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J Thorac Cardiovasc Surg 2009;137:934-941
© 2009 The American Association for Thoracic Surgery

Congenital Heart Disease

Prospective longitudinal study of coagulation profiles in children with hypoplastic left heart syndrome from stage I through Fontan completion

^a Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston, Boston, Mass
^b Division of Hematology, Children's Hospital Boston, Boston, Mass
^c Department of Cardiology, Children's Hospital Boston, Boston, Mass

Received for publication April 11, 2008; revisions received July 28, 2008; accepted for publication September 11, 2008.

^_* Address for reprints: Kirsten C. Odegard, MD, Cardiac Anesthesia Service, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115. (Email: Kirsten.odegard{at}childrens.harvard.edu).

Objective: The risk for thrombosis is increased after the Fontan operation. It is unknown whether children with univentricular heart disease have an intrinsic coagulation anomaly or acquire a defect in coagulation during the course of the staged repair. This prospective, longitudinal study evaluated changes in coagulation profiles in a cohort of patients with hypoplastic left heart syndrome from stage I palliation through completion of the Fontan operation.

Methods: Thirty-seven patients with hypoplastic left heart syndrome were enrolled prospectively, and the concentration of factors II, V, VII, VIII, IX, X, proteins C and S, fibrinogen, antithrombin, serum albumin, and liver enzymes were measured before stage I palliation (mean age 4 ± 2 days), before bidirectional Glenn (mean age 5.9 ± 1.8 months), before the Fontan procedure (mean age 27.1 ± 6.6 months), and after the Fontan procedure (mean age 49 ± 17.6months). Healthy children were used as age-matched controls for coagulation factors. Demographic, hemodynamic variables, and elapsed time after the Fontan procedure were evaluated as possible predictors of coagulation abnormalities.

Results: Significantly lower levels of both procoagulation and anticoagulation factors were demonstrated through to completion of the Fontan procedure. After the Fontan procedure, there was a significantly higher factor VIII level (P < .005) but no correlation with hemodynamic variables or liver function.

Conclusion: This longitudinal study in patients with identical cardiac disease and staged surgical procedures confirms the increase in factor VIII level after the Fontan procedure. This is an acquired defect, and although the cause remains to be determined, monitoring factor VIII levels after the Fontan operation could indicate a subset of patients at risk for thrombosis.