Absence Of Anticoagulation Research Articles

Left atrial appendage closure in patients with atrial fibrillation and haemodialysis: outcomes from an international, multicentric registry

Abstract Background Atrial fibrillation (AF) patients receiving haemodialysis (HD) face increased bleeding risks, so the net benefit of stroke prophylaxis by oral anticoagulation (OAC) is ill defined. Left atrial appendage closure (LAAC) might serve as a suitable alternative to OAC for stroke prevention in this high-risk cohort. Objective To determine the safety and clinical efficacy of LAAC in HD patients with AF. Methods In an international multi-center (n=9) registry, the clinical details were compiled from all HD+AF patients who underwent LAAC. Results The cohort included 147 patients: age 72.6 ± 10.4 yrs, 73% male, CHA2DS2-VASc 4.5 ± 1.5, HAS-BLED 4.7 ± 1.2, prior stroke/TIA 22,5%, prior major bleed 57,8%. The pre-LAAC anticoagulation regimen was heterogeneous with a wide array of at least 12 different combinations of medications utilized. A total of 149 procedures were performed and LAAC was successful in 98% (146 of 149), with a median procedure time of 43 (30-66) minutes. The most common device was Watchman (61%), followed by Amulet (23,3%). The rate of major complications was 5,4% (8), same as the rate of minor complications (5,4%), leading to an overall complication rate of 10,7% (16/149) including one fatal bleed the day after implantation, 4 (2.7%) cardiac tamponades of which 3 were treated with pericardiocentesis and one surgery, and 2 device dislodgements requiring percutaneous retrieval followed by successful reimplantation. Most patients were discharged on DAPT (61,6%). At a median of 61 days follow-up, imaging was performed in 83% of patients, revealing: only 2 (1.7%) peri-device leaks ≥5 mm, and no DRT. Subsequently, anticoagulation was shifted to SAPT so that SAPT emerged as the predominant anticoagulation regimen representing 165,9 patient years (py) of usage followed by DAPT (41,8 py). Over the follow-up of 222,9 py, the incidence of ischemic stroke was 0,9% per year (2 strokes in total), reflecting an 88% relative risk reduction (p<0,001) compared with the calculated stroke rate of 7,4% for patients with a similar CHA2DS2VASc score and no anticoagulation. Similarly, the rate of major bleeding events (defined as BARC score ≥3) was 4,5% per year, signifying a 55% relative risk reduction (p=0,023) compared to the expected rate of patients on VKA therapy, based on a comparable HAS-BLED score. Event tough time on SAPT was nearly four times longer than on DAPT, the number of major bleeding events was similar (SAPT: 5; DAPT: 4). Conclusion In light of these findings LAAO emerges as a promising solution for this unique patient cohort. By mitigating the risks of both bleeding complications associated with anticoagulation and the threat of stroke in the absence of anticoagulation, LAAO represents a well-balanced and effective therapeutic strategy for these individuals. However, the procedural complication rate was elevated compared to that observed in other LAAC cohorts, and requires further study.

Ischemic stroke risk factors not included in the CHADS-VASC score in patients with non-valvular atrial fibrillation.

In patients with atrial fibrillation, the CHA2DS2-VASC score guides stroke prevention using anticoagulants, but it is an imperfect score. Other potential risk factors such as renal failure, the type of atrial fibrillation, active smoking, cancer, sleep apnea or systemic inflammation have less well been investigated. To assess the impact of these factors on ischemic stroke risk in patients with non-valvular atrial fibrillation. On a population of 248 patients (124 patients with acute ischemic stroke and 124 controls), we performed a logistic regression to assess the impact of multiple non-classic risk factors for the prediction of acute ischemic stroke. Their impact on mortality was assessed by performing a survival analysis. A high CHA2DS2-VASc score (OR 1.75; 95% CI 1.13-2.70; p = 0.032), treatment with anticoagulants (OR 0.19; 95% CI 0.07-0.51; p < 0.001) and permanent atrial fibrillation (OR 6.31; 95% CI 2.46-16.19; p < 0.001) were independently associated with acute ischemic stroke. Renal failure and chronic obstructive pulmonary disease predicted a higher mortality. After adjusting for age, sex, the CHA2DS2-VASc score and the use of anticoagulants, the only risk factor predictive for acute ischemic stroke was the permanent type of AF (OR: 8.0 [95% CI 2.5-25.5], p < 0.001). The CHA2DS2-VASc score, the absence of anticoagulants and the permanent type of atrial fibrillation were the main predictive factors for the occurrence of acute ischemic stroke. Larger studies are necessary for conclusive results about other factors.

