Pediatric Cardiology

, Volume 30, Issue 6, pp 771–776

Thromboelastography of Patients After Fontan Compared with Healthy Children

  • Leslie Raffini
  • Alexander Schwed
  • X. Long Zheng
  • Maria Tanzer
  • Susan Nicolson
  • J. William Gaynor
  • David Jobes
Original Article

Abstract

Patients who have undergone a Fontan procedure face an increased risk for thromboembolic complications. This study aimed to evaluate whether thromboelastography, a global whole-blood assay of coagulation, can be used to detect hypercoagulability in pediatric Fontan patients compared with healthy children. This prospective, cross-sectional study investigated 25 Fontan patients and 51 healthy children in three age groups: 1–5 years, 6–10 years, and 11–16 years. Kaolin-activated thromboelastography was performed on citrated samples. No statistically significant differences in thromboelastography parameters were found among the different age groups of the 51 healthy children. None of the 25 Fontan patients demonstrated evidence of hypercoagulability on thromboelastography (95% confidence interval, 0–7%), as defined by two standard deviations above or below the normal mean. The findings suggest that the percentage of Fontan patients demonstrating hypercoagulability on thromboelastography is substantially lower than the reported incidence of thromboembolic complications. Whether thromboelastography could be helpful in predicting patients at increased risk for thromboembolic complications or not still is not known. Further studies comparing the thromboelastography of Fontan patients with the thromboembolic complications of those without Fontan are needed to delineate these issues.

