Skip to main content
SpringerLink
Log in

Development and Implementation of a Standardized Heparin Protocol for Left-Sided Pediatric Electrophysiology Procedures

  • Original Article
  • Published:
Pediatric Cardiology Aims and scope Submit manuscript

Abstract

Heparin is used to decrease the risk of thromboembolic complications during electrophysiology studies (EPS); however, there is wide practice variation and minimal evidence to guide heparin dosing, particularly in pediatric patients. This study retrospectively analyzed heparin dosing and response, measured via activated clotting time (ACT), in patients undergoing EPS and used these data (pre-protocol cohort, n = 40), as well as guidance from available literature to implement a standardized heparin protocol (phase 1, n = 43). We utilized quality improvement methodology to refine this protocol (phase 2, n = 40) to improve therapeutic heparin response. Prior to the protocol, patients achieved therapeutic ACT levels (250–350 s) only 35% of the time which improved to 60% during phase 1 (p < 0.05) and to 73% during phase 2 (p < 0.001 compared to pre-protocol). There were no thromboses or significant adverse events in any group. These results demonstrate the effectiveness of a standardized heparin protocol in achieving effective antithrombotic therapy during left-sided pediatric EPS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Blanc JJ, Almendral J, Brignole M, Fatemi M, Gjesdal K, Gonzalez-Torrecilla E, Kulakowski P, Lip GYH, Shah D, Wolpert C (2008) Consensus document on antithrombotic therapy in the setting of electrophysiological procedures. Europace 10(5):513–527

    Article  PubMed  Google Scholar 

  2. Bae EJ, Ban JE, Lee JJ et al (2005) Pediatric radiofrequency catheter ablation: results of initial 100 consecutive cases including congenital heart anomalies. J Korean Med Sci 20(5):740

    Article  PubMed  PubMed Central  Google Scholar 

  3. Miga DE, McKellar LF, Denslow S et al (1997) Incidence of femoral vein occlusion after catheter ablation in children: evaluation with magnetic resonance angiography. Pediatr Cardiol 18(3):204–207

    Article  PubMed  CAS  Google Scholar 

  4. Lee SJ, Schueller WC (2000) Tachycardias in infants, children and adolescents: safety and effectiveness of radiofrequency catheter ablation. Cardiology 94(1):44–51

    Article  PubMed  CAS  Google Scholar 

  5. Jiang H, Li X-M, Li Y-H et al (2016) Efficacy and safety of radiofrequency catheter ablation of tachyarrhythmias in 123 children under 3 years of age. PACE Pacing Clin Electrophysiol 39(8):792–796

    Article  PubMed  CAS  Google Scholar 

  6. Calkins H, Hindricks G et al (2017) 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 14(10):e275–e444

    Google Scholar 

  7. Boris JRHM (2003) The use of anticoagulation in pediatric cardiac disease. Images Paediatr Cardiol 5(3):1–35

    PubMed  PubMed Central  CAS  Google Scholar 

  8. Grady RM, Eisenberg PR, Bridges ND (1995) Rational approach to use of heparin during cardiac catheterization in children. J Am Coll Cardiol 25(3):725–729

    Article  PubMed  CAS  Google Scholar 

  9. Freed MD, Keane JF, Rosenthal A (1974) The use of heparinization to prevent arterial thrombosis after percutaneous cardiac catheterization in children. Circulation 50(3):565–569

    Article  PubMed  CAS  Google Scholar 

  10. Saxena A, Gupta RK, Raman K et al (1997) Predictors of arterial thrombosis after diagnostic cardiac catheterization in infants and children randomized to two heparin dosages. Cathet Cardiovasc Diagn 41(4):400–403

    Article  PubMed  CAS  Google Scholar 

  11. Kim GG, El Rouby S, Thompson J et al (2010) Monitoring unfractionated heparin in pediatric patients with congenital heart disease having cardiac catheterization or cardiac surgery. J Thromb Thrombolysis 29(4):429–436

    Article  PubMed  CAS  Google Scholar 

  12. Dieks JK, Müller MJ, Schneider HE et al (2016) Catheter ablation of pediatric focal atrial tachycardia: ten-year experience using modern mapping systems. Pediatr Cardiol 37(3):459–464

    Article  PubMed  Google Scholar 

  13. Hafez M, Abu-Elkheir M, Shokier M et al (2012) Radiofrequency catheter ablation in children with supraventricular tachycardias: intermediate term follow up results. Clin Med Insights Cardiol 6:7–16

    Article  PubMed  PubMed Central  Google Scholar 

  14. Woolf P, Sorbera C, Cohen M (2000) Pediatric radiofrequency ablation for tachyarrhythmias: the Westchester Medical Center experience. Heart Dis 2:336–339

    PubMed  CAS  Google Scholar 

  15. Seslar S, Dubin A, Bradley D et al (2017) What have we learned in the last 20 years? A comparison of modern and early era pediatric and congenital catheter ablation registries [abstract] in: heart Rhythm scientific sessions. Chicago; abstract C-AB37-01.

