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Thromboprophylaxis strategies for children with single-ventricle circulations (superior or total cavo-pulmonary connections) after stent implantation

Published online by Cambridge University Press:  18 June 2019

Yinn K. Ooi ,
R. Allen Ligon Open the ORCID record for R. Allen Ligon [Opens in a new window] ,
Michael Kelleman ,
Robert N. Vincent ,
Holly D. Bauser-Heaton ,
Dennis W. Kim  and
Christopher J. Petit
Yinn K. Ooi
Affiliation:
Division of Cardiology, Children’s Healthcare of Atlanta, Atlanta, GA, USA Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
R. Allen Ligon
Affiliation:
Division of Cardiology, Children’s Healthcare of Atlanta, Atlanta, GA, USA Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
Michael Kelleman
Affiliation:
Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
Robert N. Vincent
Affiliation:
Division of Cardiology, Children’s Healthcare of Atlanta, Atlanta, GA, USA Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
Holly D. Bauser-Heaton
Affiliation:
Division of Cardiology, Children’s Healthcare of Atlanta, Atlanta, GA, USA Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
Dennis W. Kim
Affiliation:
Division of Cardiology, Children’s Healthcare of Atlanta, Atlanta, GA, USA Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
Christopher J. Petit*
Affiliation:
Division of Cardiology, Children’s Healthcare of Atlanta, Atlanta, GA, USA Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
*
Author for correspondence: Christopher J. Petit, MD, Emory University School of Medicine, Children’s Healthcare of Atlanta, Division of Cardiology, 1405 Clifton Road NE, Atlanta, GA 30322, USA. Tel: (404) 785-1796; Fax: (770) 488-9039; E-mail: [email protected]
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Abstract

Objective:

To define optimal thromboprophylaxis strategy after stent implantation in superior or total cavopulmonary connections.

Background:

Stent thrombosis is a rare complication of intravascular stenting, with a perceived higher risk in single-ventricle patients.

Methods:

All patients who underwent stent implantation within superior or total cavopulmonary connections (caval vein, innominate vein, Fontan, or branch pulmonary arteries) were included. Cohort was divided into aspirin therapy alone versus advanced anticoagulation, including warfarin, enoxaparin, heparin, or clopidogrel. Primary endpoint was in-stent or downstream thrombus, and secondary endpoints included bleeding complications.

Results:

A total of 58 patients with single-ventricle circulation underwent 72 stent implantations. Of them 14 stents (19%) were implanted post-superior cavopulmonary connection and 58 (81%) post-total cavopulmonary connection. Indications for stenting included vessel/conduit stenosis (67%), external compression (18%), and thrombotic occlusion (15%). Advanced anticoagulation was prescribed for 32 (44%) patients and aspirin for 40 (56%) patients. Median follow up was 1.1 (25th–75th percentile, 0.5–2.6) years. Echocardiograms were available in 71 patients (99%), and advanced imaging in 44 patients (61%). Thrombosis was present in two patients on advanced anticoagulation (6.3%) and none noted in patients on aspirin (p = 0.187). Both patients with in-stent thrombus underwent initial stenting due to occlusive left pulmonary artery thrombus acutely post-superior cavopulmonary connection. There were seven (22%) significant bleeding complications for advanced anticoagulation and none for aspirin (p < 0.001).

Conclusions:

Antithrombotic strategy does not appear to affect rates of in-stent thrombus in single-ventricle circulations. Aspirin alone may be sufficient for most patients undergoing stent implantation, while pre-existing thrombus may warrant advanced anticoagulation.

