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High acetylsalicylic acid dosing in infants after modified Blalock–Taussig shunt

Published online by Cambridge University Press:  11 February 2019

Arun Saini ,
Ashwini D. Joshi ,
Krista M. Cowan ,
Connor Wayne Gatewood ,
Susheel T. K. Kumar ,
Jerry Allen ,
Samir H. Shah ,
Simonne S. Nouer ,
Tamekia Jones  and
Christopher J. Knott-Craig
...Show all authors
Arun Saini*
Affiliation:
Division of Pediatric CriticalCare Medicine, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, TN, USA Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
Ashwini D. Joshi
Affiliation:
School of Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
Krista M. Cowan
Affiliation:
School of Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
Connor Wayne Gatewood
Affiliation:
School of Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
Susheel T. K. Kumar
Affiliation:
Division of Pediatric Cardiothoracic Surgery, Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
Jerry Allen
Affiliation:
Division of Pediatric Cardiothoracic Surgery, Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
Samir H. Shah
Affiliation:
Division of Pediatric CriticalCare Medicine, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, TN, USA
Simonne S. Nouer
Affiliation:
Department of Pediatrics and Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
Tamekia Jones
Affiliation:
Department of Pediatrics and Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, TN, USA
Christopher J. Knott-Craig
Affiliation:
Division of Pediatric Cardiothoracic Surgery, Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
Umar S. Boston
Affiliation:
Division of Pediatric Cardiothoracic Surgery, Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
*
Author for correspondence: A. Saini, Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, 6651 Main street, MC E1420, Houston, TX, 77030, USA. Tel: +1 8238259478; Fax: +1 8328255929; E-mail: asaini@bcm.edu
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Abstract

Objective

Shunt-related adverse events are frequent in infants after modified Blalock–Taussig despite use of acetylsalicylic acid prophylaxis. A higher incidence of acetylsalicylic acid-resistance and sub-therapeutic acetylsalicylic acid levels has been reported in infants. We evaluated whether using high-dose acetylsalicylic acid can decrease shunt-related adverse events in infants after modified Blalock–Taussig.

Methods

In this single-centre retrospective cohort study, we included infants ⩽1-year-old who underwent modified Blalock–Taussig placement and received acetylsalicylic acid in the ICU. We defined acetylsalicylic acid treatment groups as standard dose (⩽7 mg/kg/day) and high dose (⩾8 mg/kg/day) based on the initiating dose.

Results

There were 34 infants in each group. Both groups were similar in age, gender, cardiac defect type, ICU length of stay, and time interval to second stage or definitive repair. Shunt interventions (18 versus 32%, p=0.16), shunt thrombosis (14 versus 17%, p=0.74), and mortality (9 versus 12%, p=0.65) were not significantly different between groups. On multiple logistic regression analysis, single-ventricle morphology (odds ratio 5.2, 95% confidence interval of 1.2–23, p=0.03) and post-operative red blood cells transfusion ⩾24 hours [odds ratio 15, confidence interval of (3–71), p<0.01] were associated with shunt-related adverse events. High-dose acetylsalicylic acid treatment [odds ratio 2.6, confidence interval of (0.7–10), p=0.16] was not associated with decrease in these events.

Conclusions

High-dose acetylsalicylic acid may not be sufficient in reducing shunt-related adverse events in infants after modified Blalock–Taussig. Post-operative red blood cells transfusion may be a modifiable risk factor for these events. A randomised trial is needed to determine appropriate acetylsalicylic acid dosing in infants with modified Blalock–Taussig.

Keywords

Modified Blalock–Taussig shuntred blood cell transfusionshunt thrombosisshunt interventionsingle ventricular physiologyaspirincyanotic congenital heart lesiontransfusion-related adverse eventsacetylsalicylic acid
Type
Original Article
Information
Cardiology in the Young , Volume 29 , Issue 3 , March 2019 , pp. 389 - 397
Copyright
© Cambridge University Press 2019 

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Footnotes

Cite this article: Saini A, Joshi AD, Cowan KM, Wayne Gatewood C, Kumar STK, Allen J, Shah SH, Nouer SS, Jones T, Knott-Craig CJ, Boston US. (2019) High acetylsalicylic acid dosing in infants after modified Blalock–Taussig shunt. Cardiology in the Young29: 389–397. doi: 10.1017/S1047951118002536

