New options for anticoagulation in congenital and pediatric acquired heart disease

Commonly used pediatric anticoagulants include unfractionated heparin, low molecular weight heparin, and vitamin K antagonists. Their use in pediatrics continues to be challenging secondary to modes of administration, less predictable pharmacokinetics, and complex drug-dietary interactions. Newer agents, notably factor Xa inhibitors and direct thrombin inhibitors, may offer solutions to some of these challenges although there are potential pitfalls since these medications have not been extensively studied within the pediatric patient population to date. This article serves to review the current established anticoagulants used in pediatrics, specifically among patients with congenital and acquired heart disease, explore several new clinical trials for use of factor Xa inhibitors and direct thrombin inhibitors in pediatrics, and discuss the future role of these new agents in children with heart disease.