Yenidoğanlarda Kardiyak Kateterizasyona İkincil ArteriyelTromboz
Amaç: Kardiyak kateterizasyon, kardiyovasküler hastalıkların tanı ve tedavisinde kullanılan temel işlemlerden biridir. Tromboz gelişimi, kateterizasyonun ciddi bir komplikasyonudur. Bu çalışmada, tanısal ya da girişimsel amaçlı kardiyak kateterizasyon işlemi yapılan yenidoğanlarda arteriyel tromboz gelişimi sıklığı ve tromboz gelişimine etki eden faktörler ileriye dönük olarak incelendi. Yöntemler: 6 aylık süreçte femoral arter kateterizasyonu yapılan 20 yenidoğan çalışmaya alındı. İşlem öncesinde tam kan sayımı, prothrombin ve aktive parsiyel tromboplastin zamanları, INR oranı, Faktör V Leiden, protrombin 20210 A, metilentetrahidrofolat redüktaz C667T ve A1298 mutasyonları için kan örnekleri alındı. İşlem sırasında 100 U/ kg dozunda bolus heparin infüzyonu yapıldı. Kateterizasyon sonrasında klinik olarak tromboz şüphesi bulunan hastalara 28 U/kg/saat dozunda heparin infüzyonu başlandı. Tüm hastalara kateterizasyon sonrası 6 saat içinde Doopler ultrasonografi yapıldı. Sonuçlar: Hastaların gestasyonel yaşları 31-40 hafta (ortanca 39 hafta) aralığındaydı. Ortalama doğum ağırlığı 2996 ± 589 gramdı (1880-4000 gr). Doopler ultrasonografi ile 10 hastada arteriyel tromboz saptandı. Arteriyel tromboz gelişimi üzerine hasta yaşının, cinsiyetinin, tanı ve tedavilerin, platelet sayısının, hemoglobin, protrombin ve aktive parsiyel tromboplastin zamanı değerlerinin, Faktör V Leiden, protrombin 20210 A, metilentetrahidrofolat redüktaz C667T ve A1298 mutasyonlarının etkili olmadığı görüldü (p>0.05). Tromboz saptanan hastaların INR değerleri diğerlerinden daha düşük bulundu (p= 0.023). Sonuç: Bu çalışmada kateterizasyon sonrası femoral arter tromboz sıklığı Doppler ultrasonografiyle %50 olarak belirlendi. Bizim çalışmamız tromboz tanısında erken klinik değerlendirmenin yanıltıcı olabileceğini fakat Doppler ultrasonografinin erken tanıda yardımcı olabileceğini öngörmektedir. Yenidoğanda arteryel kateterizasyon sonrası trombozun önlenmesi için uygun ilaçların ve / veya dozların tahmin edilmesi için ileri çalışmalara ihtiyaç vardır.
Arterial Thrombosis Secondary to Cardiac Catheterization in Neonates
Objective: Cardiac catheterization is one of the basic procedures applied in the diagnosis and treatment ofcardiovascular diseases. Development of thrombosis is a serious complication of catheterization. In this study, thefrequency and the factors affecting the development of arterial thrombosis were prospectively evaluated in neonateswho were subjected to diagnostic or interventional cardiac catheterization. Methods: Twenty newborns that received femoral artery catheterization within 6-month period were enrolled in thisstudy. Blood samples were taken for complete blood count, prothrombin, activated partial thromboplastin time, INRratio and mutations of factorV Leiden, prothrombin 20210A, methylenetetrahydrofolate reductase C667T and A1298before the procedure. 100 U/kg bolus of heparin was infused during catheterization. 28 U/kg/hour infusion ofheparin was given to the patients with clinically suspected thrombosis during first few hours after catheterization.Doppler ultrasonography was performed in all patients within 6 hours after catheterization.Results: The gestational age of patients ranged from 31 to 40 weeks (median 39). Mean birth weight was 2996 ± 589(1880-4000 gr). Arterial thrombosis was detected in 10 patients by Doppler USG. On development of arterialthrombosis, patient age, gender, diagnosis, treatments, platelet count, hemoglobin, prothrombin and activated partialthromboplastin time values, FactorV Leiden, prothrombin 20210A, methylenetetrahydrofolate reductase C667T andA1298 mutations were found as not impacting (p>0.05). Those who were found to have thrombosis in Dopplerultrasonography had lower INR levels compared to others (p= 0.023).Conclusions: The rate of femoral arterial thrombosis in newborns after catheterization detected by Dopplerultrasonography was 50% in this study. Our data suggest that early clinical assessment for the diagnosis ofthrombosis may be misleading but Doppler ultrasonography may be helpful early detection. Further studies areneeded to prediction appropriate drugs and/or doses for prevention of thrombosis after arterial catheterization innewborns.
___
- Glatz AC, Shah SS, McCarthy AL, et all. Prevalence of
and risk factors for acute occlusive arterial injury
following pediatric cardiac catheterization: a large
single-center cohort study. CatheterCardiovascInterv.
2013; 82:454-62.