Post traumatic cerebral sinovenous thrombosis in children: A retrospective and multicenter study.

Cerebral sinovenous thrombosis (CSVT) is a rare but life-threatening condition in the pediatric population and there is no pediatric guidelines regarding anticoagulation for post traumatic CSVT. This study aims to describe a cohort of children with post traumatic CSVT and the use of anticoagulant therapy in this population. A multicenter retrospective study. Patients admitted with post traumatic CSVT in the six participating Pediatric Intensive Care Unit were included. Overall, 29 patients (median age 8.2 years [IQR 4.8-14.6], n=22 (76%) males) were included in the study (Table1). CSVT was observed within the first 24h after admission for a half of the patients (n=14, 50%). Anticoagulation was initiated in 18 patients (62%). No patient received thrombolytic therapy or endovascular treatment. The presence of epidural hematoma was associated with the absence of anticoagulation (n=0 versus n=10, p=0.003). One patient (3%) died of extracranial injury (not related with adverse event of anticoagulation) and in survivors, median Pediatric Overall Performance Category Outcome (POPC) score at discharge from PICU was 2 [IQR 2-4] (i.e., mild disability). Regarding the outcomes of patients, we found no association according to the anticoagulation status (p=1). Overall, 23 patients (79%) had a follow-up cerebral imaging with a median delay of 42 days [IQR 6-63] after admission. CSVT was still seen in 9 patients (31%). We found no difference regarding the persistence of CSVT between patients according to the anticoagulation status (p=0.36). The median duration of anticoagulant treatment was 58 days [IQR 44-91] and one patient (3%) experienced adverse event related to anticoagulation. There were minimal adverse events in patients with post traumatic CSVT treated with therapeutic anticoagulation. However, the effect of anticoagulation on outcomes needs to be confirmed in further studies.

The Comparison of Platelet‐Rich Plasma Versus Injectable Platelet Rich Fibrin in Facial Skin Rejuvenation

Background/Objective. Platelet‐rich plasma (PRP) has a widespread use in various indications including dermatological conditions. Injectable platelet‐rich fibrin on the other hand is prepared without anticoagulants and seems to have a sustained action. This study aimed to compare PRP and PRF injection treatments for facial skin rejuvenation in terms of efficacy, patient satisfaction, and side effects. Patients and Methods. Patients who received facial intradermal injections of PRP or PRF for skin rejuvenation were included in this study. Patients received three injections one month apart and evaluated at follow‐up visits for cosmetic results using a high‐resolution UVA‐light video camera and a surface evaluation software at three regions (frontal, nasolabial, and canthal) as well as for patient satisfaction and side effects. Results. A significant marginal superiority of PRF over PRP was only evident for some canthal cosmetic parameters (canthal smoothness and wrinkles); however, the two groups did not differ in terms of other cosmetic regional parameters. For canthal smoothness, the difference was significant at three months. The two groups did not differ in terms of side effects, pain, and patient satisfaction. Conclusion. This study obtained slightly better outcomes with PRF injections when compared to PRP for facial rejuvenation only at canthal region and only at three months, which disappeared later during the treatment. PRF may represent a viable alternative to PRP for that indication owing to its easier preparation, absence of anticoagulants, and possibly its sustained effect. Further large studies are warranted.

Clinical Predictors of Mortality and Heart Failure Hospitalization in Patients With Severe Tricuspid Regurgitation

