Anticoagulation Therapy and the Risk of Peri-operative Brain Injury in Neonates with Congenital Heart Disease

Abstract Objective There is considerable variability in anticoagulation use in neonates with transposition of great arteries (TGA) and single ventricle physiology (SVP) for secondary stroke prevention and primary cardiovascular indications. Leveraging cross-centre differences in anticoagulation use, we compared the risk of new post-operative brain injury in neonates with TGA and SVP treated with anticoagulation relative to untreated neonates. Methods Two-centre observational cohort study of 118 term-born neonates with TGA (n=83) and SVP (n=35), undergoing cardiopulmonary bypass surgery and pre- and post-operative brain MRI. Anticoagulation and antiplatelet therapy details were obtained. MRIs were scored for stroke, white matter injury and hemorrhage. New post-operative injury was compared between neonates with and without anticoagulation for the two-centre cohort, and subsequently stratified by cardiac lesion type and anticoagulation indication. Results 36/118(29%) neonates received anticoagulation: 11(30%) for pre-operative stroke, 20(56%) for pre-operative peripheral/intracardiac thrombus, 5(14%) for Blalock-Taussig-shunt. 5/36(14%) neonates treated with anticoagulation also received antiplatelet therapy. While no differences were identified for the two-centre cohort or for TGA neonates separately, significantly more new post-operative brain injury, particularly stroke, was found in SVP neonates with compared to without anticoagulation (31vs5%). In neonates with pre-operative stroke, new subdural hemorrhage (36vs0%) was more frequent in neonates with anticoagulation compared to without. Conclusions In our TGA and SVP cohort, anticoagulation for pre-operative stroke, pre-operative thrombus and/or Blalock-Taussig-shunt does not have the anticipated benefit of preventing new peri-operative brain injury. These findings indicate the critical need for rigorous randomized trials on the safety and effectiveness of anticoagulation therapy in this population.