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Acute pulmonary embolism in pediatric patients awaiting heart transplantation
D T Hsu1, L J Addonizio, A J Hordof
1Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York.
Insights
Pediatric heart transplant candidates with end-stage heart failure face risks of pulmonary embolism. Early anticoagulant therapy is crucial for these high-risk children awaiting heart transplantation.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Pulmonology
Background:
- Acute pulmonary embolism (PE) with infarction complicates heart transplantation, potentially delaying procedures and increasing postoperative pulmonary issues.
- Limited data exist on PE in pediatric patients with end-stage congestive heart failure (CHF).
Purpose of the Study:
- To investigate the prevalence of acute pulmonary embolism in pediatric patients awaiting heart transplantation.
- To identify risk factors and outcomes associated with PE in this vulnerable population.
Main Methods:
- Prospective monitoring of 62 pediatric patients awaiting heart transplantation for PE.
- Diagnostic methods included ventilation-perfusion scans, pulmonary angiography, and pathological examination.
- Two-dimensional echocardiography was used to assess for intracardiac thrombus.
Main Results:
- Six patients (9.7%) developed acute pulmonary embolism with infarction.
- Prevalence was higher in dilated cardiomyopathy (5/36) than congenital heart disease (1/20).
- No significant clinical factors differentiated patients with or without PE; echocardiography missed intracardiac thrombus in 4/6 cases.
Conclusions:
- Pediatric patients with end-stage CHF are at significant risk for acute PE.
- No specific clinical factor predicted PE development.
- Anticoagulant therapy is strongly recommended for pediatric patients with poor ventricular function awaiting heart transplantation.
Abstract:
Acute pulmonary embolism with infarction can delay urgently needed heart transplantation and increase the postoperative pulmonary complications. Few data are available concerning pulmonary embolization in the pediatric patient with end-stage congestive heart failure. Sixty-two consecutive pediatric patients awaiting heart transplantation were monitored for evidence of acute pulmonary embolism. Acute pulmonary infarction was documented by ventilation-perfusion scan, pulmonary angiography or pathologic examination in six patients. The prevalence differed by diagnosis; 5 of 36 patients with dilated cardiomyopathy and 1 of 20 patients with congenital heart disease developed acute pulmonary embolism with infarction. No significant difference in age at the time of transplantation evaluation, duration of congestive heart failure, presence of cardiac arrhythmias or degree of cardiac dysfunction was seen between patients with and without pulmonary embolism. Two-dimensional echocardiography failed to detect the presence of an intracardiac thrombus in four of the six patients. Two patients who developed acute pulmonary infarction are alive after successful heart transplantation. The remaining four patients died within 6 weeks of initiation of anticoagulant therapy before transplantation could safely be performed. In summary, pediatric patients with end-stage congestive heart failure are at risk for acute pulmonary embolism. No specific clinical factor identified those patients who developed acute pulmonary infarction. Anticoagulant therapy is strongly recommended in the pediatric patient with poor ventricular function awaiting heart transplantation.