title: A method for anticoagulation of children on mechanical circulatory support.
abstract: Anticoagulation of children on mechanical circulatory support presents a challenge. We implanted 28 devices in children and infants using a consistent anticoagulation protocol. We performed a retrospective review of all children implanted in our program with mechanical assist devices since 1997. Heparin, dipyridamole, and aspirin were used for anticoagulation and antiaggregation. Coagulation monitoring included thromboelastography (TEG), platelet aggregration studies, international normalized ratio, partial thromboplastin time, and platelet count. Twenty-eight children, ages 1 month to 16 years (mean 5.3; median 2.4 years), were implanted for 3-107 days (mean 27; median 17). Eighteen received left ventricular assist devices, seven received biventricular assist devices, and three received total artificial hearts. Adverse events during the 720 days of device support included the following: six (21%) reoperations for bleeding; seven strokes (25%): two fatal, two with a mild residual deficit, and three without deficit; and three (11%) visceral emboli: two fatal and one nonfatal. There were eight deaths (29%). Causes of death were embolic (four), graft failure post-transplantation (one), preimplant anoxic brain damage (two), and postexplant heart failure (one). 24/28 (86%) survived to transplantation or weaning from device and 20/28 (71%) were discharged from the hospital, 10 after transplantation and 10 after native heart recovery. All 20 early survivors survived long term. We describe an anticoagulation protocol based upon TEG and platelet aggregation studies and using heparin, aspirin, and dipyridamole. Adequate anticoagulation is more difficult in children. However, 71% of the patients in our study survived long term.
authors.affiliation: Department of Surgery, University of California San Diego, San Diego, CA, USA. jgcopeland@ucsd.edu
authors.forename: Hannah
authors.initials: H
authors.lastname: Copeland
authors.forename: Paul E
authors.initials: PE
authors.lastname: Nolan
authors.forename: Diane
authors.initials: D
authors.lastname: Covington
authors.forename: Monica
authors.initials: M
authors.lastname: Gustafson
authors.forename: Richard
authors.initials: R
authors.lastname: Smith
authors.forename: Jack G
authors.initials: JG
authors.lastname: Copeland
mesh_terms: D000293:Adolescent; D000925:Anticoagulants / Q000627:therapeutic use*; D001241:Aspirin / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D004176:Dipyridamole / Q000627:therapeutic use*; D005260:Female; D006353:Heart-Assist Devices / Q000009:adverse effects; D006493:Heparin / Q000627:therapeutic use*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010974:Platelet Aggregation / Q000187:drug effects; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D012189:Retrospective Studies; D013916:Thrombelastography
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D004176:Dipyridamole; D006493:Heparin; D001241:Aspirin