Nguyen Nguyenvu, Sharathkumar Anjali
Division of Cardiology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill, USA.
Division of Hematology and Oncology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill, USA.
Congenit Heart Dis. 2015 Sep-Oct;10(5):E210-5. doi: 10.1111/chd.12268. Epub 2015 Apr 27.
This study investigated the clinician practices on perioperative anticoagulation in children with prosthetic mechanical heart valves who undergo elective surgeries.
An online survey was administered to members of PediHeartNet. The survey consisted of multiple choice questions and clinical scenarios.
The study described clinical practice patterns and variables that influence the clinicians' bridging anticoagulation decisions.
Ninety-one respondents completed the survey; 68% were affiliated with university settings; 91% were pediatric cardiologists, and 49% had ≥10 years of experience in pediatric cardiology. Approximately one-half of the respondents (54%) independently provided perioperative anticoagulation management to their patients, while 46% utilized cardiac or hematology anticoagulation services. Resources that influenced bridging decisions included hematology experts (20%), American College of Chest Physicians guidelines (34%), and the clinicians' personal experience (56%). In planning for major surgeries, 47% of the respondents hospitalized patients for unfractionated heparin (UFH) and 46% prescribed outpatient low molecular weight heparin (LMWH). For minor surgeries, 58% hospitalized patients for UFH, 22% prescribed outpatient LMWH, and 17% opted out of bridging anticoagulation. Immediately after mitral valve replacement, 23% used bridging anticoagulation with UFH. When LMWH was used, there were no reports of thromboembolic complications. Major bleeding complications were rare and reported by 2% of the respondents.
This was the first documentation that clinical practice of bridging perioperative anticoagulation in children with mechanical heart valves varies widely among pediatric cardiac specialists. There is poor adoption of published guidelines and a tendency toward more conservative strategies. Further studies comparing the safety and efficacy of LMWH vs. UFH as perioperative anticoagulation agents in children with mechanical heart valves are needed to further clarify our findings. Quality assurance initiatives and education are also needed to improve guidelines adherence and standardize practice management.
本研究调查了接受择期手术的人工机械心脏瓣膜儿童围手术期抗凝治疗的临床医生实践情况。
对儿科心脏网络（PediHeartNet）的成员进行了一项在线调查。该调查包括多项选择题和临床病例。
本研究描述了影响临床医生桥接抗凝决策的临床实践模式和变量。
91名受访者完成了调查；68%隶属于大学机构；91%为儿科心脏病专家，49%有≥10年儿科心脏病学经验。约一半的受访者（54%）独立为其患者提供围手术期抗凝管理，而46%利用心脏科或血液科的抗凝服务。影响桥接决策的资源包括血液学专家（20%）、美国胸科医师学会指南（34%）和临床医生的个人经验（56%）。在计划进行大手术时，47%的受访者将患者住院接受普通肝素（UFH）治疗，46%开具门诊低分子肝素（LMWH）处方。对于小手术，58%将患者住院接受UFH治疗，22%开具门诊LMWH处方，17%选择不进行桥接抗凝。二尖瓣置换术后立即有23%使用UFH进行桥接抗凝。使用LMWH时，未报告血栓栓塞并发症。严重出血并发症很少见，2%的受访者报告有此类情况。
这是首次记录到，小儿心脏专科医生在人工心脏瓣膜儿童围手术期桥接抗凝的临床实践差异很大。已发表的指南采用率低，且倾向于采用更保守的策略。需要进一步开展研究，比较LMWH与UFH作为人工机械心脏瓣膜儿童围手术期抗凝药物的安全性和有效性，以进一步明确我们的研究结果。还需要开展质量保证举措和教育，以提高指南依从性并规范实践管理。
