Rao MY, Sullivan PM, Takao C, Badran S, Patel ND.
Pediatr Cardiol. 2023 Jun;44(5):1009-1013. doi: 10.1007/s00246-023-03097-x. Epub 2023 Feb 2.
PMID: 36725724
Take Home Points:
- Anticoagulation was safely continued in pediatric patients undergoing cardiac catheterizations, often including interventions.
- Individualized peri-procedural decision-making is important and allows for alteration of intra-procedural anticoagulation.
Commentary from Dr. Arash Salavitabar (Columbus, OH, USA), section editor of Congenital Heart Disease Interventions Journal Watch:
Commentary:
Anticoagulation is a common need amongst patients with congenital heart disease. The authors tackle an important topic that is relevant throughout pediatric and adult cardiac catheterization, reporting on the safety of uninterrupted anticoagulation in pediatric patients undergoing cardiac catheterization in a single center. The 104 patients reported in this manuscript took a variety of anticoagulants, including warfarin, enoxaparin, heparin, fondaparinux, arivaroxaban, and antiplatelet agents. Pre-catheterization INR was available in 58 patients on warfarin and was a median of 2.35 (1.4-6.6). Pre-catheterization anti-Xa levels were available in 43 patients on heparin and 21 patients on enoxaparin and the median levels were 0.41U/ml [0.05–1.96] and 0.63 [0.23–1], respectively.
Both arterial and venous access were obtained in 95 cases (66%) and venous access only in 95 cases (29%). Importantly, the largest arterial access obtained was a 7-French sheath in 1 patient and there were 32 (22%) patients who had a venous sheath size greater than 7-French. Despite being on baseline anticoagulation, additional anticoagulation was administered during the procedure in 92 cases at a median bolus dose of heparin or bivalirudin of 72 units/kg [17.5–101.9 units/kg] and 0.5 mg/kg [0.45–0.50 mg/kg)], respectively. Interventions were common, including angioplasty in 67 (42%), stent implantation in 31 (20%), and liver biopsy in 10 (6%).
Adverse events were reported in 11 cases (7.6%), including only 2 (1.4%) minor bleeding complications. These 2 bleeding complications were in patients on warfarin with INRs of 2.8 and 3.1. While this study was limited by its retrospective nature, which depends on reported safety and complication variables in the medical records, the authors point out that these rates of adverse events are comparable to those previously reported with cardiac catheterizations. The authors stressed that the peri-procedural anticoagulation management must be individualized and that the intraprocedural anticoagulation dose should be adjusted accordingly. This work shows that there are important alternative management strategies for patients on baseline anticoagulation who often require pauses in their regimen or hospitalizations to bridge therapy prior to their procedures.