall or thrombi and pulmonary scintigraphy to evaluate possible PTE.ResultsTwo deaths in group I; 33.3% of patients had thrombus (46.7% in Group II). The previous occurrence of thrombus and low levels of coagulation protein C were the only factors that influenced the time free of thrombus (P=0.035 and 0.047). Angiotomographic evaluation: 35.7% in group II presented material accumulation greater than 2 mm (P=0.082). Scintigraphy: two patients had PTE in group II. Five patients had difficulty to comply with the treatment, 4 in group I with INR ranging from 1 to 6.4.ConclusionThe previous occurrence of thrombus is a risk factor for thrombosis in the postoperative period. Patients using AAS tend to deposit material in the tube wall. The small sample size did not allow to conclude which is the most effective drug in the prevention of thrombosis in this population.

Coagulation and Anticoagulation in Fontan Patients

“…The second RCT included 30 patients undergoing conversion to Fontan with an extracardiac conduit (ECC), and found 7 TEs in the group on ASA (47%) during 2 years of follow-up, compared to 3 in the VKA group (20%), which did not reach statistical significance (p=0.12) 28 . No bleeding was reported.…”

“…The extracardiac Fontan conduits are at risk of development of a neo-intima inside the conduit, which disrupts the endothelial balance and incites platelet reactivity and thrombus formation 27 . The presence of minor conduit depositions was demonstrated in 21 out of 30 Fontan patients on CT angiography within 2 years post-surgery in a trial on thromboprophylaxis 28 . These conduit thrombi are often laminated and clinically silent.…”

Late Follow-up of Patients Submitted to Total Cavopulmonary Derivation: Clinical Aspects, Reinterventions, and Complications Interfering in Morbidity and Mortality

“…Another prospective study carried out in our department followed for two years a group of 40 patients submitted to cavopulmonary bypass, 20 in use of antiplatelet agent and 20 in use of oral anticoagulant, evidencing the absence of a statistically significant relation in the occurrence of thrombosis between the two groups, but showing a trend towards a greater deposit of material on the wall of the extracardiac tube, which was evidenced by computed tomography, in patients taking ASA [ 6 ] .…”

Perioperative Management of the Fontan Patient for Cardiac and Noncardiac Surgery

“…Current guidelines suggest that aspirin is a reasonable first choice, with warfarin reserved for those with additional risk factors, previous thrombosis, or older age. [38][39][40] Newer direct oral anticoagulants are under investigation in paediatric Fontan patients, with their efficacy and safety yet to be determined. 2 Protein-losing enteropathy PLE, defined as the abnormal loss of serum proteins from the gut, is an important pathology seen in 4% to 13% of Fontan patients.…”