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F. Mannig. Augustana College, Rock Island Illinois.

Respiratory arrest frequently occurs in lightning strike victims kamagra soft 100 mg free shipping erectile dysfunction quizlet, and the associated hypoxia can prevent cardiac recovery from the initial electrically induced cardiac asystole or other dysrhythmia (48 effective 100mg kamagra soft erectile dysfunction treatments diabetes,52) generic 100 mg kamagra soft overnight delivery erectile dysfunction viagra cialis levitra. Initial emergency management of children struck by lightning is the same as for those with electrical injuries from man-made sources. Any child found with linear or punctate burns, clothes exploded off, tympanic membrane rupture, confusion, outdoor location of discovery, or pathognomonic feathering burns should be managed medically as a lightning strike victim. In the case of multiple casualties in a lightning strike, contrary to standard triage guidelines, resuscitation attempts should be directed first toward those who appear dead. Those who are apneic and asystolic may respond to resuscitative efforts, whereas those with spontaneous respirations are likely to already be recovering (48). Pediatric Emergency Medicine Collaborative Research Committee: Working Group on Blunt Cardiac Injury. Upper and lower limits of vulnerability to sudden arrhythmic death with chest wall impact (commotio cordis). Role of streptomycin-sensitive stretch-activated channel in chest wall impact induced sudden death (commotio cordis). Safety baseballs and chest protectors: a systemic review on the prevention of commotio cordis. Myocardial contusion in blunt trauma: clinical characteristics, means of diagnosis, and implications for patient management. Evaluation of incidence, clinical significance, and prognostic value of circulating troponin I and T elevation in hemodynamically stable patients with suspected myocardial contusion after blunt chest trauma. Determining which patients require evaluation for blunt cardiac injury following blunt chest trauma. Cardiac troponin I in pediatrics: normal values and potential use in the assessment of cardiac injury. Cardiac troponin I as a predictor of arrhythmia and ventricular dysfunction in trauma patients with myocardial contusion. Highly sensitive cardiac troponin in blunt chest trauma: after the gathering comes the scattering? Atrial septal rupture, flail tricuspid valve, and complete heart block due to nonpenetrating chest trauma. Aortic dissection in childhood and adolescence: an analysis of occurrences over a 10- year interval in New York State. Management of acute complicated and uncomplicated type B dissection of the aorta: focus on endovascular stent grafting. Posteromedial papillary muscle rupture as a result of right coronary artery occlusion after blunt chest injury. Rates of homicide, suicide, and firearm-related death among children–26 industrialized countries. These factors include pregestational diabetes, phenylketonuria, influenza and exposure to retinoids, nonsteroidal anti-inflammatory drugs, anticonvulsants, thalidomide, smoking, and alcohol (17,18,19). Pathogenesis and Anatomic Features During embryogenesis, the primitive atrium undergoes a complex septation process (Fig. In the fourth week of embryonic life, the septum primum appears as a thin-walled sagittal fold in the middle of the common atrium and grows inferiorly toward the endocardial cushion. The opening between the leading edge of the septum primum and the endocardial cushion is called the ostium primum. Before complete closure of the ostium primum, tissue reabsorption occurs in the superior portion of the septum primum resulting in another opening called the ostium secundum. Concurrently, an anterosuperior infolding of the atrial roof develops to the right of the septum primum, called the septum secundum that is concave shaped with a superior and inferior limb. The inferior limb fuses with the lowermost part of the atrial septum to join the endocardial cushion, thus separating the inferior portions of the two atria. The septum secundum thus forms the concave-shaped superior margin of the fossa ovalis, called the limbus of fossa ovalis (annulus ovalis) and the septum primum forms the valve of fossa ovalis. During fetal life, inferior vena caval flow from the placenta is deflected toward the foramen ovale by the eustachian valve, and then blood is directed from the right atrium to the left atrium via the foramen ovale. However, it may persist in 25% to 30% of adults where it is probe patent with a competent valve. In some cases, the valve of fossa ovalis is incompetent, either