  16. Thakur RK, Klein GJ, Yee R, Zardini M (1994) Embolic complications after radiofrequency catheter ablation. Am J Cardiol 74(3):278–279

    Article  PubMed  CAS  Google Scholar 

  17. de Swart CA, Nijmeyer B, Roelofs JM, Sixma JJ (1982) Kinetics of intravenously administered heparin in normal humans. Blood 60(6):1251–1258

    PubMed  Google Scholar 

  18. Garcia DA, Baglin TP, Weitz JI, Samama MM (2012) Parenteral anticoagulants: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest 141(2):e24S–e43S

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  19. Monagle P, Chan AKC, Goldenberg NA et al (2012) Antithrombotic therapy in neonates and children: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of CHEST physicians evidence-based clinical practice guidelines. Chest 141(2):e737S–e801S

    Article  CAS  Google Scholar 

  20. Bjornsson TD, Wolfram KM, Kitchell BB (1982) Heparin kinetics determined by three assay methods. Clin Pharmacol Ther 31(1):104–113

    Article  PubMed  CAS  Google Scholar 

  21. Newall F, Ignjatovic V, Monagle P, Johnston L (2009) Unfractionated heparin therapy in infants and children. Pediatrics 123(3):e510–e518

    Article  Google Scholar 

  22. Andrew M, Marzinotto V, Massicotte P et al (1994) Heparin therapy in pediatric patients: a prospective cohort study. Pediatr Res 35(1):78–83

    Article  PubMed  CAS  Google Scholar 

  23. Enriquez AD, Churchill T, Gautam S et al (2017) Determinants of heparin dosing and complications in patients undergoing left atrial ablation on uninterrupted rivaroxaban. PACE 40(2):183–190

    Article  PubMed  Google Scholar 

  24. Ren J-f, Marchlinski FE, Callans DJ et al (2005) Increased intensity of anticoagulation may reduce risk of thrombus during atrial fibrillation ablation procedures in patients with spontaneous ECHO contrast. J Cardiovasc Electrophysiol 16(5):474–477

    Article  PubMed  Google Scholar 

  25. Moffett BS, Teruya J, Petit C (2011) Heparin dosing in obese pediatric patients in the cardiac catheterization laboratory. Ann Pharmacother 45(7–8):7–8

    Google Scholar 

  26. Avila ML, Shah PS, Brandão LR (2014) Different unfractionated heparin doses for preventing arterial thrombosis in children undergoing cardiac catheterization. Cochrane Database Syst Rev 2014(3):CD010196

    Google Scholar 

  27. Kohn LT (2009) Institute of Medicine. Committee on Quality of Health Care in America. In: To err is human: building a safer health system. National Academy Press, Washington, DC

    Google Scholar 

  28. Hanslik A, Kitzmuller E, Thom K et al (2015) Monitoring unfractionated heparin in children: a parallel-cohort randomized controlled trial comparing 2 dose protocols. Blood 126(18):2091–2097

    Article  PubMed  CAS  Google Scholar 

  29. Ignjatovic V, Furmedge J, Newall F et al (2006) Age-related differences in heparin response. Thromb Res 118(6):741–745

    Article  PubMed  CAS  Google Scholar 

  30. Moore E, Armatage A, Keylon J et al (2017) Assessing use of pain medication after pediatric Cardiac catheterizations. Pediatr Nurs 43(4):163–168

    Google Scholar 

  31. Hanslik A, Kitzmüller E, Thom K et al (2011) Incidence of thrombotic and bleeding complications during cardiac catheterization in children: comparison of high-dose vs. low-dose heparin protocols. JTH 9(12):2353–2360

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiology and Cardiac Surgery, Heart Center at Seattle Children’s Hospital, 4800 Sand Point way NE Mail Stop RC 2.820, Seattle, WA, 98105, USA

    Emily F. Moore & Arlene Armatage

  2. Department of Pharmacy, Seattle Children’s Hospital, 4800 Sand Point Way NE, Mail stop BM.5.420, Seattle, WA, 98105, USA

    Jennifer Pak & Christa Jefferis-Kirk

  3. Department of Biostatistics, Collaborative Health Studies Coordinating Center, University of Washington, Bldg. 29, 6200 NE 74th St., Seattle, WA, 98115, USA

    Richard A. Kronmal

  4. Division of Pediatric Cardiology, Department of Pediatrics, University of Washington, 1959 NE Pacific St., Health Sciences Bldg., Seattle, WA, 98195, USA

    Jack C. Salerno & Matthew D. Files

Authors
  1. Emily F. Moore
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jennifer Pak
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christa Jefferis-Kirk
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Arlene Armatage
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Richard A. Kronmal
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jack C. Salerno
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Matthew D. Files
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Emily F. Moore.

Ethics declarations

Conflict of interest

None of the authors have a conflict of interest or relevant relationship with industry.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Seattle Children’s Hospital IRB approved the human research conducted in this study. Formal consent was not required.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Moore, E.F., Pak, J., Jefferis-Kirk, C. et al. Development and Implementation of a Standardized Heparin Protocol for Left-Sided Pediatric Electrophysiology Procedures. Pediatr Cardiol 39, 941–947 (2018). https://doi.org/10.1007/s00246-018-1843-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00246-018-1843-6

Keywords

Search

Navigation