Keywords

Thromboprophylaxissingle ventricle circulationssuperior and total cavopulmonary connectionsanticoagulationstent implantationchildren
Type
Original Article
Information
Cardiology in the Young , Volume 29 , Issue 7 , July 2019 , pp. 877 - 884
Copyright
© Cambridge University Press 2019 

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References

Dasi, LP, Krishnankuttyrema, R, Kitajima, HD, et al. Fontan hemodynamics: importance of pulmonary artery diameter. J Thorac Cardiovasc Surg 2009; 137: 560–564.10.1016/j.jtcvs.2008.04.036CrossRefGoogle ScholarPubMed
Fontan, F, Kirklin, JW, Fernandez, G, et al. Outcome after a “perfect” Fontan operation. Circulation 1990; 81: 1520–1536.10.1161/01.CIR.81.5.1520CrossRefGoogle ScholarPubMed
Khairy, P, Fernandes, SM, Mayer, JE Jr., et al. Long-term survival, modes of death, and predictors of mortality in patients with Fontan surgery. Circulation 2008; 117: 85–92.CrossRefGoogle ScholarPubMed
Monagle, P, Cochrane, A, Roberts, R, et al. A multicenter, randomized trial comparing heparin/warfarin and acetylsalicylic acid as primary thromboprophylaxis for 2 years after the Fontan procedure in children. J Am Coll Cardiol 2011; 58: 645–651.10.1016/j.jacc.2011.01.061CrossRefGoogle ScholarPubMed
Rosenthal, DN, Friedman, AH, Kleinman, CS, Kopf, GS, Rosenfeld, LE, Hellenbrand, WE. Thromboembolic complications after Fontan operations. Circulation 1995; 92: II287–II293.CrossRefGoogle ScholarPubMed
Bhole, V, Wright, JG, De Giovanni, JV, et al. Transcatheter interventions in the early postoperative period after the Fontan procedure. Catheter Cardiovasc Interv 2011; 77: 92–98.10.1002/ccd.22667CrossRefGoogle ScholarPubMed
Mets, JM, Bergersen, L, Mayer, JE Jr., Marshall, AC, McElhinney, DB. Outcomes of stent implantation for obstruction of intracardiac lateral tunnel Fontan pathways. Circ Cardiovasc Interv 2013; 6: 92–100.10.1161/CIRCINTERVENTIONS.112.000099CrossRefGoogle ScholarPubMed
Noonan, P, Kudumula, V, Anderson, B, et al. Stenting of the left pulmonary artery after palliation of hypoplastic left heart syndrome. Catheter Cardiovasc Interv 2016; 88: 225–232.10.1002/ccd.26450CrossRefGoogle ScholarPubMed
Sreeram, N, Emmel, M, Bennink, G. Stent therapy for acute and chronic obstructions in extracardiac Fontan conduits. Cardiol Young 2013; 23: 766–768.10.1017/S1047951112001886CrossRefGoogle ScholarPubMed
Tanase, D, Ewert, P, Eicken, A. Plastic bronchitis: symptomatic improvement after pulmonary arterial stenting in four patients with Fontan circulation. Cardiol Young 2015; 25: 151–153.10.1017/S1047951113002163CrossRefGoogle ScholarPubMed
Tang, E, McElhinney, DB, Restrepo, M, Valente, AM, Yoganathan, AP. Haemodynamic impact of stent implantation for lateral tunnel Fontan stenosis: a patient-specific computational assessment. Cardiol Young 2016; 26: 116–126.10.1017/S1047951114002765CrossRefGoogle ScholarPubMed
Udink Ten Cate, FE, Trieschmann, U, Germund, I, et al. Stenting the Fontan pathway in paediatric patients with obstructed extracardiac conduits. Heart 2017; 103: 1111–1116.10.1136/heartjnl-2016-310511CrossRefGoogle ScholarPubMed
Alsaied, T, Alsidawi, S, Allen, CC, Faircloth, J, Palumbo, JS, Veldtman, GR. Strategies for thromboprophylaxis in Fontan circulation: a meta-analysis. Heart 2015; 101: 1731–1737.10.1136/heartjnl-2015-307930CrossRefGoogle ScholarPubMed
Iyengar, AJ, Winlaw, DS, Galati, JC, et al. No difference between aspirin and warfarin after extracardiac Fontan in a propensity score analysis of 475 patients. Eur J Cardiothorac Surg 2016; 50: 980–987.10.1093/ejcts/ezw159CrossRefGoogle Scholar
