The Clinical Study Of Perioperative Coagulation Abnormalities In Children With Congenital Heart Disease

Objective To analyze the incidence rate of postoperative coagulopathy in pediatric patients with congenital heart disease(CHD)undergoing cardiac surgery by thromboelastograph(TEG).Methods A total of 661 pediatric patients admitted to Fuwai hospital for cardiac surgery from June 2016 to October 2016 were retrospectively reviewed.They were divided into the two groups accordingtotheoxygen saturation,cyanotic group(n=198)and acyanotic group(n=463)and also put in the subgroups based on age.TEG measurement was postoperatively tested and compared between the two groups.Results There were 306 patients(46.3%)postoperatively with the abnormal TEG results mainly because of platelet dysfunction(43.7%),other including low fibrinogen(13%)and low clotting factors(4.2%).For cyanotic group,it was significantly higher compared to the acyanotic group,63.4%and 39.7%,respectively.The rate of low clotting factors and fibrinogen were also both high in cyanotic group(P<0.01),while the platelet dysfunction rate was similar and no significant difference was revealed between the two groups.The subgroup analyses found that for patients younger than 1 year old,the incidence of postoperative coagulopathy with abnormal TEG results was higher than the elder children.However,low fibrinogen and platelet dysfunction were more often in cyanotic patients under 1 to 3 years old.Conclusion According to TEG monitoring,pediatric patients after cardiac surgery are more likely to suffer from coagulopathy,mainly because of platelet dysfunction.Younger children and cyanoticpatients were often occuring postoperative coagulopathy.Objective To determine the early and mid-term outcomes of shunt occlusion in infant and children after systemic-pulmonary shunt surgery and explore the risk factors of shunt occlusion in these patients.Methods Retrospective analysis was conducted for 295 patients with congenital heart disease after systemic pulmonary shunt surgery at Fuwai Hospital,from January 2010 to October 2016.There were 183 males and 112 females with their median age 7.5 months,and mean body weight 9.2 kg.The major cardiac diagnosis included pulmonary atresia(PA)and ventricular septal defect(n=110),transposition of the great arteries(TGA)(n=67),tetralogy of Fallot(TOF)(n=38)and others.The surgical procedures included central aorto-pulmonary shunt in 93 patients and modified Blalock-Taussig(BT)shunt in 198 patients.The outcomes were compared between patients with and without shunt occlusion group and risk factors were identified using univariate and multivariate logistic analysis.Results Follow-up was complete in 92.2%averaging 35 months(range 2 to 84 months).Thirty-three patients divided into the shunt occlusion group.Death occurred in 25 patients in which 16%were associated with shunt occlusion.Multivariable logistic regression analysis identified that the central aorto-pulmonary shunt type(P=0.008),shunt size less than 4mm(P=0.001),platelet transfusion(P=0.001)and poor compliance for aspirin antiplatelet therapy(P=0.001)were all the independent risk factors despite adjusting for other variables.While the increased postoperative oxygen saturation may be the protective factor(OR 0.93,P=0.001;per 1%SpO2 rising,the risk for shunt occlusion would reduce 7%).Conclusion The central aorto-pulmonary shunt type,smaller shunt size,platelet transfusion,decreased postoperative oxygen saturation and poor compliance for ASA antiplatelet therapy were important factors of shunt occlusion in patients undergoing shunt surgery.The proper identification and management would improve the prognosis of these patients.Objective To determine the prevalence of aspirin(ASA)resistance in pediatric patients with congenital heart disease and evaluate whether postoperative thrombosis is associated with aspirin resistance in this patient population.Methods A total of 52 patients undergoing high-risk congenital cardiac surgery were recruited in a prospective cohort study at Fuwai Hospital during October 2016 to December 2017.All cases received postoperative aspirin with the initial dose 3 to 5 mg/kg/d,and the response to aspirin was determined using the thromboelastography with platelet mapping(TEG-PM)system several days after administration.Based on the arachidonic acid(AA)inhibition<50%or not,they were divided into the ASA resistance group(n=14)and ASA sensitive group(n=38).Risk factors of ASA resistance were identified using univariate and multivariate analysis.Patients were monitored prospectively for three months for the development of a thrombosis event and the relationship between aspirin unresponsiveness and a thrombosis event was determined by the Fisher exact test.Results No patients lost their follow-up or died during the three months of follow-up period.Of 52 children analyzed,fourteen cases(26.9%)were ASA resistance and had<50%AA inhibition after aspirin initiation.Postoperative thrombosis event occurred in 4 patients(7.8%),while one was excluded for shunt thrombosis after 24 hours surgery before aspirin initiation.The prevalence of thrombosis after ASA antiplatelet therapy was 5.9%.Bleeding events occurred in one subjects and dropped the medicine.Dose escalation based on aspirin testing was performed in 3 of 14 patients,and ASA sensitivity was observed in one patients.Thrombosis was observed in 1of 3 patients who were unresponsive to aspirin,compared with 2 patients who were responsive to aspirin(P=0.92).In addition,no correlation was found between ASA resistance and postoperative thrombosis(r=0.04,p=0.8).Conclusion Postoperative thrombosis is not associated with aspirin resitance in this patient population.Our findings also suggest that resistance may be due to lack of aspirin doses,monitoring of aspirin therapy and consideration of dose adjustment or alternative agents for unresponsive patients may be justified and warrants further investigation in a prospective trial.