Thrombolysis in children with congenital heart disease

Thrombolysis has been investigated for some 60 years and during this period new innovations have incrementally lead to new effective treatment not necessarily optimized in the pediatric population. Increased thrombolytic efficacy is primarily supported by large clinical trials in the adult patient population. These innovations have been facilitated by the mechanistic understanding of individual reactions that comprise the inflammatory, and both the coagulation and fibrinolytic cascades but only recently has the interplay between these systems come under closer scrutiny. Specifically, differences in the circulating concentrations of any of the components, even just one, may appreciably alter or influence the overall effect on how the system(s) react and interact and respond to therapeutics. Correspondingly, attempts to determine the type and dose for therapeutic intervention may not be as straightforward as basing doses on adult constitution, particularly patient mass. On the other hand, determination of the concentration of every component in every patient, young and old, is currently unfeasible. Appropriate treatment strategies are therefore required. With respect to therapy in children, use of thrombolytics in this patient population is summarized herein and subdivided between catheter and non-catheter related thrombosis. There is hesitance on the part of clinicians to use thrombolytics in children but it is an emerging concept. Since the concentrations of plasma constituents of both cascades differ significantly in children compared to adults, rigorous pediatric-directed clinical studies might dispel hesitancy and indicate that there is considerable room for improved use of therapeutic thrombolytic strategies in this patient population.