Anticoagulation therapy and the risk of perioperative brain injury in neonates with congenital heart disease |
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| Authors: | Lara M. Leijser Vann Chau Mike Seed Kenneth J. Poskitt Anne Synnes Susan Blaser Stephanie H. Au-Young Edward J. Hickey Andrew Campbell Patrick S. McQuillen Steven P. Miller |
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| Affiliation: | 1. Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada;2. Division of Neonatology, Department of Pediatrics, University of Calgary and Alberta Children''s Hospital Research Institute, Calgary, Alberta, Canada;3. Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada;4. Department of Radiology, British Columbia Children''s and Women''s Hospitals and University of British Columbia, Vancouver, British Columbia, Canada;5. Department of Pediatrics, British Columbia Children''s and Women''s Hospitals and University of British Columbia, Vancouver, British Columbia, Canada;6. British Columbia Children''s Hospital Research Institute, Vancouver, British Columbia, Canada;7. Department of Diagnostic Imaging, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada;8. Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children and The University of Toronto, Toronto, Ontario, Canada;9. Department of Pediatric Cardiovascular and Thoracic Surgery, British Columbia Children''s and Women''s Hospitals and University of British Columbia, Vancouver, British Columbia, Canada;10. Departments of Pediatrics and Neurology, University of California, Benioff Children''s Hospital, San Francisco, California, United States |
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| Abstract: | ObjectiveThere is considerable variability in anticoagulation use in neonates with transposition of the great arteries (TGA) and single ventricle physiology (SVP) for secondary stroke prevention and primary cardiovascular indications. Leveraging cross-center differences in anticoagulation use, we compared the risk of new postoperative brain injury in neonates with TGA and SVP treated with anticoagulation relative to untreated neonates.MethodsTwo-center observational cohort study of 118 term-born neonates with TGA (n = 83) and SVP (n = 35), undergoing cardiopulmonary bypass surgery and pre- and postoperative brain magnetic resonance imaging. Anticoagulation and antiplatelet therapy details were obtained. Magnetic resonance images were scored for stroke, white matter injury, and hemorrhage. New postoperative injury was compared between neonates with and without anticoagulation for the 2-center cohort, and subsequently stratified by cardiac lesion type and anticoagulation indication.ResultsThirty-six out of 118 neonates (29%) received anticoagulation: 11 (30%) for preoperative stroke, 20 (56%) for preoperative peripheral/intracardiac thrombus, and 5 (14%) for Blalock-Taussig shunt. Five out of 36 neonates (14%) treated with anticoagulation also received antiplatelet therapy. Although no differences were identified for the 2-center cohort or for neonates with TGA separately, significantly more new postoperative parenchymal brain injury (P = .04), particularly stroke, was found in SVP neonates with compared to without anticoagulation (31% vs 5%). In neonates who experienced preoperative stroke, new subdural hemorrhage (36% vs 0%) was more frequent in neonates treated with anticoagulation therapy compared with those without anticoagulation therapy.ConclusionsIn our cohort of neonates with TGA and SVP, anticoagulation for preoperative stroke, preoperative thrombus, and/or Blalock-Taussig shunt did not have the anticipated benefit of preventing new perioperative brain injury. These findings indicate the critical need for rigorous randomized trials on the safety and effectiveness of anticoagulation therapy in this population. |
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| Keywords: | Address for reprints: Steven P. Miller, MDCM, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children, 555 University Ave, Rm 6546, Toronto, Ontario M5G 1X8 Canada. stroke white matter injury transposition of the great arteries single ventricle physiology heparin anticoagulation ASA acetylsalicylic acid BCCH The British Columbia Children's Hospital HSC The Hospital for Sick Children LMWH low-molecular-weight heparin MRI magnetic resonance imaging SVP single ventricle physiology TGA transposition of the great arteries |
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