congenitally or acquired due to elevated right or left atrial pressures allowing interatrial shunting across the foramen. Embryology of the atrioventricular canal region and pathogenesis of endocardial cushion defects. These defects usually are single, but rarely can occur as multiple atrial septal fenestrations. It is formed by the limbus of the fossa ovalis on the right atrial side and the valve of the fossa ovalis toward the left. The interatrial communication in these defects is, in fact, the orifice of the unroofed right pulmonary vein and is not a true defect in the atrial septum per se (21). Associated Cardiovascular Anomalies Interatrial communications can occur in isolation, but often are associated with other congenital heart defects. The presence of an interatrial communication may be crucial for survival in some such defects such as hypoplastic left heart syndrome, D-transposition of great arteries, tricuspid atresia, and total anomalous pulmonary venous return. Unlike the original description by Lutembacher, where the mitral stenosis was considered to be congenital in origin, the current consensus is that it is of rheumatic origin (22). Therefore, the magnitude of the atrial level shunt is directly related to the degree of obstruction at the mitral valve. Pathophysiology During fetal life, the majority of the blood reaching the left atrium comes via the foramen ovale since there is minimal flow to the lungs. The increased pulmonary venous return to the left atrium results in the left atrial pressure exceeding the right atrial pressure causing functional closure of the foramen ovale. The primary determinant of the magnitude and direction of the shunt is the relative compliance of the P. During the neonatal transition period as the pulmonary vascular resistance drops and the right ventricular wall becomes thinner and hence more compliant than that of the left ventricle, there is an increase in left-to-right shunting. Maximum left-to-right shunting occurs during diastole when all four cardiac chambers are in communication. Conversely, during expiration, when the intrathoracic pressure is increased, there is an increase in the left-to-right shunt. The volume- overloaded right ventricle alters the diastolic configuration of the left ventricle with septal bowing toward the left. Occasionally, the abnormal left ventricular geometry may result in prolapse of the mitral valve or superior systolic motion of the mitral leaflet (23). As a result of the increased flow into the lungs, the pulmonary arteries, capillaries, and the veins are dilated and there can be flow-related pulmonary artery hypertension. Over time this can lead to medial hypertrophy of pulmonary arteries and muscularization of the arterioles resulting in pulmonary vascular obstructive disease (24,25). With severe pulmonary vascular obstructive disease, patients develop Eisenmenger syndrome as the atrial level shunt becomes right-to-left, resulting in cyanosis (see Fig. The mechanism of heart failure in these infants is not well understood since the hemodynamics are quite similar to those who are asymptomatic.

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During labor discount generic kamagra soft uk erectile dysfunction jacksonville doctor, there is a 10% increase in cardiac output beyond the pre-labor level order 100 mg kamagra soft with mastercard erectile dysfunction treatment forums, mediated by increases in the heart rate and stroke volume generic kamagra soft 100 mg free shipping erectile dysfunction at the age of 18, augmented by yet a further increase of 7% to 15% in response to each uterine contraction, with maximal augmentation noted during the second stage of labor (21). Immediately following delivery, cardiac output may transiently increase to as much as 80% above pre-labor values due to relief of inferior vena cava compression and autotransfusion from the placenta, but output returns to pre-labor levels by approximately 1 hour postpartum. Thereafter, the hemodynamic changes that developed during pregnancy return toward baseline values; most of the changes resolve early after delivery, although complete resolution of all measureable pregnancy-associated effects may take as long as 6 months (22). Cardiac Findings in Normal Pregnancy Fatigue, dyspnea, light-headedness, and palpitations are symptoms associated with normal pregnancy but overlap with symptoms of cardiac decompensation. The hemodynamic changes of pregnancy are responsible for corresponding changes in the physical examination P. They include displacement of the apical impulse, prominence of the jugular venous pulsation, wide splitting of the first and second