References

1. Ahmad, U, Fatimi, SH, Naqvi, I, et al. Modified Blalock–Taussig shunt: immediate and short-term follow-up results in neonates. Heart Lung Circ 2008; 17: 54–58.Google Scholar
2. Guzzetta, NA, Foster, GS, Mruthinti, N, Kilgore, PD, Miller, BE, Kanter, KR. In-hospital shunt occlusion in infants undergoing a modified Blalock–Taussig shunt. Ann Thorac Surg 2013; 96: 176–182.Google Scholar
3. Gedicke, M, Morgan, G, Parry, A, Martin, R, Tulloh, R. Risk factors for acute shunt blockage in children after modified Blalock–Taussig shunt operations. Heart Vessels 2010; 25: 405–409.Google Scholar
4. Celestin, C, Guillot, M, Ross-Ascuitto, N, Ascuitto, R. Computational fluid dynamics characterization of blood flow in central aorta to pulmonary artery connections: importance of shunt angulation as a determinant of shear stress-induced thrombosis. Pediatr Cardiol. 2015; 36: 600–615.Google Scholar
5. Adipurnama, I, Yang, MC, Ciach, T, Butruk-Raszeja, B. Surface modification and endothelialization of polyurethane for vascular tissue engineering applications: a review. Biomater Sci 2016; 5: 22–37.Google Scholar
6. Toulon, P, Berruyer, M, Brionne-Francois, M, et al. Age dependency for coagulation parameters in paediatric populations. Results of a multicentre study aimed at defining the age-specific reference ranges. Thromb Haemost 2016; 116: 9–16.Google Scholar
7. Del Vecchio, A, Motta, M, Romagnoli, C. Neonatal platelet function. Clin Perinatol 2015; 42: 625–638.Google Scholar
8. Mir, A, Frank, S, Journeycake, J, et al. Aspirin resistance in single-ventricle physiology: aspirin prophylaxis is not adequate to inhibit platelets in the immediate postoperative period. Ann Thorac Surg 2015; 99: 2158–2164.Google Scholar
9. Agarwal, A, Firdouse, M, Brar, N, et al. Incidence and management of thrombotic and thromboembolic complications following the Norwood procedure: a systematic review. Clin Appl Thromb/Hemost: Official Journal of the International Academy of Clinical and Applied Thrombosis/Hemostasis 2017; 23: 911–921.Google Scholar
10. Li, JS, Yow, E, Berezny, KY, et al. Clinical outcomes of palliative surgery including a systemic-to-pulmonary artery shunt in infants with cyanotic congenital heart disease: does aspirin make a difference? Circulation 2007; 116: 293–297.Google Scholar
11. Emani, S, Trainor, B, Zurakowski, D, et al. Aspirin unresponsiveness predicts thrombosis in high-risk pediatric patients after cardiac surgery. J Thorac Cardiovasc Surg 2014; 148: 810–814; discussion 4-6.Google Scholar
12. Heistein, LC, Scott, WA, Zellers, TM, et al. Aspirin resistance in children with heart disease at risk for thromboembolism: prevalence and possible mechanisms. Pediatr Cardiol 2008; 29: 285–291.Google Scholar
13. Truong, DT, Johnson, JT, Bailly, DK, et al. Platelet inhibition in shunted infants on aspirin at short and midterm follow-up. Pediatr Cardiol 2017; 38: 401–409.Google Scholar
14. Lev, EI, Solodky, A, Harel, N, et al. Treatment of aspirin-resistant patients with omega-3 fatty acids versus aspirin dose escalation. J Am Coll Cardiol 2010; 55: 114–121.Google Scholar
15. Gurbel, PA, Bliden, KP, DiChiara, J, et al. Evaluation of dose-related effects of aspirin on platelet function: results from the Aspirin-Induced Platelet Effect (ASPECT) study. Circulation 2007; 115: 3156–3164.Google Scholar
16. Monagle, P, Chan, AKC, Goldenberg, NA, et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl 2): e737S–e801S.Google Scholar
