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Scenario
A preterm female infant was born at 27+1 weeks of gestational age (GA) (birth weight 690 g) and an umbilical vein catheter (UVC) was placed. The tip was located, using chest X-ray (CXR), at T6 thoracic spine level, inside the right atrium of the heart, thus was pulled back and subsequently identified at correct position on CXR. On day 10, routine echocardiography showed a right atrial mass consistent with clot (sized 4.8×4.8 mm) (online supplemental video 1). The UVC presented no continuity with the clot and was well placed. Thus, it was removed and replaced with a central venous catheter. Low molecular weight heparin (LMWH) (enoxaparin) was started at a low dose (100 IU/kg two times per day) but the clot increased in size and was oscillating near the orifice of the tricuspid valve. Unfractionated heparin infusion at 20 IU/kg/hour was started. However, the thrombus continued to increase in size reaching the tricuspid valve and protruded in the right ventricle (online supplemental video 2). Our question is: is recombinant tissue plasminogen activator (rt-TPA) the appropriate treatment choice in order to dissolve this life-threatening clot?
Supplementary video
Supplementary video
Structured clinical question
In a very or extremely preterm newborn with intracardiac thrombosis not responsive to heparin treatment, is rt-TPA safe and effective (reduce or dissolve the clot), and if so what dose should be used?
Search
We searched PubMed, EMBASE and Google Scholar for evidence relating to thrombolysis in preterm infants until 31 July 2021 using: (“preterm infant” OR “extremely low birth weight”) AND thrombosis AND (“recombinant tissue plasminogen activator” OR thrombolysis). The search yielded 86 articles after removing duplicates. All reference lists were also cross-checked, and four articles were added. No randomised controlled trial on this topic was available; therefore, case report, case series and retrospective studies were eligible for the review. Forty-two articles were fully evaluated, and 12 studies met …
Footnotes
Contributors MC conducted the literature search, interpreted results and drafted the manuscript. IC conducted the literature search, interpreted results, contributed to the manuscript and edited through multiple revisions, and supervised the entire process. CD contributed to the manuscript and edited through multiple revisions. FM, ML, CC and SP were involved in the literature search and interpreting the results, and edited through multiple revisions.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.