Marrone, C, Galasso, G, Piccolo, R, et al. Antiplatelet versus anticoagulation therapy after extracardiac conduit Fontan: a systematic review and meta-analysis. Pediatr Cardiol 2011; 32: 32–39.10.1007/s00246-010-9808-4CrossRefGoogle ScholarPubMed
Potter, BJ, Leong-Sit, P, Fernandes, SM, et al. Effect of aspirin and warfarin therapy on thromboembolic events in patients with univentricular hearts and Fontan palliation. Int J Cardiol 2013; 168: 3940–3943.10.1016/j.ijcard.2013.06.058CrossRefGoogle ScholarPubMed
Faircloth, JM, Miner, KM, Alsaied, T, et al. Time in therapeutic range as a marker for thrombotic and bleeding outcomes in Fontan patients. J Thromb Thrombolysis 2017; 44: 38–47.10.1007/s11239-017-1499-8CrossRefGoogle ScholarPubMed
McCrindle, BW, Manlhiot, C, Cochrane, A, et al. Factors associated with thrombotic complications after the Fontan procedure: a secondary analysis of a multicenter, randomized trial of primary thromboprophylaxis for 2 years after the Fontan procedure. J Am Coll Cardiol 2013; 61: 346–353.10.1016/j.jacc.2012.08.1023CrossRefGoogle ScholarPubMed
Hirono, K, Ibuki, K, Tomita, H. Percutaneous catheter aspiration thrombectomy for the occluded stents of pulmonary artery in children with single ventricle physiology after Fontan surgery. Catheter Cardiovasc Interv 2014; 84: 1153–1156.10.1002/ccd.25470CrossRefGoogle ScholarPubMed
Schilling, C, Dalziel, K, Iyengar, AJ, d’Udekem, Y. The cost differential between warfarin versus aspirin treatment after a Fontan procedure. Heart Lung Circ 2017.10.1016/j.hlc.2017.02.003CrossRefGoogle ScholarPubMed
Vlachojannis, GJ, Smits, PC, Hofma, SH, et al. Biodegradable polymer biolimus-eluting stents versus durable polymer everolimus-eluting stents in patients with coronary artery disease: final 5-year report from the COMPARE II trial (Abluminal biodegradable polymer biolimus-eluting stent versus durable polymer everolimus-eluting stent). JACC Cardiovasc Interv 2017; 10: 1215–1221.10.1016/j.jcin.2017.02.029CrossRefGoogle Scholar
Wiebe, J, Hoppmann, P, Colleran, R, et al. Long-term clinical outcomes of patients treated with everolimus-eluting bioresorbable stents in routine practice: 2-year results of the ISAR-ABSORB registry. JACC Cardiovasc Interv 2017; 10: 1222–1229.10.1016/j.jcin.2017.03.029CrossRefGoogle ScholarPubMed
Hanson, SR, Sakariassen, KS. Blood flow and antithrombotic drug effects. Am Heart J 1998; 135: S132–S145.CrossRefGoogle ScholarPubMed
Sakariassen, KS, Hanson, SR, Cadroy, Y. Methods and models to evaluate shear-dependent and surface reactivity-dependent antithrombotic efficacy. Thromb Res 2001; 104: 149–174.10.1016/S0049-3848(01)00344-9CrossRefGoogle ScholarPubMed
Spivack, A, Troutman, D, Dougherty, M, Calligaro, K. Changing strategies to treat venous thrombotic occlusions of the upper and lower extremities secondary to compressive phenomena. Vasc Endovascular Surg 2013; 47: 274–277.10.1177/1538574413481857CrossRefGoogle ScholarPubMed
Lin, PH, Zhou, W, Dardik, A, et al. Catheter-direct thrombolysis versus pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis. Am J Surg 2006; 192: 782–788.10.1016/j.amjsurg.2006.08.045CrossRefGoogle ScholarPubMed
Goldenberg, NA, Branchford, B, Wang, M, Ray, C Jr., Durham, JD, Manco-Johnson, MJ. Percutaneous mechanical and pharmacomechanical thrombolysis for occlusive deep vein thrombosis of the proximal limb in adolescent subjects: findings from an institution-based prospective inception cohort study of pediatric venous thromboembolism. J Vasc Interv Radiol 2011; 22: 121–132.10.1016/j.jvir.2010.10.013CrossRefGoogle ScholarPubMed