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Thromboembolic complications after Fontan procedures: comparison of different therapeutic approaches
Ralf G Seipelt1, Andreas Franke, Jaime F Vazquez-Jimenez
1Department of Thoracic and Cardiovascular Surgery, Medical Clinic I, Aachen, Germany. rseipelt@childrensmemorial.org
Insights
Thromboembolism is common after Fontan procedures. Coumadin (warfarin) significantly reduces these risks compared to no medication, suggesting its use for Fontan patients.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Cardiovascular Surgery
Background:
- Patients undergoing the Fontan procedure face a high risk of thromboembolic complications.
- Anticoagulant therapy management varies significantly among these patients.
- This study investigates thromboembolism frequency and clinical relevance post-Fontan.
Purpose of the Study:
- To analyze the incidence and clinical significance of thromboembolism following Fontan procedures.
- To compare the effectiveness of different anticoagulant therapeutic approaches.
Main Methods:
- 101 patients (mean age 7.3 years) underwent Fontan-type procedures (modified Fontan or total cavopulmonary connection) between 1986-1998.
- Follow-up averaged 5.7 years, with echocardiography and/or angiography performed on survivors.
- Three anticoagulant groups were compared: no medication (n=45), aspirin (n=14), and Coumadin (n=26).
Main Results:
- Thromboembolic events occurred in 15.3% of patients (3.3 events/100 patient-years), peaking in the first year and again after 10 years.
- Coumadin therapy showed a significant benefit in preventing thromboembolism compared to no medication (p=0.031).
- Cumulative event rates were 4.2/100 patient-years (no medication), 1.6/100 patient-years (aspirin), and 1.1/100 patient-years (Coumadin), with no significant bleeding complications.
Conclusions:
- Thromboembolism is a frequent complication after Fontan procedures, with distinct early and late peaks.
- Coumadin demonstrates superior efficacy in preventing thromboembolic events post-Fontan.
- Initial oral anticoagulation therapy with Coumadin is recommended for patients undergoing Fontan-type operations.
Background:
Although patients after Fontan procedure have a high incidence of thromboembolic complications, anticoagulant therapy is not handled uniformly. We analyzed the frequency and clinical relevance of thromboembolism after Fontan procedure and compared different therapeutic approaches.
Methods:
From 1986 to 1998, 101 patients (mean age, 7.3 +/- 8.1 years) underwent Fontan type procedure (modified Fontan, n = 40; total cavopulmonary connection, n = 61). In 85 of 87 survivors, transthoracic echocardiography was performed; and in 31 transesophageal echocardiography and/or angiography was performed. Mean follow-up was 5.7 +/- 3.5 years. Three groups with different anticoagulant regimen were compared: group I without medication (n = 45), group II with acetylsalicylic acid therapy (n = 14) and group III with Coumadin (n = 26).
Results:
Thromboembolic events occurred in 13 of 85 patients (15.3%; 3.3 events/100 patient-years). Type of operation as well as other known risk factors had no influence on the rate of thromboembolism. Within the first postoperative year, seven of 13 events occurred. A second peak developed beyond 10 years of follow-up. Patients benefit significantly from Coumadin compared with those who did not receive any medication, with similar results in the entire population and the subgroup of patients with total cavopulmonary connection (log-rank, p = 0.031 and p = 0.033, respectively). With 4.2 events/100 patient-years, the cumulative event rate was substantially higher in group I than with 1.6 in group II and with 1.1 in group III. No relevant bleeding complications occurred.
Conclusions:
Thromboembolism is frequent after Fontan procedure with a peak during the first postoperative year and another peak beyond 10 years of follow-up. Coumadin is the most effective prophylactic therapy in preventing thromboembolism. Therefore, we suggest initial oral anticoagulation therapy in patients with Fontan type operation.