Hostname: page-component-cd9895bd7-dzt6s Total loading time: 0 Render date: 2024-12-23T04:44:41.717Z Has data issue: false hasContentIssue false
  • English
  • Français

Atrial thrombus after the Fontan-operation: predisposing factors, treatment and prophylaxis

Published online by Cambridge University Press:  19 August 2008

R. Kaulitz ,
G. Ziemer ,
F. Bergmann ,
I. Luhmer  and
H. C. Kallfelz
R. Kaulitz*
Affiliation:
Division of Pediatric Cardiology; Medical School, Hanover, Germany
G. Ziemer
Affiliation:
Division of Thoracic and Cardiovascular Surgery; Medical School, Hanover, Germany
F. Bergmann
Affiliation:
Division of Pediatric Cardiology; Medical School, Hanover, Germany
I. Luhmer
Affiliation:
Division of Pediatric Cardiology; Medical School, Hanover, Germany
H. C. Kallfelz
Affiliation:
Division of Pediatric Cardiology; Medical School, Hanover, Germany
*
Renate Kaulitz, M.D. Div. of Pediatric Cardiology, Medical School Hannover, 30625 Hannover, Germany. Tel: 49 511 532 3220, Fax: 49 511 532 9038
Get access Rights & Permissions [Opens in a new window]

Abstract

Thrombosis of the right side of the heart has previously been a rarely reported early or late postoperetive complication after a modified Fontan-procedure.

In 4(5.5%) of 72 surviving patients who underwent a total cavopulmonary connection for various forms of univentricular atrioventricular connection or other complex lesion a thrombus within the right atrium was diagnosed by transthoracic echocardiogaphy either early (in 3 cases) or late (in one cases) postoperatively. Predisposing haemodynamic abnormalities could be identified in all four patients, but no patient was found to have severe abnormalities of coagulation. Two patients presented with acute clinical symptoms on the third and twelfth day after initial surgery. They underwent emergency reoperation with thrombectomy followed by prophylactic treatment with coumadin or aspirin after initial heparinization. In the other 2 patients, routine postoperative echocardiography revealed a right atrial thrombus without specific clinical symptoms 25 days or 3 months postoperatively. Thrombolytic therapy with an initial bolus of tissue plasminogen activator (0.1 mg/kg) followed by continuous infusion (1 mg/kg/day) combined with heparinization yielded complete resolution of the thrombus after 27 and 40 hours, respectively, as demonstrated on follow-up echocardiograms. Our own experience, coupled with a review of the literature, indicate that prophylactic anticoagulation therapy with coumadin should continue for at least 4 to 6 months for patients with an increased risk for postoperative thrombosis. For infants and young children with a low risk for postoperative thrombosis, aspirin should be given routinely for 6 months postoperatively.

Keywords

Fontan-operationvenous-thrombosisthrombolysistissue plasminogen activator
Type
Original Articles
Information
Cardiology in the Young , Volume 7 , Issue 1 , January 1997 , pp. 37 - 43
Copyright
Copyright © Cambridge University Press 1997

