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Current Perioperative Anticoagulation Practices in Children with Prosthetic Mechanical Heart Valves
Nguyenvu Nguyen1, Anjali Sharathkumar2
1Division of Cardiology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill, USA.
Insights
Pediatric clinician practices for perioperative anticoagulation in children with mechanical heart valves vary widely. Further studies are needed to compare unfractionated heparin (UFH) and low molecular weight heparin (LMWH) for improved guideline adherence.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Children with prosthetic mechanical heart valves require anticoagulation management during elective surgeries.
- Perioperative anticoagulation practices for this population are not well-defined.
Purpose of the Study:
- To investigate current clinician practices regarding perioperative anticoagulation in pediatric patients with mechanical heart valves undergoing elective surgery.
- To identify factors influencing bridging anticoagulation decisions.
Main Methods:
- An online survey was distributed to members of PediHeartNet, including pediatric cardiologists.
- The survey utilized multiple-choice questions and clinical scenarios to assess practice patterns.
Main Results:
- Ninety-one pediatric specialists responded, with most having extensive experience.
- Practices varied significantly, with diverse approaches to bridging anticoagulation using unfractionated heparin (UFH) or low molecular weight heparin (LMWH).
- Guideline adherence was suboptimal, with a trend towards more conservative management; major bleeding was rare, and no thromboembolic complications were reported with LMWH.
Conclusions:
- Clinical practice for perioperative anticoagulation in pediatric mechanical heart valve patients is highly variable.
- There is a need for further research comparing LMWH and UFH safety and efficacy.
- Quality improvement initiatives and education are essential to standardize care and improve adherence to guidelines.
Objective:
This study investigated the clinician practices on perioperative anticoagulation in children with prosthetic mechanical heart valves who undergo elective surgeries.
Design:
An online survey was administered to members of PediHeartNet. The survey consisted of multiple choice questions and clinical scenarios.
Outcome Measures:
The study described clinical practice patterns and variables that influence the clinicians' bridging anticoagulation decisions.
Results:
Ninety-one respondents completed the survey; 68% were affiliated with university settings; 91% were pediatric cardiologists, and 49% had ≥10 years of experience in pediatric cardiology. Approximately one-half of the respondents (54%) independently provided perioperative anticoagulation management to their patients, while 46% utilized cardiac or hematology anticoagulation services. Resources that influenced bridging decisions included hematology experts (20%), American College of Chest Physicians guidelines (34%), and the clinicians' personal experience (56%). In planning for major surgeries, 47% of the respondents hospitalized patients for unfractionated heparin (UFH) and 46% prescribed outpatient low molecular weight heparin (LMWH). For minor surgeries, 58% hospitalized patients for UFH, 22% prescribed outpatient LMWH, and 17% opted out of bridging anticoagulation. Immediately after mitral valve replacement, 23% used bridging anticoagulation with UFH. When LMWH was used, there were no reports of thromboembolic complications. Major bleeding complications were rare and reported by 2% of the respondents.
Conclusions:
This was the first documentation that clinical practice of bridging perioperative anticoagulation in children with mechanical heart valves varies widely among pediatric cardiac specialists. There is poor adoption of published guidelines and a tendency toward more conservative strategies. Further studies comparing the safety and efficacy of LMWH vs. UFH as perioperative anticoagulation agents in children with mechanical heart valves are needed to further clarify our findings. Quality assurance initiatives and education are also needed to improve guidelines adherence and standardize practice management.
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