Hostname: page-component-cd9895bd7-q99xh Total loading time: 0 Render date: 2024-12-29T11:37:46.979Z Has data issue: false hasContentIssue false
  • English
  • Français

Intracardiac thrombus in adults with the Fontan circulation

Published online by Cambridge University Press:  24 October 2007

Wendy Tsang ,
Bengt Johansson ,
Omid Salehian ,
Johan Holm ,
Gary Webb ,
Michael A. Gatzoulis  and
Judith Therrien
Wendy Tsang
Affiliation:
Toronto Congenital Cardiac Centre for Adults, Division of Cardiology Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
Bengt Johansson
Affiliation:
Adult Congenital Heart Program, Department of Cardiology, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College School of Medicine, London, United Kingdom
Omid Salehian
Affiliation:
Toronto Congenital Cardiac Centre for Adults, Division of Cardiology Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
Johan Holm
Affiliation:
Toronto Congenital Cardiac Centre for Adults, Division of Cardiology Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
Gary Webb
Affiliation:
Toronto Congenital Cardiac Centre for Adults, Division of Cardiology Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
Michael A. Gatzoulis
Affiliation:
Adult Congenital Heart Program, Department of Cardiology, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College School of Medicine, London, United Kingdom
Judith Therrien*
Affiliation:
Adult Congenital Heart Centre, Division of Cardiology, Department of Medicine, Sir MB Davis Jewish General Hospital, McGill University, Montreal, Quebec, Canada
*
Correspondence to: Judith Therrien, Sir MB Davis Jewish General Hospital, 3755 Cote Ste. Catherine, Montreal, Quebec, H3 T 1E2, Canada. Tel: 514 340 7140; Fax: 514 340 7534; E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives

To determine the treatment and outcomes of a cohort of adults with the Fontan circulation diagnosed with intracardiac thrombus.

Background

Formation of thrombus is common after the Fontan operation, albeit little has been published on the treatment and outcomes of these patients once they have developed an intracardiac thrombus.

Methods

We identified all patients who had been converted to the Fontan circulation from the cardiology database at the Toronto Congenital Cardiac Centre for Adults, Toronto, and The Royal Brompton Hospital, London, studying the period from 1981 to 2003. We then reviewed the relevant echocardiograms and medical records.

Results

Intracardiac thrombus was identified in 28 of 235 patients with the Fontan circulation, the patients having an average age of 27 plus or minus 9 years. Of the patients, 21 were initially medically treated, 19 with heparin or warfarin, and 2 with thrombolysis, whereas 7 patients underwent immediate surgical removal of the clot. Overall mortality was 18%, with residual clots seen in 39% of surviving patients at 1 year of follow up. At presentation, the haemodynamic stability of each patient with intracardiac thrombus dictated initial strategies for management, with 17% of those with stable presentations undergoing immediate surgical treatment, as opposed to 75% of those with unstable presentations (p-value equals 0.04), as well as correlating with ultimate clinical outcome. The rate of death was 8% in haemodynamically stable patients, versus 75% in haemodynamically unstable patients (p value equals 0.01).

Conclusion

Formation of intracardiac thrombus is not rare in adults with the Fontan circulation, and carries a significant risk of death, especially in clinically unstable patients. Emphasis on prevention of formation of the clot is warranted.

Keywords

Treatmentsoutcomesfunctionally univentricular circulation
Type
Original Article
Information
Cardiology in the Young , Volume 17 , Issue 6 , December 2007 , pp. 646 - 651
Copyright
Copyright © Cambridge University Press 2007

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. de Leval, MR. The Fontan circulation: what have we learned? What to expect? Pediatr Cardiol 1998; 19: 316–320.CrossRefGoogle ScholarPubMed
2. Bull, K. The Fontan procedure: lessons from the past. Heart 1998; 79: 213–214.CrossRefGoogle ScholarPubMed
3. Driscoll, DJ, Offord, KP, Feldt, RH, Schaff, HV, Puga, FJ, Danielson, GK. Five- to fifteen-year follow-up after Fontan operation. Circulation 1992; 85: 469–496.CrossRefGoogle ScholarPubMed
4. Shirai, LK, Rosenthal, DN, Reitz, BA, Robbins, RC, Dubin, AM. Arrhythmias and thromboembolic complications after the extracardiac Fontan operation. J Thorac Cardiovasc Surg 1998; 115: 499–505.CrossRefGoogle ScholarPubMed
5. Comme-Dijkhuis, AH, Hess, J, Hahlen, K, et al. . Specific sequelae after Fontan operation at mid- and long-term follow-up. Arrhythmia, liver dysfunction, and coagulation disorders. J Thorac Cardiovasc Surg 1993; 106: 1125–1132.Google Scholar
6. Monagle, P, Cochrane, A, McCrindle, B, Benson, L, Williams, W, Andrew, M. Thromboembolic complications after Fontan procedures – the role of prophylactic anticoagulation. J Thorac Cardiovas Surg 1998; 115: 493–498.CrossRefGoogle ScholarPubMed
7. Jacobs, ML, Pourmoghadam, KK, Geary, EM, et al. . Fontan’s operation: is aspirin enough? Is Coumadin too much? Ann Thorac Surg 2002; 73: 64–68.CrossRefGoogle ScholarPubMed
8. Seipelt, RG, Franke, A, Vazques-Jimenez, JF, et al. . Thromboembolic complications after Fontan procedures: comparison of different therapeutic approaches. Ann Thorac Surg 2002; 74: 556–562.Google Scholar
9. Coon, PD, Rychik, J, Novello, RT, Ro, PS, Gaynor, JW, Spray, TL. Thrombus formation after the Fontan operation. Ann Thorac Surg 2001; 71: 1990–1994.Google Scholar
10. Jahangiri, M, Ross, DB, Redington, AN, Lincoln, C, Shinebourne, EA. Thromboembolism after the Fontan procedure and its modifications. Ann Thorac Surg 1994; 58: 1409–1414.CrossRefGoogle ScholarPubMed
11. Rosenthal, DN, Friedman, AH, Kleinman, CS, Kopf, GS, Rosenfeld, LE, Hellenbrand, WE. Thromboembolic complications after Fontan operations. Circulation 1995; 92 (Suppl): II287–293.CrossRefGoogle ScholarPubMed
12. Fyfe, DA, Kline, CH, Sade, RM, Gillette, PC. Transesophageal echocardiography detects thrombus formation not identified by transthoracic echocardiography after the Fontan operation. J Am Coll Cardiol 1991; 18: 1733–1737.CrossRefGoogle Scholar
13. Sharma, GV, Cella, G, Parisi, AF, Sasahara, AA. Thrombolytic therapy. N Engl J Med 1982; 306: 1268–1276.Google ScholarPubMed
14. Balling, G, Vogt, M, Kaemmerer, H, Eicken, A, Meisner, H, Hess, J. Intracardiac thrombus formation after the Fontan operation. J Thorac Cardiovasc Surg 2000; 119: 745–751.CrossRefGoogle ScholarPubMed
15. Streif, W, Andrew, M, Marzinotto, V, et al. . Analysis of warfarin therapy in pediatric patients: a prospective cohort study of 319 patients. Blood 1999; 94: 3007–3014.Google Scholar