BackgroundThere is an incomplete understanding of the predictors of morbidity and mortality in patients with severe tricuspid regurgitation (TR). This study sought to identify key risk factors for all-cause mortality and heart failure (HF) hospitalization among patients with severe TR. MethodsPatients with severe TR were identified from 2 centers, Oregon Health & Science University and Abrazo Health, from January 01, 2016 to December 31, 2018. Patients with any concomitant severe valvular diseases or prior valvular intervention were excluded. Multivariable regression was utilized to identify demographic, clinical, and echocardiographic variables independently associated with all-cause mortality or HF hospitalization. Results435 patients with severe TR were followed for a median of 2.8 years. The mean age of the population was 66.9 ± 18.5 years and 58% were female. All-cause mortality was identified in 20.5% of the population. Of the cohort, 35.4% of patients were hospitalized for HF. Isolated tricuspid valve intervention was performed in 2.5% of patients. Independent predictors of all-cause mortality included history of solid tumor (odds ratio [OR] 6.6, 95% confidence interval [CI] 2.1-19.1, p = 0.001), history of peripheral artery disease (OR 3.5, 95% CI 1.2-9.4, p = 0.013), and elevated international normalized ratio in the absence of anticoagulation (OR 1.9, 95% CI 1.2-3.2, p = 0.008). Predictors of HF hospitalization included history of diabetes mellitus (OR 2.2, 95% CI 1.1-4.0, p = 0.014) and history of reduced left ventricular ejection fraction (OR 5.7, 95% CI 2.9-11.7, p < 0.0001). ConclusionsSevere untreated TR is associated with high mortality and frequent HF hospitalizations. Understanding predictors of these outcomes is important to identify patients who may benefit from early tricuspid valve intervention to help improve outcomes in this patient population.

Anticoagulants decrease the risk for catheter-related venous thrombosis in patients with chronic intestinal failure: A long-term cohort study.

BackgroundCatheter‐related venous thrombosis (CRVT) is a severe complication of home parental nutrition. Although primary prevention of CRVT is crucial, there is no consensus on anticoagulant use to prevent this adversity. The aim was to compare CRVT risk in patients with chronic intestinal failure (CIF) in the presence or absence of anticoagulants, and to identify CRVT risk factors.MethodsThis retrospective cohort study comprised adult patients with CIF with a central venous access device (CVAD) between 2010 and 2020 that were treated at our national CIF referral center. Analyses were performed at a CVAD level.ResultsOverall, 1188 CVADs in 389 patients were included (540.800 CVAD days). Anticoagulants were used in 403 CVADs. In total, 137 CRVTs occurred in 98 patients, resulting in 0.25 CRVTs/1000 CVAD days (95% CI, 0.22–0.29). Anticoagulant use was associated with a decreased CRVT risk (odds ratio [OR] = 0.53; 95% CI, 0.31–0.89; P = 0.02). Left‐sided CVAD insertion (OR = 2.00; 95% CI, 1.36–2.94), a history of venous thrombosis (OR = 1.73; 95% CI, 1.05–2.84), and a shorter period postinsertion (OR = 0.78; 95% CI, 0.65–0.92) were independently associated with an increased CRVT risk.ConclusionAnticoagulants decreased the CRVT risk. In addition, we identified left‐sided vein insertion, a history of venous thrombosis, and a shorter period post‐CVAD insertion as CRVT risk factors. Further prospective studies should provide guidance whether prophylactic anticoagulant use, especially in higher‐risk patients with a left‐sided CVAD or a history of venous thrombosis, is justified.

Anticoagulants decrease the risk for catheter-related thrombosis in home parenteral nutrition patients

Rationale: Catheter-related venous thrombosis (CRVT) is a severe complication of home parental nutrition (HPN). Although primary prevention of CRVT is crucial, there is no consensus on anticoagulant use to prevent these adversities. The most recent updated ESPEN guidelines for chronical intestinal failure does not recommend thrombosis prophylaxis as primary prevention. The aim of this study was to compare CRVT risk in HPN patients in the presence or absence of anticoagulants, and to identify risk factors for CRVTs.

