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Retrosternal Clots After Fontan Surgery by Systematic Evaluation With Transthoracic Ultrasound
Massimiliano Cantinotti1, Raffaele Giordano2, Pietro Marchese3
1Fondazione CNR-Regione Toscana G. Monasterio (FTGM), Massa, Pisa, Italy; Institute of Clinical Physiology, National Research Institute, Pisa, Italy.
Insights
Retrosternal clots are common after total cavopulmonary connection surgery, with thoracic ultrasound detecting them in nearly half of patients. While most clots are small and asymptomatic, large ones may necessitate surgical intervention.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Diagnostic Imaging
Background:
- Bleeding is a significant complication following total cavopulmonary connection (TCPC) surgery.
- Early detection of postoperative complications like retrosternal clots is crucial for patient management.
Purpose of the Study:
- To determine the incidence of retrosternal clots after TCPC surgery.
- To evaluate the utility of transthoracic ultrasound in detecting these clots.
Main Methods:
- A retrospective single-center study reviewed 37 children who underwent TCPC surgery between January 2016 and May 2019.
- Transthoracic ultrasound was systematically performed postoperatively at multiple time points to assess for retrosternal clots.
Main Results:
- Retrosternal clots were identified in 18 (48.6%) of the 37 children.
- Clot sizes varied, with 16.2% having large clots (>3 cm), 4 of which required surgical revision.
- No significant differences in patient demographics or surgical factors were observed between groups with different clot sizes.
Conclusions:
- Transthoracic ultrasound is effective in identifying retrosternal clots after TCPC surgery, revealing a high incidence.
- While most clots are small and clinically insignificant, the detection of large clots highlights the need for vigilant monitoring and potential intervention.
Objectives:
Bleeding is a common, serious, and often subtle complication after total cavopulmonary connection surgery. The aim of the present study was to assess the incidence of retrosternal clots after surgery, which were searched for systematically with transthoracic ultrasound.
Design:
Retrospective study.
Setting:
Single center.
Participants:
Total cavopulmonary surgeries were reviewed from January 2016 to May 2019.
Interventions:
Thoracic ultrasound with careful evaluation of the retrosternal area was performed at different postoperative times (12-36 hours, 5-7 days, and before discharge) as completion of routine echocardiography.
Measurements And Main Results:
Among 37 children undergoing total cavopulmonary connection (mean age 5.5 ± 1.8 years [range 2.4-11.7]; mean body surface area 0.7 ± 0.1 m2 [range 0.3-1.6 m2]), retrosternal clots were detected in 18 (48.6%). Of these, 7 (13.5%) had small clots (<1 cm), 2 (5.4%) small to moderate sized clots (>1 cm-<2 cm), 3 (8.1%) moderate sized clots (>2-<3 cm), and 6 (16.2%) large clots (>3 cm). Four of the 6 detected large clots required surgical revision, and in the other 2 patients, the clots were not treated because the patients' conditions were clinically stable. When 3 major groups (group 1-no or small clots, group gropu 2 are small to moderate or moderate, group 3-large clots) were evaluated, no significant differences were noted in age, body surface area, CPB time, conduit type, or the number of previous surgeries.
Conclusions:
With thoracic ultrasound diagnosis, existence of retrosternal clots was found to be very common after total cavopulmonary connection. Most clots were small or moderate with no clinical effect; however, large clots that required redo surgery also were detected.
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