heart sounds, soft systolic flow murmurs and continuous murmurs. Sinus tachycardia and premature atrial or ventricular ectopic beats may also increase in frequency during normal pregnancy and do not necessarily reflect cardiac decompensation or any cardiac disease. This overlap of signs and symptoms may make diagnosis of cardiac decompensation during pregnancy challenging; brain natriuretic peptide can be a useful test to adjudicate the basis for symptoms and signs when a benign basis is not certain (23). Echocardiographic studies during normal pregnancy reveal that dimensions of all four cardiac chambers increase and there is an increase in left ventricular wall thickness and mass (16,22,24,25). Mitral, tricuspid, and pulmonic annular diameters increase and may result in increasing degrees of mitral, tricuspid, and pulmonic regurgitation, respectively (26). Assessment of Pregnancy Risk in Women with Congenital Heart Disease: General Concepts and Global Evaluation Women with cardiac disease are at increased risk of developing adverse maternal cardiac events during pregnancy (27). Maternal cardiac risk can usually be estimated after a complete cardiovascular history and physical examination, a 12-lead electrocardiogram, a transthoracic echocardiogram, and arterial oxygen saturation when indicated. Prepregnancy exercise testing, specifically focusing on measures of heart rate responsiveness to exercise, may aid risk stratification (28). Prepregnancy stress testing to assess functional capacity and blood pressure response to exercise can help with risk stratification in women with severe aortic stenosis. Stress echocardiography can be used to assess ischemia in women with coronary anomalies. Additional risk factors identified from subsequent studies on pregnancy risk (33,34). Early studies showed that poor maternal functional class and cyanosis are associated with adverse maternal cardiac events (30,31). Based on these predictors, women can be classified into low- (0 predictor), intermediate- (1 predictor), or high- (>1 predictor) risk categories. The study showed that women in low-, intermediate-, and high-risk categories have, respectively, a 5%, 25%, or >75% chances of developing an adverse cardiac event during pregnancy (Table 69. In a single-center retrospective study examining outcomes in 1,741 women, the largest to date, the maternal cardiac event rate was 9. For example, women with Marfan syndrome and dilated aortic root, Eisenmenger syndrome, or those with a Fontan circulation were underrepresented in the derivation sets and therefore their known pregnancy- associated risks will not be reliably predicted by the global risk scores. The various risk indices are helpful in placing patients into risk groups, but clinical judgment and expertise are required to fine tune risk stratification. Furthermore, the prediction rules reported discriminative (differentiate between those that will vs. At our center, we use global risk scores to place patients into low-, intermediate-, and high-risk groups, avoiding quantifying risk numerically in view of the previous-mentioned limitations. If pregnancy is decided upon, intensive specialist cardiac and obstetric monitoring needed throughout pregnancy, childbirth and the puerperium. Additional described factors that increase pregnancy risk include the presence of a prosthetic valve or conduit (especially if associated with abnormal prosthetic valve function), occurrence of an obstetric complication such as preeclampsia, and use of anticoagulants or teratogenic drugs. Some of these matters are elaborated further in sections below on prosthetic heart valves, management of anticoagulation and preconception issues. In comprehensive assessment of maternal risk it is helpful to integrate a global risk index with contemporary lesion-specific and other markers of risk, as well as expert opinion. When there is discordance between the global and the lesion- specific estimates of risk, the higher risk estimate should drive the care plan to avoid false reassurance. High-risk obstetric characteristics include smoking, use of anticoagulation, multiple gestations, and maternal age. Heart disease group with neither left heart obstruction nor poor functional class/cyanosis is represented by gray bars. Heart disease group with left heart obstruction or poor functional class/cyanosis is represented by black bars. Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease. Maternal risk factors for adverse fetal and neonatal outcomes have been identified (see Table 69. The risk of neonatal complications is further increased if there are concomitant maternal noncardiac (obstetrical and other) risk factors (see Table 69. Finally, there is cardiac-lesion- specific variation in the risk for adverse obstetric outcomes during pregnancy (see Fig. Women with an intermediate to high risk of adverse maternal cardiac events during pregnancy or those at increased risk for fetal and neonatal complications should be considered for enhanced multidisciplinary surveillance in specialized high-risk cardiac and obstetric programs (29). As well, the impact of maternal heart disease on the probability of adverse obstetric outcomes should be considered when evaluating the need for enhanced intensity of obstetric oversight of pregnancy. The relationship between maternal cardiac status and fetal outcomes may be manifested by changes in uterine and umbilical Doppler flow patterns (40). Hemodynamic and hormonal changes of pregnancy may continue to impact maternal outcomes late after pregnancy (41,42,43,44,45). For example, adverse cardiac events late after pregnancy occurred more often in women who had adverse cardiac events during pregnancy (Fig. Pregnancy has been associated with an increased likelihood of requiring valve intervention late after pregnancy in women with moderate or severe aortic stenosis (45). At this time, the full extent and mechanisms of the late effects of pregnancy on the heart are poorly understood. Pregnancy outcomes stratified solely by diagnosis can be helpful, but in addition it is important to consider the specific surgical history, the history of prior cardiac events, the functional status of the woman and ventricular and valve function, since individual variation in these factors may influence risk over and above the risk imparted by diagnosis alone. Potential complications include atrial arrhythmias and heart failure, particularly if the shunt is large. If cardiac shunts are associated with pulmonary hypertension, risk is dominated by the impact of the elevated pulmonary vascular resistance, which is discussed elsewhere in this chapter. Right Ventricular Outflow Tract Obstruction If pulmonic stenosis is mild or has been previously corrected surgically or by valvuloplasty, it is typically well tolerated during pregnancy (32,46,51). In severe pulmonic stenosis, the increase in preload associated with pregnancy may not be tolerated and may result in atrial arrhythmias or right heart failure. Thus, correction of severe pulmonic stenosis prior to pregnancy should be considered. If decompensation develops during pregnancy, balloon valvuloplasty can be carried out if initial medical therapy proves insufficient (52). Although one group has reported high rates of obstetric and fetal complications in women with pulmonary stenosis (53), this differs from experience reported elsewhere (32,46,51).

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A tive propylene glycol cheap kamagra soft 100mg without a prescription erectile dysfunction pills cost, present in most creams purchase kamagra soft 100mg amex erectile dysfunction treatment after surgery, it is recent study cheap 100mg kamagra soft mastercard erectile dysfunction caused by vicodin, however, showed that women using prudent to prescribe steroid ointments that do not an oral contraceptive containing Drospirone for contain this agent. This commercially available ointment contains ness and the vaginal introitus area was signifcantly propylene glycol and should be avoided if propyl- decreased. Concomitant use containing Drospirone, we have suggested the use of vaginal estradiol tablets twice weekly seems to of an alternative oral contraceptive, although one improve patient response rates with locally applied published study found a lower mechanical pain steroids. If the vulvar infammation is localized, a threshold in the posterior vestibule in women tak- trial of a commercial estradiol cream that the patient ing oral contraceptives. History tak- oral contraceptives containing only 20 µg of ethinyl ing is important, for if the patient has had a prior estradiol. To obtain local to stop oral contraceptives and treat locally with an estradiol therapy, there are alternatives. She returned for the to the vaginal vestibule for several hours three times Vulvovaginal Infections 144 a week. Although this will numb the area locally have been used with some successes seen with all while the lidocaine is in contact, the most impor- of the drugs. To date, not one agent provides bet- tant result comes from evidence that this applica- ter results than another. The dosage is increased Although in theory this was an encouraging option, incrementally at 1-week intervals if the patient has a study by Foster with placebo controls showed no lessening of the