Clinical Outcomes of Palliative Surgery Including a Systemic-to-Pulmonary Artery Shunt in Infants With Cyanotic Congenital Heart Disease

Abstract

Background-Aspirin (ASA) often is used to prevent thrombosis in infants with congenital heart disease after placement of a systemic-to-pulmonary artery shunt, but its effect on outcomes is unknown. Methods and Results-The present multicenter study prospectively collected data on 1-year postoperative rates of death, shunt thrombosis, or hospitalization age Ͻ4 months for bidirectional Glenn/hemi-Fontan surgery in 1004 infants. The use and dose of ASA were recorded. Kaplan-Meier event rates were calculated for each event and the composite outcome, and a Cox regression model was constructed for time to event. Model terms were ASA use and type of surgery, with adjustment for age at surgery. Diagnoses were hypoplastic left heart syndrome (nϭ346), tricuspid atresia (nϭ103), tetralogy of Fallot (nϭ127), pulmonary atresia (nϭ177), heterotaxy syndrome (nϭ38), and other (nϭ213

Thrombosis in the critically ill neonate: incidence, diagnosis, and management

“…We and others reported a 12% incidence of aortopulmonary shunt thrombosis in a prospective multicenter observational study (Li et al 2007), indicating a hypercoagulable state of cyanotic children after insertion of intravascular artifi cial prostheses. Furthermore, acquired thrombophilia in cyanotic children has been described in terms of elevated markers as platelet p-selectin, and decreased levels of thrombomodulin and protein C activity (Kajimoto et al 2007).…”

Antithrombotic Therapy in Neonates and Children

“…A retrospective series of 546 MBTS procedures reported no signifi cant differences between heparin and no heparin in early failure rate (1.4% vs 3.4%, P 5 .29), in later failure rate (9.1% vs 13.6%, P 5 .17), or between aspirin and no aspirin (11.0% vs 6.7%, P 5 .18), 293 and Li et al 294 reported reduced thrombosis in a large cohort of patients treated with aspirin for 12 months after shunt surgery. In another, much smaller case study, aspirin was reported to decrease the incidence of stent thrombosis after MBTS surgery.…”

Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease

“…Shunt thrombosis in infants has been reported to be 8% to 12% in different series and is usually life-threatening unless quickly resolved. 71,72 In addition, the placement of mechanical heart valves in children requires long-term oral anticoagulation equaling considerable patient-years. [73][74][75] Likewise, many patients with single-ventricle palliation or a history of vascular thrombosis require long-term oral anticoagulation.…”

“…Perhaps limited by inadequate power, no risk factor other than smaller shunt size could be identified in this cohort. Using a broader definition for shunt thrombosis and longer follow-up, Li et al 72 reported a 12% incidence (99 of 1004 patients) of shunt thrombosis. Such past and current experiences raise the question of timing for prophylactic antithrombotic therapy in these patients.…”

“…71 Recently, the results of a large multicenter observational trial in which infants palliated with aortopulmonary shunts who were prospectively monitored for clinical outcome demonstrated that those receiving low-dose aspirin were found to have a reduced risk of shunt thrombosis (P=0.008) and death compared with those infants not receiving aspirin. 72 The antiplatelet effect of other pharmacological agents has contributed favorably to outcome in various adult cardiovascular diseases. In 2 smaller single-institution series, aspirin use was not found to be a significant predictor of interstage death (n=146; P=0.49) or shunt failure (n=313; P=0.…”