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Pre-operative management of anticoagulation therapy pathway for paediatric patients with congenital heart disease

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To provide a consistent and safe approach to the preoperative management of anticoagulation therapy for paediatric patients with congenital heart disease (CHD)


Applies to all pre-operative paediatric patients with congenital heart disease receiving anticoagulation therapy.


All health care professionals providing pre-operative care to paediatric patients with congenital heart disease receiving anticoagulation therapy should be familiar with this guideline

Pre-operative anti-coagulation pathway

Anticoagulation pathway additional notes

Aortic Valve Prosthesis

Low Risk 
A standard bi-leaflet aortic valve prosthesis with no additional risk is considered low risk.

High Risk 
An increased risk of thrombosis may result from a number of factors, including:

  • Previous thromboembolism
  • Left ventricular dysfunction
  • Hypercoagulable conditions
  • Atrial fibrillation

Therapeutic low molecular weight heparin (Enoxaparin) should be administered for these situations as per the pathway for mechanical mitral valve prosthesis.

Low Molecular Weight Heparin (LMWH) For bridging to cardiac catheter/surgery


<2 months of age  
>2 months of age 
1.5mg/kg twice daily
1mg/kg twice daily

Anti Xa level

3-4 hours post dose 
Order ‘control of heparin – child’ on trakcare 
Target range 0.5-1 i.u/ml 
Guideline for adjusting dose: Anticoagulation Therapy for Post Op Cardiac Patients in PICU 
If level sub therapeutic (low) adjust dose, re prescribe enoxaparin for current time and 12 hourly thereafter (do not wait until next dose is due).


Do not administer Enoxaparin via insuflon. 
Doses of <0.1ml in volume to be diluted up to 0.1ml with 0.9% sodium chloride

INR Level

If INR is >2 when checked on day -1, inform the consultant cardiac anaesthetist and the cardiology consultant on call, so a decision for reversal can be made. 
If reversal is appropriate:

  • Seek haematology advice
  • As per BNF for Children: Vitamin K 30micrograms/kg IV or oral (max 1mg) If given orally, use Konakion MM Paediatric

Dental surgery in children receiving warfarin therapy

Follow: Anti Thrombotic Protocol


Baglin TP & Rose R E. (1998) Guidelines on oral anticoagulation, 3rd edition, British Journal of Haematology, vol 101, pp 374-387

British National Formulary for Children 

Begg C. (2015) Anticoagulation Therapy for Post Op Cardiac Patients in PICU: NHSGGC

Chalmers E. (2014) Anti-thrombotic Protocol: NHSGGC

Chan A, David M, Massicotte P. (2009) Cincinnati Children’s Hospital Medical Center Best Evidence Statement Management of warfarin therapy

Douketis, J.D. (2011) Perioperative management of patients who are receiving Warfarin therapy: an evidence-based and practical approach. Blood. Vol 17, no 19, pp 5044-5049

Hirsh J, Guyatt G, Albers G, Harrington R & Schunemann H. (2008) Executive summary : American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, 8th Edition, Chest, vol 133, 71S-10S

Motz,R., Wessel,A., Ruschewski,W. & Bursch,J. (1999) Reduced frequency of occlusion of aorto-pulmonary shunts in infants receiving aspirin. Cardiol. Young. 9, 474-477

Palaniswamy C, Selvaraj DR  (2011) Periprocedural bridging anticoagulation : current perspectives. American Journal of Therapeutics. Vol 18 pp 89-94

Tweddell,J.S. (2007) Aspirin: a treatment for the headache of shunt dependent pulmonary blood flow and parallel circulation? Circulation 116, 236-237

Editorial Information

Last reviewed: 23 July 2020

Next review: 23 July 2023

Author(s): Alison Buller

Version: 2

Approved By: Paediatric & Neonatal Clinical Risk & Effectiveness Committee