The Use of Alteplase in a Newborn Receiving Extracorporeal Membrane Oxygenation

Abstract

Alteplase is an effective thrombolytic agent in neonates receiving ECMO support. Additional experience with alteplase is necessary to determine the optimal dose and duration of therapy in this patient population.

Systemic Thrombolysis of an Occlusive Aortic Thrombus in a Neonate on Extracorporeal Membrane Oxygenation

“…There are few other reports of the use of systemic tPA for the treatment of various types of thrombus in a neonate while on ECMO including aortic, intracardiac, and radial artery thromboses. [1][2][3] Each were successful in clearing the thrombus within 6 to 12 hours of starting thrombolysis, whereas in our case, 30 hours of treatment was required, and there was still remaining thrombus, although it was no longer occlusive. One explanation could be the amount of clot burden in each case: the two cases cleared by six hours were of a radial artery thrombus 3 and an intracardiac thrombus at the tip of the arterial ECMO cannula.…”

“…[1][2][3] Each were successful in clearing the thrombus within 6 to 12 hours of starting thrombolysis, whereas in our case, 30 hours of treatment was required, and there was still remaining thrombus, although it was no longer occlusive. One explanation could be the amount of clot burden in each case: the two cases cleared by six hours were of a radial artery thrombus 3 and an intracardiac thrombus at the tip of the arterial ECMO cannula. 2 The latter thrombus was not quantified other than described as small.…”

“…As mentioned previously, the starting dose (0.03 mg/kg/h) was lower than had been recommended in two of the prior reports (0.1 mg/kg/h and 0.5 mg/kg/h) although all recommendations came from the same source (1-800-NOCLOTS); 1, 2 the third team determined their starting dose based on literature review. 3 This difference in recommendations is likely from evolution based on assimilation of new data over time: as time has passed, the recommended starting dose has continued to decrease from 0.5 to 0.1 to 0.03 mg/kg/h, likely as the International Thrombophilia Programme group was able to see successful results with the lower doses while avoiding bleeding complications. It is possible that we may have seen results even without the increase in infusion rate, as none of the other reports saw substantial changes after the initial infusion.…”

The use of recombinant tissue-type plasminogen activator in a newborn with an intracardiac thrombus developed during extracorporeal membrane oxygenation

“…Although tPA has been used during ECMO, the experience has been limited. Glover et al [6] described the successful use of tPA in a neonate with a spontaneous upper extremity arterial occlusion. Olarte et al [7] described the administration of intravesicular tPA in a neonate who developed a bladder thrombus.…”