We read the study by Niesert et al in a recent edition of the American Journal of Cardiology . The investigators present the first clinical evidence on the use of novel oral anticoagulants (NOACs) in adult congenital heart disease (ACHD). In their study, 55 patients with congenital heart disease were started on NOACs. Median follow-up was 6 months and during this period only one NOAC therapy was stopped as a result of bleeding.
In our institution, we have commenced 13 patients on NOACs either for thromboprophylaxis in arrhythmias (10 patients) and Fontan circulation (2 patients) or treatment of thromboembolic disease (1 patient). The underlying congenital heart lesions are listed in Table 1 . Median duration of anticoagulation with an NOAC was 570 days. Six patients were treated with a direct factor Xa inhibitor (rivaroxaban: n = 5 and apixaban: n = 1) and 7 patients with a direct thrombin inhibitor (dabigatran). In our patients, we noted a higher rate of side effects: 2 patients taking dabigatran reported gastrointestinal symptoms necessitating change from NOAC to warfarin and 1 patient on rivaroxaban suffered from bleeding from a Hickmann line and menorrhagia although this resolved.
| Diagnosis | Number of patients | Indication for anti-coagulation | NOAC | Side effects |
|---|---|---|---|---|
| Severe/complex | ||||
| Pulmonary atresia, VSD, MAPCAs | 1 | Arrhythmia – atrial fibrillation | Dabigatran | Abdominal discomfort & diarrhoea |
| Pulmonary atresia, VSD, MAPCAs | 1 | Arrhythmia – SVT/re-entrant tachycardia | Dabigatran | – |
| ccTGA | 1 | Arrhythmia – atrial flutter | Dabigatran | – |
| ccTGA | 1 | Arrhythmia – atrial flutter | Dabigatran | Dyspepsia |
| Double inlet left ventricle | 1 | Arrhythmia – atrial tachycardia | Rivaroxaban | – |
| Double inlet left ventricle, post-Fontan | 1 | Fontan circulation | Rivaroxaban | Migraines |
| Tetralogy of Fallot, pulmonary atresia | 1 | Arrhythmia – atrial flutter | Rivaroxaban | Menorrhagia & bleeding from Hickman line |
| Tricuspid atresia, post-Fontan | 1 | Atrial arrhythmias & Fontan circulation | Apixaban | – |
| Moderate | ||||
| Pulmonary stenosis | 1 | Arrhythmia – atrial flutter | Rivaroxaban | – |
| Pulmonary stenosis | 1 | Arrhythmia – atrial fibrillation | Dabigatran | – |
| Inferior sinus venosus defect | 1 | Arrhythmia – atrial fibrillation | Dabigatran | – |
| Secundum ASD with pulmonary hypertension | 1 | Treatment of thromboembolic disease – previous pulmonary emboli; factor VII & XII deficiency | Rivaroxaban | – |
| Simple | ||||
| VSD | 1 | Arrhythmia – atrial flutter | Dabigatran | – |
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