Antiplatelet therapy in children with left-sided mechanical prostheses
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J G LeBlanc1, S S Sett, D J Vince
1Department of Cardiovascular and Thoracic Surgery, University of British Columbia, British Columbia's Children's Hospital, Vancouver, Canada.
Insights
Pediatric valve replacement using warfarin followed by antiplatelet therapy showed no deaths and low thromboembolism. This approach effectively manages anticoagulation in children undergoing cardiac valve surgery.
Area of Science:
- Pediatric Cardiac Surgery
- Cardiovascular Medicine
- Prosthetic Valve Research
Background:
- Pediatric valve replacement historically faces challenges including high mortality, prosthetic valve outgrowth, and anticoagulation management difficulties.
- Left-sided cardiac valve replacement in children requires careful consideration of surgical techniques and long-term patient outcomes.
Purpose of the Study:
- To evaluate the safety and efficacy of a specific anticoagulation regimen in pediatric patients undergoing left-sided cardiac valve replacement.
- To assess the incidence of thromboembolism, bleeding, and valve thrombosis in children following prosthetic valve implantation.
Main Methods:
- Retrospective analysis of 20 pediatric patients (median age 85 months) who underwent left-sided cardiac valve replacement between 1985 and 1991.
- Utilized Bjork-Shiley and St. Jude prostheses for aortic and left atrioventricular valve replacements.
- Employed a 3-month warfarin regimen followed by long-term aspirin and persantine therapy.
Main Results:
- No early or late mortality was observed in the study cohort.
- A low incidence of thromboembolism (1.7%/patient-year) and bleeding (6.8%/patient-year) was reported.
- No instances of valve thrombosis occurred during the median follow-up of 12.3 months.
Conclusions:
- The anticoagulation strategy of initial warfarin followed by long-term antiplatelet therapy is associated with a low risk of thromboembolic events and no valve thrombosis in pediatric cardiac valve replacement.
- This regimen appears effective in managing anticoagulation and improving outcomes for children requiring prosthetic valve implantation.
Abstract:
Valve replacement in children has always been associated with a high mortality, outgrowth of the prosthetic valve and difficulty in managing anticoagulation. Between January 1985 and April 1991, 20 patients (14 males and 6 females) underwent replacement of a left-sided cardiac valve. The median age at diagnosis was 21.6 months (1 to 120 months) and the median age at surgery was 85 months (11 to 213 months). Six patients were under 4 years of age. The site of valve replacement was aortic in 11 patients and left atrioventricular (AV) valve in 9 patients. The indications for aortic valve replacement were stenosis (6) and incompetence (5). The left AV valve was replaced in three patients following repair of AV septal defect, in one patient with corrected transposition of the great arteries (LTGA), in one patient with severe dysplasia and insufficiency, and in four patients for congenital mitral stenosis. A Bjork-Shiley prosthesis was used in three mitral and one aortic position, all the other patients receiving a St. Jude prosthesis: six mitral and ten aortic. All patients were anticoagulated (warfarin) for 3 months post implantation and then switched to a regimen of aspirin and persantine. There was no early or late death. Median follow-up was 12.3 months (4 to 72 months). Total follow-up was 59 patient-years or 708 months. There was one incident of thromboembolism (1.7%/patient-year) and four instances of bleeding (6.8%/patient-year). There was no valve thrombosis. Our regime of early warfarin followed by long-term antiplatelet therapy has been associated with a low incidence of thromboembolism and no valve thrombosis.
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