Monash University, School of Clinical Sciences, Clayton, Victoria, Australia; Murdoch Children's Research Institute, Hematology Research Group, Parkville, Victoria, Australia; Royal Children's Hospital, Department of Clinical Hematology, Parkville, Victoria, Australia.
Murdoch Children's Research Institute, Hematology Research Group, Parkville, Victoria, Australia; Royal Children's Hospital, Department of Clinical Hematology, Parkville, Victoria, Australia; University of Melbourne, Department of Pediatrics, Parkville, Victoria, Australia.
Thromb Res. 2018 Dec;172:194-203. doi: 10.1016/j.thromres.2018.02.145. Epub 2018 Mar 2.
Ventricular Assist Devices (VADs) are increasingly utilised in children with end-stage heart failure, and experience high bleeding and clotting rates. In particular, pediatric VAD patients are more challenging than adults to anticoagulate due to developmental hemostasis, lack of suitable drug preparations, and difficult anticoagulation monitoring often due to poor vascular access; in addition to difficulties of VAD design in smaller children. This review aims to summarize the current evidence related to antithrombotic therapy in pediatric VAD patients.
A search of 2 databases across a 17-year period of time was undertaken using key words selected a priori. Identified publications were then categorized according to VAD types utilised and the anticoagulation protocols described.
27 articles were identified consistent with the inclusion criteria developed for this review. Devices included in the cohort were Berlin Heart EXCOR, Thoratec, Medos, Novacor, HeartMate II and HeartWare HVAD. Most studies reported the use of unfractionated heparin post-operatively with a transition to low molecular weight heparin and warfarin. Antiplatelet regimens most commonly included aspirin and dipyridamole. Definition of bleeding and clotting events differed between cohorts. The incidence of bleeding overall was 37% (209/558; range of 0 to 89%) and 26% (143/554; range of 8.3 to 100%) for thromboembolism events. All studies reported had significant methodological limitations.
The clinical use of antithrombotic therapies - including dosages, timing and monitoring - varies considerably. This review highlights the further research required to improve understanding of hemostasis in the pediatric VAD field.
心室辅助装置（VAD）在患有终末期心力衰竭的儿童中越来越多地被使用，并且出血和凝血率很高。特别是，由于发育性止血、缺乏合适的药物制剂以及由于血管通路困难（除了在较小的儿童中 VAD 设计的困难之外），儿科 VAD 患者比成人更难以抗凝。本综述旨在总结与儿科 VAD 患者抗血栓治疗相关的现有证据。
使用预先选择的关键字，在 17 年的时间内对 2 个数据库进行了搜索。然后根据所使用的 VAD 类型和描述的抗凝方案对确定的出版物进行分类。
确定了 27 篇符合本综述制定的纳入标准的文章。该队列中包括柏林心脏 EXCOR、Thoratec、Medos、Novacor、HeartMate II 和 HeartWare HVAD。大多数研究报告术后使用未分级肝素，随后过渡到低分子量肝素和华法林。抗血小板方案最常包括阿司匹林和双嘧达莫。出血和血栓形成事件的定义在不同的队列之间存在差异。总的出血发生率为 37%（209/558；范围为 0 至 89%），血栓栓塞事件发生率为 26%（143/554；范围为 8.3 至 100%）。所有报告的研究都存在严重的方法学局限性。
抗血栓治疗的临床应用 - 包括剂量、时间和监测 - 差异很大。本综述强调了进一步研究的必要性，以提高对儿科 VAD 领域止血的理解。