INTRACTABLE COUGH CAUSING SPONTANEOUS RECTUS SHEATH HEMATOMA

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cough is a physiologic mechanism that causes airways to be cleared of foreign materials and excess secretions. The violent expiration is associated with rapid contraction of the diaphragm and the abdominal wall muscles leading to an increase in intraabdominal pressures. Longstanding untreated cough can lead to spontaneous abdominal wall hematomas. (1) CASE PRESENTATION: A 65-year-old gentleman presented to the Emergency Room with right lower quadrant abdominal pain of one-week duration. He had no past medical history. He was noted to have a persistent intractable cough for one month. Prior to the onset of cough, he had one week of loss of taste and smell, nasal congestion, nasal discharge and postnasal drip. According to him, the cough was so bad that he felt like he was going to burst. Although his family insisted, he did not get the cough evaluated. His vital signs were stable. Physical examination showed ecchymosis, a small palpable mass and tenderness in the right lower quadrant. Lung exam was unremarkable. Lab work unremarkable with normal platelet count and coagulation profile. Computed Tomography (CT) of the abdomen/pelvis showed an intramuscular vascular mass of 9 cm within the right rectus abdominis suggestive of a hematoma which was managed conservatively. Of note, he was not on any anticoagulants. On 1 month follow-up, he had complete resolution of abdominal pain, ecchymosis, mass and tenderness in the right lower quadrant. However, he continued to have a persistent cough for which he was referred to pulmonology. He visited the pulmonary clinic after 5 months of referral. At that time, he had become dependent on over-the-counter (OTC) oral decongestants and antihistamines. He had no reflux symptoms, no allergies, was a lifetime nonsmoker, employed as a banker and had a Labrador for 11 years. CT chest showed normal lung parenchyma. Pulmonary function tests revealed features of mild obstructive lung disease. His OTC medications were stopped and he was given a course of oral prednisone along with fluticasone and azelastine nasal spray with dramatic improvement and complete resolution of cough. DISCUSSION: Sustained cough results in over contraction and overstretching of abdominal muscles with an increase in intra-abdominal pressures. (2) Vigorous coughing plausibly generates shear forces high enough to tear superior and inferior epigastric vessels along the posterior aspect of long rectus muscle which results in rectus sheath hematomas. Almost 29% of spontaneous rectus sheath hematomas are the result of sustained cough the risk of which increases with the use of anticoagulants. (3) While these hematomas are conservatively managed, patients should undergo a thorough evaluation and treatment of cough to prevent its recurrence. CONCLUSIONS: This case highlights the potential of sustained vigorous cough to cause abdominal wall hematomas even in the absence of anticoagulants. REFERENCE #1: 1. Fuller RW, Jackson DM. Physiology and treatment of cough. Thorax. 1990;45(6):425-430. doi:10.1136/thx.45.6.425 REFERENCE #2: 2. Kodama K, Takase Y, Yamamoto H, Noda T. Cough-induced internal oblique hematoma. J Emerg Trauma Shock. 2013;6(2):132-134. doi:10.4103/0974-2700.110789 REFERENCE #3: 3. Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine (Baltimore). 2006;85(2):105-110. doi:10.1097/01.md.0000216818.13067.5a DISCLOSURES: No relevant relationships by Fady Jamous, source=Web Response No relevant relationships by Swaminathan Perinkulam Sathyanarayanan, source=Web Response

Aspirin Versus Clopidogrel as Single Antithrombotic Therapy After Transcatheter Aortic Valve Replacement: Insight From the OCEAN-TAVI Registry

Current guidelines recommend dual antiplatelet therapy for the first 1 to 6 months after transcatheter aortic valve replacement (TAVR); however, recent studies have reported better outcomes with single antiplatelet therapy than with dual antiplatelet therapy in the occurrence of bleeding events, while not increasing thrombotic events. However, no data exist about optimal single antiplatelet therapy following TAVR. Patients who underwent TAVR between October 2013 and May 2017 were enrolled from the OCEAN-TAVI Japanese multicenter registry (Optimized Transcatheter Valvular Intervention). After excluding 1759 patients, 829 who received aspirin (100 mg/d) or clopidogrel (75 mg/d) after TAVR were identified and stratified according to the presence or absence of anticoagulation. Propensity score matching was performed to adjust the baseline characteristics between the aspirin and clopidogrel groups. Outcomes of interest were all-cause and cardiovascular deaths, stroke, and life-threatening or major bleeding within 2 years following TAVR. After propensity score matching, 98 and 157 pairs of patients without and with anticoagulation, respectively, were identified. Falsification end points of pneumonia, urinary tract infection, and hip fracture were evaluated, and their rates were not different between groups. All-cause deaths were not statistically different between the groups in patients with (aspirin, 17.5%; clopidogrel, 11.1%; log-rank P=0.07) and without (aspirin, 29.6%; clopidogrel, 20.1%; log-rank P=0.15) anticoagulation at 2 years post-TAVR, whereas clopidogrel was associated with a lower cardiovascular mortality at 2 years in patients with (aspirin, 8.5%; clopidogrel, 2.7%; log-rank P=0.03) and without (aspirin, 18.0%; clopidogrel, 5.2%; log-rank P=0.02) anticoagulation. We demonstrated that clopidogrel monotherapy was associated with a lower incidence of cardiovascular death compared with aspirin monotherapy during the 2-year follow-up after TAVR regardless of anticoagulation use. URL: https://upload.umin.ac.jp; Unique identifier: UMIN000020423.

