Comparative trial of the use of antiplatelet and oral anticoagulant in
               thrombosis prophylaxis in patients undergoing total cavopulmonary operation with
               extracardiac conduit: echocardiographic, tomographic, scintigraphic, clinical and
               laboratory analysis

Pessotti, Cristiane Felix Ximenes; Jatene, Marcelo Biscegli; Jatene, Ieda Biscegli; Oliveira, Patrícia Marques; Succi, Fabiana Moreira Passos; Moreira, Valeria de Melo; Lopes, Rafael Willain; Pedra, Simone Rolim Fernandes Fontes

doi:10.5935/1678-9741.20140111

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Brazilian Journal of Cardiovascular Surgery

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ORIGINAL ARTICLES • Rev Bras Cir Cardiovasc 29 (4) • Oct-Dec 2014 • https://doi.org/10.5935/1678-9741.20140111 copy

Comparative trial of the use of antiplatelet and oral anticoagulant in thrombosis prophylaxis in patients undergoing total cavopulmonary operation with extracardiac conduit: echocardiographic, tomographic, scintigraphic, clinical and laboratory analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

To compare the efficacy of aspirin and warfarin for prophylaxis of thrombosis in patients undergoing total cavopulmonary anastomosis. Evaluate whether coagulation factors (VII, VIII and protein C), clinical data, fenestration or hemodynamic factors, interfere with postoperative thrombosis.

Methods:

A prospective, randomized study of 30 patients, randomized into Group I (Warfarin) and Group II (AAS), underwent total cavopulmonary shunt with extracardiac conduit, between 2008 and 2011, with follow-up by clinical visits to evaluate side effects and adhesion. Performed transesophageal echocardiography in post operatory time, 3, 6,12 and 24 months; angiotomography at 6, 12 and 24 months to evaluate changes in the internal tube wall or thrombi and pulmonary scintigraphy to evaluate possible PTE.

Results:

Two deaths in group I; 33.3% of patients had thrombus (46.7% in Group II). The previous occurrence of thrombus and low levels of coagulation protein C were the only factors that influenced the time free of thrombus (P=0.035 and 0.047). Angiotomographic evaluation: 35.7% in group II presented material accumulation greater than 2 mm (P=0.082). Scintigraphy: two patients had PTE in group II. Five patients had difficulty to comply with the treatment, 4 in group I with INR ranging from 1 to 6.4.

Conclusion:

The previous occurrence of thrombus is a risk factor for thrombosis in the postoperative period. Patients using AAS tend to deposit material in the tube wall. The small sample size did not allow to conclude which is the most effective drug in the prevention of thrombosis in this population.

Fontan Procedure; Thrombosis; Warfarin; Aspirin; Prospective Studies

Abbreviations, acronyms and symbols
ASA	Acetylsalicylic acid
HLHS	Hypoplastic Left Heart Syndrome
IPO	Immediate postoperative
PTE	Pulmonary thromboembolism

	ASa (n=15)	OAC (n=15)	Total (n=30)	P
gender
female	8 53.3%	5 33.3%	13 43.3%	0.269^a a Chi-square test,
male	7 46.7%	10 66.7%	17 56.7%
age (years)
mean	4.8	5.8	5.3	0.330^b b Mann-Whitney test,
median	3.7	4.1	4.0
minimum	2.0	2.7	2.0
maximum	15.6	15.6	15.6
standard deviation	3.3	3.8	3.5
diagnosis
VUE	4 26.7%	5 33.3%	9 30.0%	0.026^c c Fisher's Exact test or its extension, Student's
AT	8 53.3%	1 6.7%	9 30.0%
VUD	3 20.0%	8 53.3%	11 36.7%
SHCE	- -	1 6.7%	1 3.3%
pulmonary pressure (mmHg)
mean	14.9	16.7	15.8	0.102^d d t-test for independent samples
median	15.0	16.0	15.5
minimum	11.0	9.0	9.0
maximum	19.0	23.0	23.0
standard deviation	2.3	3.6	3.1