pain and is having no problems tak- beneft. Again, an alternate medication option Ancillary local therapies include the use of lard should be chosen if the dosage has reached 50 mg a (Crisco®) or coconut oil after voiding to reduce the day and the patient has not reached the point where infammatory response of the infamed mucosa to she can have intercourse. We comfortable vaginal penetration may be accelerated prefer these two options to Vaseline®, which is more by the use of either physical therapy or biofeedback occlusive and may cause tissue breakdown when techniques. There are four but who are too sedated with the drug, newer tri- classes of drugs that have been used in this patient cyclic antidepressants such as desipramine and nor- population, each of which has been effective for triptyline can be tried. The underlying rationale for another group of antidepressants, those that inhibit the use of these drugs has been their record of suc- the central nervous system neuronal uptake of sero- cess in other pain syndromes such as fbromyalgia tonin, including sertraline and paroxetine. There is a rhythm in the Another drug used is the muscle relaxant, cyclo- physician’s use of these drugs, beginning with the benzaprine. A good ini- they are not given this drug to relax their pelvic tial drug is hydroxyzine, a member of the antihista- foor muscles, but instead to modulate the excessive mine family, at a dosage level of 10 mg at bedtime. This Patients should be counseled that they will probably drug can markedly sedate some women, so that they sleep better with this drug and that their mouth remain groggy from the bedtime dose when they may be dry in the morning when they awaken. To obviate this, the patient Two weeks of observation will determine the initial should begin with the lowest dose, 5 mg at bedtime. If In women weighing less than 110 lb, the patients the patients do not require alternative therapy, the should cut the tablets in half to begin with 2. If the patient notices If they tolerate this and show improvement, the dos- improvement, not a cure, and is tolerating the medi- age can be increased incrementally to 10 mg. There cation, the dose of the hydroxyzine can be increased are concerns about the long-term use of the drug, gradually. If improvement continues, the dose can and cases of liver toxicity have been reported, albeit be increased to 50 mg. If the treatment regimen is extended are still not able to have intercourse at this dosage, beyond 1–2 months, it is prudent to check liver func- this is the time to use another drug. Again, there will be patients who do not improvement and the mucous membranes of the respond to this drug, and they should discontinue it. Again, the rationale The next group of drugs employed is comprised is that this agent will lessen the impact of the exces- of mood elevators. It is a good strategy not to begin sive number of nerve signals sent from the vulva to with these drugs, for many patients are nonplussed the brain. The starting dose is 100 mg three times a when, on the one hand, they are told they have day. To obtain symptom relief, the dosage is gradu- vulvar disease and, on the other, they are being ally increased. Some women require 1500–1800 mg treated with a drug they think is aimed at their per day for a response. It should be emphasized All of these oral drugs have side effects associated that these drugs are used in an effort to decrease with their use, primarily sedation. To avoid this, the number of nerve-pain messages from the vulva these medications have been compounded in creams to the brain, and the prescribed dose is much less to use locally. Lidocaine gel 2% this gene polymorphism, whose babies have the should be applied frst to the treatment area for 10 same polymorphism, are at risk for premature labor minutes and then removed before the capsaicin is and delivery. Patients with this polymorphism also 2%, 4%, or 6% cream, can be applied three times daily have an increased rate of recurrent Candida vul- for a minimum of 8 weeks of therapy. The local injection of produced and is currently being studied in patients interferon-α and interferon-β locally has dropped undergoing liver transplantation. Any physician who has combined with patient discomfort with this multiple repeatedly seen patients who are operative failures injection approach, plus the prohibitive associated becomes more selective when considering this thera- costs, strongly suggest that this approach should peutic option. A study from continuing emphasis in some quarters upon the role the Netherlands had the best result in women under of excess urinary oxalates as a source of the