Abstract
Thromboembolism (TE), including venous thromboembolism (VTE), arterial TE, arterial ischemic stroke (AIS), and myocardial infarction (MI), is considered a relatively rare complication in the pediatric population. Yet, the incidence is rising, especially in hospitalized children. The vast majority of pediatric TE occurs in the setting of at least one identifiable risk factor. Most recently, acute COVID-19 and multisystem inflammatory syndrome in children (MIS-C) have demonstrated an increased risk for TE development. The mainstay for the management pediatric TE has been anticoagulation. Thrombolytic therapy is employed more frequently in adult patients with ample data supporting its use. The data for thrombolysis in pediatric patients is more limited, but the utilization of this therapy is becoming more commonplace in tertiary care pediatric hospitals. Understanding the data on thrombolysis use in pediatric TE and the involved risks is critical before initiating one of these therapies. In this paper, we present the case of an adolescent male with acute fulminant myocarditis and cardiogenic shock likely secondary to MIS-C requiring extracorporeal life support (ECLS) who developed an extensive thrombus burden that was successfully resolved utilizing four simultaneous catheter-directed thrombolysis (CDT) infusions in addition to a review of the literature on the use of thrombolytic therapy in children.
Highlights
Specialty section: This article was submitted to Pediatric Hematology and Hematological Malignancies, a section of the journal Frontiers in Pediatrics
We present the case of an adolescent male with acute fulminant myocarditis and cardiogenic shock likely secondary to multisystem inflammatory syndrome in children (MIS-C) requiring extracorporeal life support (ECLS) who developed an extensive thrombus burden that was successfully resolved utilizing four simultaneous catheter-directed thrombolysis (CDT) infusions in addition to a review of the literature on the use of thrombolytic therapy in children
Significant fibrin deposits in the ECLS circuit developed in the first hour after cannulation and the patient was transitioned to bivalirudin [0.25 mg/kg/h starting dose with escalation up to 1.15 mg/kg/h based on activated partial thromboplastin time goal of 2–3 times his baseline (60–85 s)] due to concern for heparin resistance
Summary
Thrombolytic therapy has been employed for the management of pediatric TE for decades and the use is increasing [5, 6]. Thrombolytic therapy can be administered either systemically or via an endovascular route, including CDT or pharmaco-mechanical thrombolysis. An increased risk for major bleeding in children receiving systemic thrombolysis has been associated with lower fibrinogen activity right after completion of thrombolysis and longer rtPA infusions [11]. While the directed therapy may lower the risk of major bleeding (reported in up to 3% of children who undergo endovascular thrombolysis), it does require more healthcare utilization, including: longer intensive care stays, utilization of interventionalists, and general anesthesia [1]. With improved laboratory monitoring capabilities, radiographic imaging, and interventional radiology and surgical interventions, the use of thrombolysis in pediatrics has risen in the last 10– 20 years and recent guidelines acknowledged that certain patients could benefit from this therapy [1, 7]. Despite the lack of specific evidence in pediatric populations, there are many reported case series and cohort reports on the use of thrombolysis in pediatric populations that show similar results in efficacy, major bleeding, and TE recurrence rates (Table 1)
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