Surgical Procedure	OAC Group:	Grupo II:
Surgical Procedure	n(%)	n (%)
Isolated ECC	11 (73.33%)	12 (80%)
Fenestrated ECC	1 (6.66%)	3 (20%)
ECC and Damus-Kaye-Stansel	2 (13.33%)	0
ECC and Glenn Anastomosis	1 (6.66%)	0

	ASA		OAC		Total
Preoperative period (history of thrombus)	n	%	N	%	n	%
present	4	26.7%	2	13.3%	6	20.0%
ausent	11	73.3%	13	86.7%	24	80.0%
Total	15	100.0%	15	100.0%	30	100.0%
Immediate postoperative period
present	4	26.7%	2	13.3%	6	20.0%
ausent	11	73.3%	13	86.7%	24	80.0%
Total	15	100.0%	15	100.0%	30	100.0%
3 months after surgery
present	-	-	-	-	-	-
ausent	11	73.3%	12	80.0%	23	76.7%
death	-	-	1	6.7%	1	3.3%
Total	15	100.0%	15	100.0%	30	100.0%
6 months after sur
present	-	-	-	-	-	-
ausent	11	73.3%	12	80.0%	23	76.7%
death	-	-	1	6.7%	1	3.3%
Total	15	100.0%	15	100.0%	30	100.0%
12 months after surgery
present	2	13.3%	1	6.7%	3	10.0%
ausent	9	60.0%	10	66.7%	19	63.3%
death	-	-	2	13.3%	2	6.7%
Total	15	100.0%	15	100.0%	30	100.0%
24 months after surgery
present	1	6.7%	-	-	1	3.3%
ausent	8	53.3%	10	66.7%	18	60.0%
death	-	-	2	13.3%	2	6.7%
Total	15	100.0%	15	100.0%	30	100.0%

	ASA		AOC		Total		P
6 months after surgery
altered	11	78.6%	8	66.7%	19	73.1%	0.665^c c Fisher's Exact test
non-altered	3	21.4%	4	33.3%	7	26.9%
Total	14	100.0%	12	100.0%	26	100.0%
12 months after surgery
altered	11	78.6%	10	83.3%	21	80.8%	>0.999^c c Fisher's Exact test
non-altered	3	21.4%	2	16.7%	5	19.2%
Total	14	100.0%	12	100.0%	26	100.0%
24 months after surgery
altered	10	83.3%	6	66.7%	16	76.2%	0.611^c c Fisher's Exact test
non-altered	2	16.7%	3	33.3%	5	23.8%
Total	12	100.0%	9	100.0%	21	100.0%

	AAS		ACO		Total		P
thickness (phase 4)
greater or equal to a 2mm	3	23.1%	4	36.4%	7	29.2%	0.603^a a aunilateral test comparing proportions
less than 2 mm	10	76.9%	7	63.6%	17	70.8%
Total	13	100.0%	11	100.0%	24	100.0%
thickness (phase 5)
greater or equal to 2 mm	3	23.1%	3	30.0%	6	26.1%	0.500^a a aunilateral test comparing proportions
less than 2 mm	10	76.9%	7	70.0%	17	73.9%
Total	13	100.0%	10	100.0%	23	100.0%
thickness (phase 6)
greater or equal to 2 mm	5	35.7%	-	-	5	22.7%	0.082^a a aunilateral test comparing proportions
less than 2 mm	9	64.3%	8	100.0%	17	77.3%
Total	14	100.0%	8	100.0%	22	100.0%

Authors' roles & responsibilites
CFXP	Study design, data collection, reference search
MBJ	Study design
BJ	Study design
PMO	Data collection
FMPS	Data collection
VMM	Data collection
RWL	Data collection
SRFFP	Data collection

Sociedade Brasileira de Cirurgia Cardiovascular Rua Afonso Celso, 1178 Vila Mariana, CEP: 04119-061 - São Paulo/SP Brazil, Tel +55 (11) 3849-0341, Tel +55 (11) 5096-0079 - São Paulo - SP - Brazil
E-mail: bjcvs@sbccv.org.br

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[1] Correspondence address: Cristiane Felix Ximenes Pessotti, Instituto do Coração (InCor) of Hospital das Clínicas of Faculdade de Medicina of Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44 - Cerqueira César, São Paulo, SP, Brasil – CEP: 05403-000. E-mail: crisximenes08@gmail.com