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Choussat, p, Fontan, F, Besso, P, Vallor, F, Chauve, A, Bricaud, H. Selection criteria for Fontan's procedure. In: Anderson, R, Shineborne, E (eds): Paediatric Cardiology. Churchill-Livingstone, New York, 1977, 559–560.Google Scholar
2.Driscoll, DJ, Offord, KP, Feldt, RH, Schaff, HV, Puga, FJ, Danielson, GK. Five-to fifteen-year follow-up after Fontan opreation. Circulation 1992; 85: 469–496.CrossRefGoogle Scholar
3.Mayer, JE, Helgason, H, Jonas, RD, Lang, P, Vargas, FJ, Cook, N, Castaneda, AR. Extending the limits of modified Fontan precedures. J Thorac Cardiovasc Surg 1986; 92: 1021–1028.CrossRefGoogle Scholar
4.Mayer, JE, Helgason, H, Jonas, RD, Lang, P, Vargas, FJ, Cook, N, Castaneda, AR. Extending the limits of modified Fontan precedures. J Thorac Cardiovasc Surg 1986; 92:1021–1028.CrossRefGoogle Scholar
5.Bartmus, D, Driscoll, DJ, Offord, KP, Humer, RA, Mair, DD, Schaff, HV, Puga, FJ, Danielson, GK. The modified Fontan operation for children less than 4 years old. J Am Coll Cardiol. 1990: 15: 429–435.CrossRefGoogle Scholar
6.Dobell, ARC, Trusler, GA, Smallhorn, JF, Williams, WG. Atrial thrombi after the Fontan operation. Ann Throac Surg 1986; 42: 664–667.CrossRefGoogle ScholarPubMed
7.Crome-Dijkhuis, AH, Henkens, CMA, Bijleveld, CMA, Hillege, HL, Bom, VJJ, van der Meer, J. Coagulation factor abnormalities as possible thrombotic risk factors after Fontan operations. Lancet 1990; 336: 1087–1090.CrossRefGoogle Scholar
8.Mahony, L, Nikaidoh, H, Fixler, DE. Thrombolytic treatment with streptokinase for late intraatrial thrombosis after modified Fontan procedure. Am J Cardiol 1988; 62: 343–344.CrossRefGoogle ScholarPubMed
9.Shannon, FL, Campbell, DN, Clarke, DR. Right atrial thrombosis: rare complication of the modified Fontan procedure. Pediatr Cardiol 1986; 7: 209–212.CrossRefGoogle ScholarPubMed
10.Fontan, F, Kirklin, KW, Fernandez, G, Costa, F, Naftel, D, Tritto, F, Blackstone, E. Outcome after a “Perfect” Fontan operation. Circulation 1990; 81: 1520–1536.CrossRefGoogle ScholarPubMed
11.Jonas, RA. Invited letter concerning: The importance of pulsatile flow when systemetic venous return is connected directly to the pulmonary arteries. J Thorac Cardiovasc Surg 1993; 105: 173–188.CrossRefGoogle Scholar
12.De Leval, MR, Kilner, P, Gewillig, M, Bull, C. Total cavopulmonary connection: A logical alternative to atriopulmonary connection for complex Fontan operations. J Thorac Cardiovasc Surg 1988, 96: 682–695.CrossRefGoogle ScholarPubMed
13.Jonas, RA, Castaneda, AR. Modified Fontan procedure: atrial baffle and systemic venous to pulmonary artery anastomotic techniques. J Cardiac Surg 1988; 3: 91–96.CrossRefGoogle ScholarPubMed
14.Hedrick, M, Elkins, RC, Knott-Craig, C, Razook, JD. Successful thrombectomy for thrombosis of the right side ofthe heart after the Fontan operation. J Thorac Cardiovasc Surg 1993; 105: 297–301.CrossRefGoogle Scholar
15.Kopf, GS, Kleinman, CS, Hijazi, ZM, Fahey, JT, Dewar, ML, Hellenbrand, WE. Fenestrated Fontan operation with delayed transcatheter closure of atrial septal defect. J Thorac Cardiovasc Surg 1992; 103: 1039–1048.CrossRefGoogle ScholarPubMed
16.Stumper, O, Sutherland, GR, Geuskens, R, Roelandt, J, Bos, E, Hess, J. Transesophageal echocardiography in evaluation and management after a Fontan procedure. J Am Coll Cardiol 1991; 17: 1152–1160.CrossRefGoogle ScholarPubMed
17.Dajee, H, Deutsch, LS, Benson, LN, Perloff, JK, Laks, H. Thrombolytic therapy for superior vena cava thrombosis following superior vena cava-pulmonary artery anastomosis. Ann Thorac Surg 1984; 38: 637–639.CrossRefGoogle ScholarPubMed
18.Okita, Y, Miki, S, Kusuhara, K, Ueda, Y, Tahata, T, Komeda, M, Tamura, T. Massive systemic venous thrombosis after Fontan operation; report of a case. Thorac Cardiovasc Surg 1988; 36: 234–236.CrossRefGoogle ScholarPubMed
19.Ino, T, Benson, LN, Freedom, RM. Thrombolytic therapy for femoral artery thrombosis after pediatric cardiac catheterization. Am Heart J 1988; 115: 633–639.CrossRefGoogle ScholarPubMed
20.Levy, M, Benson, LN, Burrows, PE. Tissue plasminogen activator for the treatment of thromboembolism in infants and children. J Pediatr, 1991; 118: 467–472.CrossRefGoogle ScholarPubMed
21.Marder, VJ. The use of thrombolytic agents: choice of patients, drug administration, laboratory monitoring, Ann Intern Med 1979; 90: 802.CrossRefGoogle ScholarPubMed
22.Tuner-Gomes, SO, Andrew, M, Coles, J, Trusler, GA, Williams, WG, Rabinovitch, M. Abnormalities in von Willebrand factor and antithrombin III after cardiopulmonary bypass operations for congenital heart disease. J Thorac Cardiovasc Surg 1992; 103: 87–97.CrossRefGoogle Scholar
23.Cromme-Dijkhuis, AH, Hess, J, Hählen, K, Henkens, CMA, Bink-Boelkens, M, Eygelaar, AA, Bos, E. Specific sequelae after Fontan operation at mid- and longterm folllow-up. J Thorac Cardiovasc Surg 1993; 106: 1126–1132.CrossRefGoogle Scholar
24.Hoek, JA, ten Cate, JW, Lamping, J, Berends, F, Borm, JJ. Laboratory and clinical evaluation of an assay of thrombinantithrombin III complexes. Clin Chem 1988; 34: 2058–2062.CrossRefGoogle ScholarPubMed