In-vivo Evaluation of a Novel Surgical Heart Valve Prosthesis Designed to Be Durable, Anticoagulant-free and Silent

Objective: Heart valves prostheses still face limitations: reoperations with tissue valves or lifelong anticoagulation with mechanical valves. The Triflo valve, a tri-leaflet valve made of high-resistant bio-inert materials, aimed at overcoming these limitations. We studied safety and performance in a chronic sheep model. Methods: The Triflo valve (size 21mm) was implanted in two models: 90 days in aortic position (n=7) and 70 days in pulmonary position (n=4). In the pulmonary model, On-X valves (n=2) were used as control. After 7 days of low-molecular-weight heparin, no further anticoagulant was administered. Serial blood testing, echocardiography, acoustic measurements, fluoroscopy and autopsy were done. Results: The Triflo valve demonstrated excellent surgical handling. There were one aborted procedure and one early death in the aortic study, both unrelated to the prosthesis. All other sheep (n=9) recovered fast and remained in excellent clinical condition until the scheduled sacrifice. In aortic position, we observed low peak and mean gradients (8.1+/-2.7 and 4.8+/-1.9 mmHg), high effective orifice area (2.3+/-0.2 cm2), no valvular regurgitation, and perfect left ventricular function. At explantation, the surface of all Triflo valves was clean, without any valve thrombosis. All major organs were free from thrombo-embolic (TE) damage. In pulmonary position, leaflet mobility of all valves remained also normal and no TE-damage was found in the lungs. Hematological parameters were stable without any sign of hemolysis. On-X valves in pulmonary position functioned well, but generated significantly louder acoustic signals (p < 0.05). Conclusions: The Triflo valve showed safety and effectiveness in both aortic and pulmonary position. These favorable in-vivo results, with excellent hemodynamic behavior and stable long-term function even in the absence of anticoagulants, demonstrate that this valve can proceed to first-in-human studies.

Proximal deep vein thrombosis and pulmonary embolism in COVID-19 patients: a systematic review and meta-analysis

BackgroundCOVID-19 appears to be associated with a high risk of venous thromboembolism (VTE). We aimed to systematically review and meta-analyze the risk of clinically relevant VTE in patients hospitalized for COVID-19.MethodsThis meta-analysis included original articles in English published from January 1st, 2020 to June 15th, 2020 in Pubmed/MEDLINE, Embase, Web of science, and Cochrane. Outcomes were major VTE, defined as any objectively diagnosed pulmonary embolism (PE) and/or proximal deep vein thrombosis (DVT). Primary analysis estimated the risk of VTE, stratified by acutely and critically ill inpatients. Secondary analyses explored the separate risk of proximal DVT and of PE; the risk of major VTE stratified by screening and by type of anticoagulation.ResultsIn 33 studies (n = 4009 inpatients) with heterogeneous thrombotic risk factors, VTE incidence was 9% (95%CI 5–13%, I2 = 92.5) overall, and 21% (95%CI 14–28%, I2 = 87.6%) for patients hospitalized in the ICU. Proximal lower limb DVT incidence was 3% (95%CI 1–5%, I2 = 87.0%) and 8% (95%CI 3–14%, I2 = 87.6%), respectively. PE incidence was 8% (95%CI 4–13%, I2 = 92.1%) and 17% (95%CI 11–25%, I2 = 89.3%), respectively. Screening and absence of anticoagulation were associated with a higher VTE incidence. When restricting to medically ill inpatients, the VTE incidence was 2% (95%CI 0–6%).ConclusionsThe risk of major VTE among COVID-19 inpatients is high but varies greatly with severity of the disease. These findings reinforce the need for the use of thromboprophylaxis in all COVID-19 inpatients and for clinical trials testing different thromboprophylaxis regimens in subgroups of COVID-19 inpatients.Trial registrationThe review protocol was registered in PROSPERO International Prospective Register of Systematic Reviews (CRD42020193369).

Propofol Safety in Anticoagulated and Nonanticoagulated Patients During Extracorporeal Membrane Oxygenation.