Keywords

CHD Fontan Hematology Thrombosis 

References

  1. 1.
    Andrew M, Paes B, Milner R, Johnston M, Mitchell L, Tollefsen DM et al (1987) Development of the human coagulation system in the full-term infant. Blood 70:165–172PubMedGoogle Scholar
  2. 2.
    Andrew M, Vegh P, Johnston M, Bowker J, Ofosu F, Mitchell L (1992) Maturation of the hemostatic system during childhood. Blood 80:1998–2005PubMedGoogle Scholar
  3. 3.
    Barnes C, Monagle P (2001) Haemostatic changes following the modified Fontan procedure. Thromb Haemost 86:1341, author reply 2Google Scholar
  4. 4.
    Chaloupecky V, Svobodova I, Hadacova I, Tomek V, Hucin B, Tlaskal T et al (2005) Coagulation profile and liver function in 102 patients after total cavopulmonary connection at midterm follow-up. Heart 91:73–79PubMedCrossRefGoogle Scholar
  5. 5.
    Chan KL, Summerhayes RG, Ignjatovic V, Horton SB, Monagle PT (2007) Reference values for kaolin-activated thromboelastography in healthy children. Anesth Analg 105:1610–1613, table of contentsPubMedCrossRefGoogle Scholar
  6. 6.
    Cromme-Dijkhuis AH, Henkens CM, Bijleveld CM, Hillege HL, Bom VJ, van der Meer J (1990) Coagulation factor abnormalities as possible thrombotic risk factors after Fontan operations. Lancet 336:1087–1090PubMedCrossRefGoogle Scholar
  7. 7.
    Francis JL, Francis DA, Gunathilagan GJ (1994) Assessment of hypercoagulability in patients with cancer using the Sonoclot Analyzer and thromboelastography. Thromb Res 74:335–346PubMedCrossRefGoogle Scholar
  8. 8.
    Goobie SM, Soriano SG, Zurakowski D, McGowan FX, Rockoff MA (2001) Hemostatic changes in pediatric neurosurgical patients as evaluated by thromboelastograph. Anesth Analg 93:887–892PubMedCrossRefGoogle Scholar
  9. 9.
    Haizinger B, Gombotz H, Rehak P, Geiselseder G, Mair R (2006) Activated thromboelastogram in neonates and infants with complex congenital heart disease in comparison with healthy children. Br J Anaesth 97:545–552PubMedCrossRefGoogle Scholar
  10. 10.
    Jahangiri M, Shore D, Kakkar V, Lincoln C, Shinebourne E (1997) Coagulation factor abnormalities after the Fontan procedure and its modifications. J Thorac Cardiovasc Surg 113:989–992, discussion 92–93PubMedCrossRefGoogle Scholar
  11. 11.
    Kang YG, Martin DJ, Marquez J, Lewis JH, Bontempo FA, Shaw BWJr et al (1985) Intraoperative changes in blood coagulation and thromboelastographic monitoring in liver transplantation. Anesth Analg 64:888–896PubMedCrossRefGoogle Scholar
  12. 12.
    Kaulitz R, Luhmer I, Bergmann F, Rodeck B, Hausdorf G (1997) Sequelae after modified Fontan operation: postoperative haemodynamic data and organ function. Heart 78:154–159PubMedGoogle Scholar
  13. 13.
    McCrath DJ, Cerboni E, Frumento RJ, Hirsh AL, Bennett-Guerrero E (2005) Thromboelastography maximum amplitude predicts postoperative thrombotic complications including myocardial infarction. Anesth Analg 100:1576–1583PubMedCrossRefGoogle Scholar
  14. 14.
    Monagle P, Cochrane A, McCrindle B, Benson L, Williams W, Andrew M (1998) Thromboembolic complications after Fontan procedures: the role of prophylactic anticoagulation. J Thorac Cardiovasc Surg 115:493–498PubMedCrossRefGoogle Scholar
  15. 15.
    Odegard KC, McGowan FX Jr, Zurakowski D, DiNardo JA, Castro RA, del Nido PJ et al (2002) Coagulation factor abnormalities in patients with single-ventricle physiology immediately prior to the Fontan procedure. Ann Thorac Surg 73:1770–1777PubMedCrossRefGoogle Scholar
  16. 16.
    Odegard KC, McGowan FX Jr, Zurakowski D, DiNardo JA, Castro RA, del Nido PJ et al (2003) Procoagulant and anticoagulant factor abnormalities following the Fontan procedure: increased factor VIII may predispose to thrombosis. J Thorac Cardiovasc Surg 125:1260–1267PubMedCrossRefGoogle Scholar
  17. 17.
    Orlikowski CE, Payne AJ, Moodley J, Rocke DA (1992) Thromboelastography after aspirin ingestion in pregnant and nonpregnant subjects. Br J Anaesth 69:159–161PubMedCrossRefGoogle Scholar
  18. 18.
    Osthaus WA, Boethig D, Johanning K, Rahe-Meyer N, Theilmeier G, Breymann T et al (2008) Whole blood coagulation measured by modified thromboelastography (ROTEM) is impaired in infants with congenital heart diseases. Blood Coagul Fibrinolysis 19:220–225PubMedCrossRefGoogle Scholar
  19. 19.
    Rauch R, Ries M, Hofbeck M, Buheitel G, Singer H, Klinge J (2000) Hemostatic changes following the modified Fontan operation (total cavopulmonary connection). Thromb Haemost 83:678–682PubMedGoogle Scholar
  20. 20.
    Ravn HB, Hjortdal VE, Stenbog EV, Emmertsen K, Kromann O, Pedersen J et al (2001) Increased platelet reactivity and significant changes in coagulation markers after cavopulmonary connection. Heart 85:61–65PubMedCrossRefGoogle Scholar
  21. 21.
    Rosenthal DN, Friedman AH, Kleinman CS, Kopf GS, Rosenfeld LE, Hellenbrand WE (1995) Thromboembolic complications after Fontan operations. Circulation 92(9):287–293Google Scholar
  22. 22.
    Salooja N, Perry DJ (2001) Thromboelastography. Blood Coagul Fibrinolysis 12:327–337PubMedCrossRefGoogle Scholar
  23. 23.
    Shirai LK, Rosenthal DN, Reitz BA, Robbins RC, Dubin AM (1998) Arrhythmias and thromboembolic complications after the extracardiac Fontan operation. J Thorac Cardiovasc Surg 115:499–505PubMedCrossRefGoogle Scholar
  24. 24.
    Shore-Lesserson L, Manspeizer HE, DePerio M, Francis S, Vela-Cantos F, Ergin MA (1999) Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg 88:312–319PubMedCrossRefGoogle Scholar
  25. 25.
    Traverso Cl AJ, Gomez E, Luna D, Lopez-Cantarero M, Garcia JM (1993) Prospective assessment of the risk of deep vein thrombosis in elective abdominal surgery: predictive role of thromboelastography. Thromb Haemorrh Disord 71:15Google Scholar
  26. 26.
    van den Bosch AE, Roos-Hesselink JW, Van Domburg R, Bogers AJ, Simoons ML, Meijboom FJ (2004) Long-term outcome and quality of life in adult patients after the Fontan operation. Am J Cardiol 93:1141–1145PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Leslie Raffini
    • 1
  • Alexander Schwed
    • 2
  • X. Long Zheng
    • 3
  • Maria Tanzer
    • 3
  • Susan Nicolson
    • 4
  • J. William Gaynor
    • 5
  • David Jobes
    • 4
  1. 1.Division of Hematology, Department of PediatricsThe Children’s Hospital of Philadelphia, University of Pennsylvania School of MedicinePhiladelphiaUSA
  2. 2.University of Pennsylvania School of MedicinePhiladelphiaUSA
  3. 3.Department of Pathology and Laboratory MedicineThe Children’s Hospital of Philadelphia, University of Pennsylvania School of MedicinePhiladelphiaUSA
  4. 4.Division of Cardiac Anesthesia, Department of Anesthesia and Critical CareThe Children’s Hospital of Philadelphia, University of Pennsylvania School of MedicinePhiladelphiaUSA
  5. 5.Division of Cardiothoracic Surgery, Department of SurgeryThe Children’s Hospital of Philadelphia, University of Pennsylvania School of MedicinePhiladelphiaUSA

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