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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: cjpetit@emory.edu
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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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