vulvar the age of 30 when they had this operative proce- infammation. Postoperatively, these patients require standard oral therapies are discarded and alternative biofeedback to increase the success rate of the opera- approaches are tried. These women have had 100 mg, is given twice a day if these women have no a pattern of months or years of painful intercourse allergies to sulfa drugs. Vulvovaginal Infections 146 This is the current state of the therapeutic arma- 14. As more information is obtained about the and the minor vestibular gland syndrome. Am J Obstet Gynecol distribution of mannose-binding lectin alleles 2002;186:696–700. Vestibular nerve pro- els of interleukin-1β and tumor necrosis liferation in vulvar vestibulitis syndrome. Vestibular tactile and pain thresholds in Interleukin-1β gene polymorphism in women women with vulvar vestibulitis syndrome. Ital J Gynaecol Obstet Epidemiology of vulvar vestibulitis syndrome: 2010;22:59–64. Vestibulodynia: characterization of women with vulvar ves- A multifactorial syndrome. The tissue obtained should then be evalu- represent diffcult diagnostic and therapeutic chal- ated by a competent dermatopathologist. These are cutaneous problems diagnosis is made, physicians need to be aware that that disrupt the patient’s lifestyle. Most affected elimination of the lesions and a total cure is seldom women have constant symptoms, and these chronic achieved. Instead, the focus will be on the minimal problems make them a trial to themselves, to their dose of an effective medication that will control families, and to the physicians trying to formulate symptoms without drug toxicity.

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Thrombin generation is increased via the extrinsic system in response to cytokines discount generic kamagra soft uk erectile dysfunction treatment san diego, ischemia purchase kamagra soft 100mg mastercard erectile dysfunction 3 seconds, sheer stress cheap kamagra soft 100 mg line erectile dysfunction ring, and activated platelets and via the contact system in response to the contact of blood with the circuit. The procoagulant state may persist well into the postoperative period (175,176,177,178). Coagulation abnormalities have been identified to include altered coagulation protein levels, increased thrombin generation potential, decreased endogenous inhibitors of coagulation, and decreased fibrinolytic proteins among others. Such coagulopathies were first identified in children and adolescents with a Fontan circulation but more recently have been found in children through all stages of single-ventricle palliation and also in children with acyanotic and acquired heart disease (151,153,155,160,161,164,179,180,181,182,183,184). Although of great interest, there is a paucity of data on the predictability of hypercoagulability panel testing in prospectively identifying children at risk for postoperative thrombosis (161,163). This may be exacerbated by iron deficiency anemia which makes red cells more ridged and less deformable as well as by dehydration (153,168,185). Endothelial injury and dysfunction: occurs from turbulent flow on endothelial surfaces as well as from vessel wall endothelial damage from insertion and persistence of central lines and catheters. Endothelial injury exposes tissue factor and subendothelial collagen stimulating platelet aggregation and coagulation at the site of injury. Inflammation and bloodstream infection Inflammation and the potential of blood stream infection are further risk factors for thrombosis in many children with heart disease. In addition, tissue factor has been documented to become accessible via activated monocytes or endothelial cells through cytokine production during inflammation or when stimulated by sepsis (174,186). In recent clinical studies, sepsis was associated with increased thrombus formation especially in the presence of an indwelling central venous catheter (188,189,190). Children with heart disease especially infants with single-ventricle disease appear to be particularly vulnerable, often carrying these derangements well beyond the perioperative period. Consequence of Significant Thrombi in Children and Adolescents with Cyanotic Heart Disease Children and Adolescents with cyanotic heart disease are at particular risk of devastating complications from both venous as well as arterial thrombi. Occlusion of systemic-to-pulmonary shunts or Fontan circuits are both lethal without immediate intervention. Post-catheterization arterial or venous thrombotic occlusions may make performance of further essential diagnostic and/or therapeutic cardiac catheterizations difficult or