Abstract Number: PB1277
Meeting: ISTH 2020 Congress
Background: Pediatric right atrial thrombosis (RAT) carries potential for morbidity and mortality. However, the benefit of anticoagulation is unknown. Risk-stratification utilizing RAT echocardiographic characteristics has been suggested. RAT clinical outcomes with anticoagulation treatment based on published risk factors have not been reported. Furthermore, interrater reliability (IRR) of RAT characterization by echocardiography has not been studied.
1) Describe RAT outcomes managed with and without anticoagulation.
2) Measure IRR of echocardiographic RAT characterization.
Methods: Retrospective single-center cohort study at The Johns Hopkins Hospital. Patients 0 to 21 years with RAT from 2013 to 2018 were included. Anticoagulation was initiated based on discretion of treating clinicians, but informed by presence/absence of echocardiographic RAT characteristics. The medical record was reviewed for demographics, treatments and outcomes. Adverse thromboembolic (TE) outcomes included RAT progression, pulmonary embolism (PE), clinically-relevant bleeding (ISTH-defined), and death due to TE or bleeding. For IRR of RAT characteristics, echocardiograms from 50 randomly selected subjects were reviewed by three mutually-blinded pediatric cardiologists.
Results: We identified 131 patients with RAT (Table 1). Median age was 25 days. A provoking clinical factor was present in 125 (95%). Anticoagulation was given in 67 (51%) patients. Enoxaparin was the most commonly used anticoagulant (46) followed by unfractionated heparin (21). Adverse outcomes included RAT progression in 7, PE in 2, and clinically relevant bleeding in 9. There were no deaths related to TE or bleeding.
IRR assessment demonstrated that all RAT characteristics (Table 2) had poor reliability except acoustic reflection (moderate agreement; K=0.62 [95%CI, 0.47-0.78]).
Conclusions: We report large single-center outcomes of pediatric RAT. While echocardiographic assessment was used in decision-making regarding anticoagulation therapy, our study showed poor reliability for RAT characteristics other than acoustic reflect. Future research must focus on improving risk stratification in pediatric RAT, in order to inform interventional studies of treatment paradigms, including use and duration of anticoagulation.
|Total (n =131)|
|Demographics||Median (observed range) in age||25d (2d-20y)|
|Male (%)||67 (51)|
|Weight (Kg)||3.1 (0.6-109.6)|
|Outcomes||No Adverse Outcome (%)||99 (76)|
|Death due to Thromboembolism or Bleeding||0|
|Clinically Relevant Bleeding||9|
[Study patient demographics and outcomes. Multiple adverse outcomes were seen in several patients.]
|Categorical Measure||n Patients||Fleiss Kappa||95% CI||Agreement|
|Acoustic Reflection||42||0.62||(0.47, 0.78)||Moderate|
|Mass Location||42||0.51||(0.41, 0.61)||Weak|
|Continuous Measure||n Patients||Carrasco et al´s CCC||95% CI||Agreement|
|Longest Dimension||44||0.76||(0.64, 0.85)||Poor|
|Orthogonal Dimension||44||0.78||(0.67, 0.86)||Poor|
|Longest Adherence Dimension||43||0.6||(0.43, 0.73)||Poor|
|Pulmonary Valve Dimension||39||0.94||(0.9, 0.96)||Moderate|
[Interrater reliability assessment of RAT characterization by echocardiography. Pulmonary valve dimension is a control measurement.]
To cite this abstract in AMA style:Barnes BT, Ravekes W, Freire G, Amankwah E, Chiu J, Sellers AR, Procaccini D, Takemoto CM, Goldenberg N. Right Atrial Thrombosis in Children: Patient Characteristics, Outcomes, and Interrater Reliability of Echocardiographic Characterization [abstract]. Res Pract Thromb Haemost. 2020; 4 (Suppl 1). https://abstracts.isth.org/abstract/right-atrial-thrombosis-in-children-patient-characteristics-outcomes-and-interrater-reliability-of-echocardiographic-characterization/. Accessed September 29, 2023.
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