Prospective study of the incidence and predictors of thrombus in children undergoing palliative surgery for single ventricle physiology

Abstract

Purpose To determine the incidence and clinical and biomarker predictors of perioperative thrombosis in children with single ventricle physiology undergoing staged palliation. Methods Nineteen patients were enrolled and 16 completed the study. Serial ultrasounds of the central venous system were performed to evaluate for thrombus. Plasma antithrombin III, thrombin–antithrombin complex, protein C, protein S, tissue factor pathway inhibitor, plasminogen activator inhibitor-1, tissue plasminogen activator antigen, D-dimer, soluble CD40 ligand, and urinary thromboxane were measured serially before and after surgery. Cardiopulmonary bypass time, aortic cross clamp time, blood product administration, inotrope score, chest tube output, cardiac function by echocardiography, intensive care unit and hospital lengths of stay, and central venous catheter days were recorded. Results The incidence of perioperative thrombus was 31%. Patients who developed a thrombus had poorer preoperative ventricular function (p = 0.03) and longer cardiopulmonary bypass times (p = 0.03) than those who did not develop a thrombus. Preoperative plasma antithrombin III was lower (p = 0.01) and tissue plasminogen activator antigen concentrations were higher (p = 0.02) in patients with a thrombus compared with patients without a thrombus. When measured over time, antithrombin III remained lower (p = 0.002) and tissue plasminogen activator antigen higher (p = 0.005) in those who developed a thrombus compared with those who did not. There were no other statistically significant differences in biomarkers of coagulation between patients with and without thrombosis. Conclusion One-third of patients undergoing palliative surgery for single ventricle physiology develop thrombosis. Decreased ventricular function, low antithrombin III, and increased tissue plasminogen activator may predict those most suitable for randomized clinical trials of anticoagulation.

Acquired von Willebrand syndrome in congenital heart disease surgery: results from an observational case‐series

“…A postoperative transient CSVT was diagnosed in one case, but this patient also received rFVIIa, which is a known thrombogenic agent associated with increased mortality after cardiac surgery . Neonates and infants with CHD are generally at increased risk of thromboembolic complications because of a CHD‐associated imbalance between pro‐ and antithrombotic activity, abnormally low blood flow velocities and prothrombotic foreign materials . Hunt et al .…”

Elevated preoperative von Willebrand factor is associated with perioperative thrombosis in infants and neonates with congenital heart disease

“…Prior efforts to identify predictive markers of thrombosis have focused on specific CHD subpopulations (e.g. single‐ventricle neonates ).…”

Pediatric Cardiac Intensive Care Society 2014 Consensus Statement

“…Aspirin is often used as a part of the thromboprophylaxis regime with VADs although specifics vary with device. Controversy exists in the use of aspirin in single hypoplastic left heart disease palliated with a stage I with Sano modification (1,4,91), single ventricle physiology beyond stage I (1,4,32,(92)(93)(94), and with intravascular stents (1,4). Aspirin has been recommended as an adjunct to warfarin in the thromboprophylaxis of mechanical valves in the mitral and aortic positions although the practice in children varies (51,95).…”