impossible. Occlusion of large veins of the upper body may make it impossible for a single-ventricle patient to go on to a bidirectional cavopulmonary anastomosis or to a Fontan palliation, rendering transplant the only long-term option. Common Thrombotic Complications in Congenital Heart Disease: Prevention, Diagnosis, and Treatment Table 75. Recently there has been much interest in the novel oral anticoagulants dabigatran, a direct thrombin inhibitor, and the factor Xa inhibitors rivaroxaban, apixaban, and edoxaban. The advantage of the novel anticoagulants is that routine laboratory monitory is not required. The disadvantage is that there currently are no specific antidotes for major bleeding complications in children. Neonates and infants are at particular risk (164,191), because of an immature coagulation system that has a low capacity to inhibit clot formation and a high resistance to anticoagulation. In addition, the vessel to catheter diameter ratio is lower in neonates and infants compared to older children and adolescents making clotting more likely. Overall, there is a paucity of information on the true scope of thrombotic complications in children and adolescents after cardiac surgery. Two retrospective studies and two prospective studies have reviewed thrombotic incidence and risk factors in cardiovascular surgical populations. Deep venous thrombosis associated with indwelling central lines was the most common type and site of thrombus. Serious complications occurred in 28% of patients with thrombi and were associated with thrombus location (intrathoracic, the highest risk), symptoms, and partial/full occlusion. The only significant clinical risk factor for thrombosis was single-ventricle physiology. The mortality rate was significantly higher in patients with thrombosis (15%) compared with those without (0%). Significantly, this study demonstrated that elevated preoperative hypercoagulability biomarkers (namely the P. The diagnosis may be equally elusive since thrombi may be missed by routine imaging (echocardiography or ultrasound) unless there is a high degree of suspicion and vigilance in imaging. Areas notorious for difficult-to-image thrombi are Fontan baffles/conduits (193) and right ventricular outflow tract patches/conduits, both of which are often seated anteriorly, limiting noninvasive imaging. Always be suspicious of thrombi in high-risk patients and proceed to imaging studies as clinically indicated. Treat arterial, venous, and intracardiac thrombi as per established guidelines following for persistence, resolution, extension, and/or new thrombosis (194,195). Infants and children with an initial thrombus are more likely to develop subsequent thrombi. Prior to discharge develop and document a follow-up plan for each patient with thrombosis with clearly documented site of thrombosis, outpatient medication, therapeutic goal, and follow-up appointments. There is a paucity of data on the efficacy of prophylactic anticoagulation in preventing early postoperative thrombosis. It is unclear, however, whether subgroups exist where prophylaxis may be beneficial (i. In this study there was a high early risk of thrombotic complications over time after each of the three stages followed by a lower but constant risk up to 45 weeks after stage I, 3. In a smaller prospective study Todd-Tzanetos (167) reported a 31% incidence of perioperative venous thrombosis among 16 patients with single- ventricle heart disease across all three stages of palliation when evaluated by serial venous Doppler. Patients who developed thrombi had poorer preoperative ventricular function ( p = 0. There is less information on the effectiveness of antiplatelet agents in preventing postoperative thrombosis other than in the aortopulmonary shunt population, see below (198). Risk factors for shunt thrombosis include dehydration, pleural/chylous effusions, shunt distortion, and bloodstream infection. In a 2011 review of 206 neonates undergoing shunt placement as part of their initial palliation, 20 (9. Shunt malfunction was secondary to thrombosis (33%), distortion (38%), combination of thrombosis and distortion (19%), and indeterminate (10%) (188). Complete or near-complete thrombosis of an aortopulmonary shunt is a medical emergency requiring prompt recognition, diagnosis, and treatment. Maneuvers to increase systemic blood pressure thereby increasing shunt flow (phenylephrine, epinephrine). Maximize oxygen delivery and minimize oxygen consumption (intubation, mechanical ventilation, muscle paralysis). Occlusion or near-occlusion must be treated expeditiously with intravascular stenting, manual shunt manipulation, or shunt revisions.