Use of Intravesical Tranexamic Acid for Severe Macroscopic Hematuria in a Biventricular Assist Device-Implanted Child

Mechanical circulatory support (MCS) is increasingly used in children who have end-stage heart failure as a bridge to heart transplantation in children who have end-stage heart failure. Antithrombotic drugs are the cornerstone of the treatment of patients who have been monitored with a ventricular assist device (VAD). As expected, bleeding is the most common complication in these patients. In cases where continuity of extracorporeal support is required, this complication poses a problem in terms of continuation of the treatment. Applying local procoagulant agents into the bleeding focus will provide great convenience for such patients.

Acetylsalicylic acid, warfarin, enoxaparin, and heparin are the most commonly used antithrombotic agents in patients receiving extracorporeal therapy. In the study conducted by Bhatt et al,¹ among the antithrombotic agents, warfarin was found to be the riskiest agent in terms of hematuria. Hematuria is a common complication following implementation of a left ventricular assist device (LVAD).^2,3 It has been reported in the literature that anticoagulant treatment was interrupted and cystoscopic interventions were performed for bleeding control.³ Although intravesical tranexamic acid was used in a case with ataxia telangiectasia⁴ and in an adult patient group presenting to the emergency department with gross hematuria,⁴ as far as we know, such an application is not available in the patient group receiving anticoagulant treatment due to LVAD.

Tranexamic acid (TXA) is a frequently preferred agent in acute major bleeding. Although it only has an intravenous and oral form, topical, inhaler, and intravesical applications have also been successful.^5-7 There is limited literature data on intravesical use in pediatric patients, and it was tried in a patient diagnosed with ataxia-telangiectasia due to macroscopic hematuria, but no success was achieved.² We wanted to share our experience with intravesical TXA application for macroscopic hematuria in a patient with VAD and receiving anticoagulant treatment.

A 10-year-old girl with diagnosed dilated cardiomyopathy was admitted to the pediatric intensive care unit (PICU) after LVAD implantation and together with veno-arterial (femoral vein to pulmonary artery) extracorporeal membrane oxygenation (ECMO) support due to the development of right heart failure. Otherwise, the patient was supported by a biventricular assist device (BiVAD). She was then taken off ECMO, and biventricular support with Levitronix Centrimag was started after a clot was observed in the set on the 3rd day of ECMO. Heparin infusion was started after BiVAD implantation. Macroscopic hematuria occurred on the 7th day of follow-up. Leukocyte esterase and nitrite were negative on urinalysis and the urine culture came back negative. Fibrin clots and an increase in wall thickness were detected in the bladder wall on urinary ultrasonography. It was thought that the hematuria of the patient developed due to the urinary catheter’s mechanical trauma. We could not control her macroscopic hematuria and decreased hemoglobin levels despite heparin dose adjustment and obtained normal coagulation parameters. Then, we decided to apply intravesical TXA therapy to provide local bleeding control. After administered of 1 g TXA intravesically with 250 mL saline every 6 hours for 48 hours, the patient's urine color returned to normal. Twenty-four hours after the termination of intravesical TXA treatment, macroscopic hematuria recurred. After this, 4 more doses were administered and the urine color returned completely to normal. The patient, who was anticoagulated with simultaneous heparin and then warfarin, did not experience hematuria after the second TXA treatment. The patient was extubated on the 19th day. After 21 days of PICU follow-up, she was transferred to the service. The patient, who continued her treatment in the ward for 33 days, was discharged with full mobilization.

TXA is a synthetic lysine analog that inhibits plasmin activation by binding to the lysine-binding region of plasminogen. It directly affects without being metabolized in the body. Therefore, we think that the intravesical administration of TXA can improve severe macroscopic hematuria in patients who must receive anticoagulants.