- Feltes TF, Bacha E, Beekman RH 3rd, et all; American
Heart Association Congenital Cardiac Defects
Committee of the Council on Cardiovascular Disease in
the Young; Council on Clinical Cardiology; Council on
Cardiovascular Radiology and Intervention; American
Heart Association. Indications for cardiac
catheterization and intervention in pediatric cardiac
disease: a scientific statement from the American Heart
Association. Circulation. 2011;123:2607-52.
- Roushdy AM1, Abdelmonem N, El Fiky AA. Factors
affecting vascular access complications in children
undergoing congenital cardiac catheterization. Cardiol
Young. 2012; 22:136-44.
- Rizzi M, Albisetti M. Treatment of arterial thrombosis
in children: Methods and mechanisms. Thromb Res.
2018; 169:113-9.
- Casa L.D.C, Ku D.N. Thrombus Formation at High Shear
Rates. Annu Rev Biomed Eng.2017; 19:415-33.
- Giglia TM, Massicotte MP, Tweddell JS, et all; American
Heart Association Congenital Heart Defects Committee
of the Council on Cardiovascular Disease in the Young,
Council on Cardiovascular and Stroke Nursing, Council
on Epidemiology and Prevention, and Stroke Council.
Prevention and treatment of thrombosis in pediatric
and congenital heart disease: a scientific statement
from the American Heart Association. Circulation.
2013; 128:2622-703.
- Mortezaiyan H, Aarabi-Moghadam M, Asadpour N, et
all. Treatment of femoral artery thrombosis with
streptokinase and heparin after cardiac catheterization.
Res Cardiovasc Med. 2014;3:e13552.
- Avila ML, Shah PS, Brandão LR. Different
unfractionated heparin doses for preventing arterial
thrombosis in children undergoing cardiac
catheterization. Cochrane Database Syst Rev. 2014;
3:CD010196.
- Seldinger SI. Catheter replacement of the needle in
percutaneous arteriography; a new technique.
Actaradiol. 1953; 39:368-76.
- Bulbul ZR, Galal MO, Mahmoud E, et all. Arterial
complications following cardiac catheterization in
children less than 10 kg. Asian CardiovascThorac Ann
2002; 10:129–32.
- Grady RM, Eisenberg PR, Bridges ND. Rational
approach to use of heparin during cardiac
catheterization in children. J Am CollCardiol 1995;
25:725–9.
- Girod DA, Hurwitz RA, Caldwell RL. Heparinization
for prevention of thrombosis following pediatric
percutaneous arterial catheterization. PediatrCardiol
1982; 3:175–80.
- Laurin S, Lundstrom NR. Venous thrombosis after
cardiac catheterization in infants. ActaRadiol 1987;
28:241–6.
- Miga DE, McKellar LF, Denslow S, et all. Incidence of
femoral vein occlusion after catheter ablation in
children: evaluation with magnetic resonance
angiography. PediatrCardiol 1997; 18:204–7.
- Ruud E, Natvig S, Holmstrom H, Wesenberg F. Low
prevalence of femoral venous thrombosis after cardiac
catheterizations in children: a prospective study.
Cardiol Young 2002; 12:513–8.
- Keane JF, Lang P, Newburger J, Fyler DC. Iliac veininferior
caval thrombosis after cardiac catheterization
in infancy. PediatrCardiol 1980; 1:257–61.
- Monagle P1. Anticoagulation in the young. Heart.
2004; 90:808-12.
- Brotschi B, Hug M, Kretschmar O, Rizzi M, Albisetti M.
Incidence and predictors of cardiac catheterisationrelated
arterial thrombosis in children. Heart.
2015;101:948-53.
- Veldman A, Nold MF, Michel-Behnke I. Thrombosis in
the critically ill neonate: incidence, diagnosis, and
management. Vasc Health Risk Manag. 2008; 4:1337–
48.
- Hanslik A, Kitzmüller E, Thom K, et all. Incidence of
thrombotic and bleeding complications during cardiac
catheterization in children: comparison of high-dose vs.
low-dose heparin protocols. J ThrombHaemost. 2011;
9:2353-60.
- Monagle P, Chalmers E,Chan A, et all. Antithrombotic
therapy in children: American College Of Chest
Physicians Evidence Based Clinical Practice Guidelines
(8th Edition). Chest 2008; 133:887S-968S.
- Hanslik A, Kitzmüller E, Tran US, et all. Monitoring
unfractionated heparin in children: a parallel-cohort
randomized controlled trial comparing 2 dose
protocols. Blood. 2015 29;126:2091-7.
- Heller C1, Nowak-Göttl U. Maternal thrombophilia
and neonatal thrombosis. Best Pract Res ClinHaematol.
2003; 16:333-45.
- Kosch A, Kuwertz-Broking E, Heller C, et all. Renal
venous thrombosis in neonates: prothrombotic risk
factors and long-term followup. Blood 2004;104:1356–
60
- Ghasemi A, Horri M, Salahshour Y. Coagulation
Abnormalities in Pediatric Patients with Congenital
Heart Disease: A Literature Review. International
Journal of Pediatrics, 2014; 2:141-3.
- Tempe DK, Viramani S. Coagulation abnormalities in
patients with cyanotic congenital heart disease. J
CardiothoracVascAnesth 2002; 16:752-65.