The use of recombinant tissue-type plasminogen activator in a newborn with an intracardiac thrombus developed during extracorporeal membrane oxygenation.
Extracorporeal membrane oxygenation (ECMO) support is often used to support infants and children with hemodynamic or respiratory failure. One of the major obstacles of safely treating a child with ECMO is balancing the risk of hemorrhage with the potential for thrombus development. Managing thrombosis in the setting of ECMO is challenging and has no defined algorithm. The use of recombinant tissue-type plasminogen activator (tPA) for thrombolysis has been previously described in cases where thrombi have developed despite adequate anticoagulation. In such situations, the risk of hemorrhage must be carefully balanced with the benefit of dissolving the clot and reestablishing flow. We present a case of an infant who required ECMO because of severe primary pulmonary hypertension and subsequently developed a right atrial thrombus adjacent to the ECMO cannula. The patient was treated with tPA with immediate improvement but had fatal intracranial hemorrhage almost 3 days after the tPA was administered. In this report, we review the current literature on tPA use during ECMO support and suggest a rational approach.
Division of Pediatric Surgery, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY 10032, USA. alg2025@columbia.edu
Alejandro
A
Garcia
Jeffrey W
JW
Gander
Erica R
ER
Gross
Ari
A
Reichstein
Sujit S
SS
Sheth
Charles J
CJ
Stolar
William
W
Middlesworth
D002585:Cesarean Section; D004200:Diseases in Twins; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects*; D017809:Fatal Outcome; D005260:Female; D005307:Fertilization in Vitro; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D054092:Foramen Ovale, Patent / Q000150:complications*; D006325:Heart Atria; D006331:Heart Diseases / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications; D007231:Infant, Newborn; D020300:Intracranial Hemorrhages / Q000139:chemically induced* / Q000000981:diagnostic imaging; D008297:Male; D008478:Mediastinal Emphysema / Q000151:congenital; D011030:Pneumothorax / Q000151:congenital; D011247:Pregnancy; D011994:Recombinant Proteins / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D012127:Respiratory Distress Syndrome, Newborn / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000009:adverse effects*; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D014463:Ultrasonography
D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator