日本小児循環器学会雑誌 Pediatric Cardiology and Cardiac Surgery

Online ISSN: 2187-2988 Print ISSN: 0911-1794
特定非営利活動法人日本小児循環器学会 Japanese Society of Pediatric Cardiology and Cardiac Surgery
〒162-0801東京都新宿区山吹町358-5アカデミーセンター Japanese Society of Pediatric Cardiology and Cardiac Surgery Academy Center, 358-5 Yamabuki-cho, Shinju-ku, Tokyo 162-0801, Japan
Pediatric Cardiology and Cardiac Surgery 31(5): 229-237 (2015)
doi:10.9794/jspccs.31.229

原著Original

抗凝固,抗血小板療法中に梗塞,出血のイベントを起こしたフォンタン術後患者の検討Thrombotic or Bleeding Complications in Patients Undergoing the Fontan Procedure and Receiving Prophylactic Anticoagulation and/or Antiplatelet Therapy

独立行政法人国立病院機構鹿児島医療センター診療部小児科Department of Pediatrics, Division of Medicine, National Hospital Organization Kagoshima Medical Center ◇ 〒892-0853 鹿児島県鹿児島市城山町8番1号8-1 Shiroyama-cho, Kagoshima-shi, Kagoshima 892-0853, Japan

受付日:2014年12月2日Received: December 2, 2014
受理日:2015年7月31日Accepted: July 31, 2015
発行日:2015年9月1日Published: September 1, 2015
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背景:従来フォンタン術後患者に血栓塞栓予防目的で抗凝固,抗血小板治療が行われているが,薬剤使用にあたっての基準が存在しない.

目的:抗凝固,抗血小板治療の現状を把握し,フォロー中に梗塞,出血のイベントを起こした患者の特徴を調べること.

方法:1998~2012年に当科にて外来フォローしたフォンタン術後患者49名を後方視的に検討した.性別は男性34名,女性15名,平均年齢16.3±7.7歳,TCPC手術時年齢4.5±3.7歳,平均術後経過59.1±45ヶ月であった.

結果:ワーファリンは全員,アスピリンは48名が内服していた.梗塞例は脳梗塞3名,腎梗塞1名に認めたが,幸い早期治療で後遺症なく治癒していた.出血例は肺出血3名中1名が死亡,消化管出血を3名で6回経験,5回は緊急輸血が必要であった.他に皮下出血,肉眼的血尿,卵巣出血,過多月経があり,出血イベント時の平均PT-INRは1.9±0.5であった.各々でアスピリン中止やワーファリン減量で対処されていた.

結論:アスピリン,ワーファリン併用が良好なフォンタン循環を保つのかどうかを含め,今後根拠に基づく戦略が必要である.ただし治療にあたっては,出血合併症へ最大限の配慮をして個別に薬物選択を検討しなければならない.

Background: Although many patients undergoing the Fontan procedure require anticoagulants or antiplatelet drugs, there is no consensus regarding thromboprophylaxis after this procedure.

Methods: To clarify the incidence of thrombotic or bleeding complications and their characteristics, we retrospectively studied 49 patients (34 male and 15 female) who underwent the Fontan procedure between 1989 and 2012. Their average age was 16.3±7.7 years, the average age at which total cavopulmonary connection surgery was performed was 4.5±3.7 years, and the mean duration of postoperative observation was 59.1±45 months.

Results: All patients received warfarin and all but one received aspirin. Three patients developed cerebral infarction, one of whom also developed renal infarction. With prompt treatment, all three patients recovered without sequelae. With regard to bleeding complications, one of three patients who developed pulmonary hemorrhage died. Gastrointestinal bleeding occurred on six occasions in three patients, only one of whom had associated abdominal pain. Urgent blood transfusions were necessary on five of these occasions. Additionally, subcutaneous hemorrhage, macrohematuria, ovarian hemorrhage, and polyhypermenorrhea also occurred. In patients with bleeding complications, the mean prothrombin time/international normalized ratio was 1.9±0.5. These hemorrhagic events were managed by the discontinuation of aspirin and reduction of the warfarin dosage.

Conclusion: It is necessary to determine whether a combination of aspirin and warfarin is indicated for maintaining adequate circulation after the Fontan procedure. Because combination treatments are likely to cause more bleeding complications, the use of individual drugs should be investigated.

Key words: Fontan; thromboprophylaxis; anticoagulation; antiplatelet; bleeding ulcer

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