17. Cholette, JM, Rubenstein, JS, Alfieris, GM, et al. Elevated risk of thrombosis in neonates undergoing initial palliative cardiac surgery. Ann Thorac Surg 2007; 84: 1320–1325.Google Scholar
18. Fenton, KN, Siewers, RD, Rebovich, B, Pigula, FA. Interim mortality in infants with systemic-to-pulmonary artery shunts. Ann Thorac Surg 2003; 76: 152–156; discussion 6-7.Google Scholar
19. Rajasekhar, D, Kestin, AS, Bednarek, FJ, Ellis, PA, Barnard, MR, Michelson, AD. Neonatal platelets are less reactive than adult platelets to physiological agonists in whole blood. Thromb Haemost 1994; 72: 957–963.Google Scholar
20. Straub, A, Smolich, J, d’Udekem, Y, Brizard, C, Peter, K, Horton, S. Activation of platelets in young infants during cardiopulmonary bypass. Thromb Haemost 2010; 103: 466–469.Google Scholar
21. Manlhiot, C, Brandao, LR, Kwok, J, et al. Thrombotic complications and thromboprophylaxis across all three stages of single ventricle heart palliation. J Pediatr 2012; 161: 513–519 e3.Google Scholar
22. Todd Tzanetos, DR, Yu, C, Hernanz-Schulman, M, Barr, FE, Brown, NJ. Prospective study of the incidence and predictors of thrombus in children undergoing palliative surgery for single ventricle physiology. Intensive Care Med 2012; 38: 105–112.Google Scholar
23. Redford, DT, Paidy, SR, Steinbrenner, EB, Nielsen, VG. Effects of profound hypoxemia on coagulation & fibrinolysis in normal individuals. Blood Coagul Fibrinolysis: An International Journal in Haemostasis and Thrombosis 2016; 27: 228–231.Google Scholar
24. Mace, S, Borkat, G, Liebman, J. Hepatic dysfunction and cardiovascular abnormalities. Occurrence in infants, children, and young adults. Am J Dis Child 1985; 139: 60–65.Google Scholar
25. Haga, P, Cotes, PM, Till, JA, Minty, BD, Shinebourne, EA. Serum immunoreactive erythropoietin in children with cyanotic and acyanotic congenital heart disease. Blood. 1987; 70: 822–826.Google Scholar
26. Cholette, JM, Swartz, MF, Rubenstein, J, et al. Outcomes using a conservative versus liberal red blood cell transfusion strategy in infants requiring cardiac operation. Ann Thorac Surg 2017; 103: 206–214.Google Scholar
27. Garcia-Roa, M, Del Carmen Vicente-Ayuso, M, Bobes, AM, et al. Red blood cell storage time and transfusion: current practice, concerns and future perspectives. Blood Transfus. 2017; 15: 222–231.Google Scholar
28. Anderson, BR, Blancha, VL, Duchon, JM, et al. The effects of postoperative hematocrit on shunt occlusion for neonates undergoing single ventricle palliation. J Thorac Cardiovasc Surg 2017; 153: 947–955.Google Scholar
29. Sahoo, TK, Chauhan, S, Sahu, M, Bisoi, A, Kiran, U. Effects of hemodilution on outcome after modified Blalock-Taussig shunt operation in children with cyanotic congenital heart disease. J Cardiothorac Vasc Anesth 2007; 21: 179–183.Google Scholar
30. Manlhiot, C, McCrindle, BW, Menjak, IB, et al. Longer blood storage is associated with suboptimal outcomes in high-risk pediatric cardiac surgery. Ann Thorac Surg 2012; 93: 1563–1569.Google Scholar
31. Howard-Quijano, K, Schwarzenberger, JC, Scovotti, JC, et al. Increased red blood cell transfusions are associated with worsening outcomes in pediatric heart transplant patients. Anesth Analg 2013; 116: 1295–1308.Google Scholar
32. Dasgupta, R, Parsons, A, McClelland, S, et al. Association of haematocrit and red blood cell transfusion with outcomes in infants with shunt-dependent pulmonary blood flow and univentricular physiology. Blood Transfus 2015; 13: 417–422.Google Scholar
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