Sedation management during extracorporeal membrane oxygenation(ECMO) is a common challenge encountered by treating intensivists. Data about the safety of propofol use during ECMO has been contradictory. We aimed to investigate associated risks of propofol use on oxygenator lifespan and to explore the effect of propofol use on oxygenator membranes when therapeutic anticoagulation was omitted. Adult respiratory ECMO patients who received propofol were retrospectively compared with those who did not, and outcomes were assessed by means of duration of oxygenator functionality before requiring an exchange, and number of exchanges during propofol use and/or ECMO support. Out of the 63patients included in the analysis, 46%received propofol during ECMO as part of sedation regimen. The use of propofol was not found to be associated with an increased incidence of oxygenator failure when compared with cohorts who did not receive propofol (21% propofol arm vs. 6% control, p = 0.13). When analyzed for anticoagulation omission effects, propofol did not increase the risk of oxygenator failure (p = 0.63). The only predictor that statistically predicted the risk of oxygenator failure was development of heparin-induced thrombocytopenia (HIT) during ECMO. The results of this study further support the previously reported safety of propofol utilization during respiratory ECMO even in the absence of anticoagulation.

Association between prosthesis geometry and leaflet thrombosis following transcatheter aortic valve replacement

Abstract Introduction Leaflet thrombosis (LT) following transcatheter aortic valve replacement (TAVR) is a recognised condition. The association between prosthesis geometry [expansion, implant depth and commissural alignment (CA)] and LT is unclear. Methods Patients that received intra-annular TAVR prosthesis and post-procedure computed tomography (CT) with a 320-slice scanner were included. LT, defined as at least 50% restricted leaflet motion, was assessed with a dedicated 3Mensio workstation by two experienced CT readers. Prosthesis expansion was defined as actual divided by expected prosthesis area as a percentage of expected area whilst eccentricity was [(maximum diameter − minimum diameter) / maximum diameter) × 100%], both measured at prosthesis inflow, annulus and outflow. Implant depth was the average distance between prosthesis inflow and nadir of each cusp. CA was the average angle between each native and prosthesis leaflet coaptations. Significant commissural misalignment (CMA) was defined as CA greater than 30 degrees. To exclude anticoagulation bias, similar analysis was also performed in the cohort of non-anticoagulated patients. Results 117 patients were included; the prevalence of LT was 13.7% [13/93 cases (14.0%) of Lotus valves and 3/24 cases (12.5%) of Sapien 3 valves]. Baseline demographics (age, STS score, cardiac risk factors) and procedural characteristics (access site, post-dilation, repositioning) were similar in both groups. None of the patients with LT were discharged on anticoagulation therapy (0.0% vs 22.8%, p&amp;lt;0.01). There were no differences in actual prosthesis area, perimeter or eccentricity at the three prosthesis levels. Patients with LT had reduced annulus expansion (89.3±9.8% vs 94.6±8.3%, p=0.02), lower implant depth (6.9±1.5mm vs 4.9±1.5mm, p&amp;lt;0.01) and more significant CMA (81.3% vs 48.5%, p=0.02). These findings were similar in patients that were not anticoagulated (94/117 patients). Conclusion Patients with LT had reduced annulus expansion, lower implant depth and greater CMA. These findings were not affected by presence or absence of anticoagulation. These factors may be important considerations during procedural planning for TAVR. Graphical abstract Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Health and Medical Research Council (NHMRC). National Heart Foundation (NHF) Australia.

Standalone totally thoracoscopic left appendage exclusion for stroke prevention and absolute contraindication to anticoagulation: a referral centre experience

Abstract Introduction Left atrial appendage is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). ESC guidelines state as class IIB indication left appendage exclusion in patients with contraindication to oral anticoagulation. Here we give our contribute to the issue of safety and efficacy of standalone totally thoracoscopic left appendage exclusion (TT-LAE) for stroke prevention in patients with contraindication to oral anticoagulant or at risk of life threatening hemorrhage on antiplatelet therapy: a large single Centre experience. Materials and methods 60 patients with non valvular AF and contraindication to oral anticoagulation (25 cerebral hemorrhages,8 GI bleeding, 18 non cerebral/Gi bleeding requiring multiple transfusions, 2 myelodysplastic syndrome, 7 anatomy unsuitable for percutaneous closure, 75%male, patients age ranged 53–87 years,mean CHAD-VASC 6.4,mean HASBLED range 4.7, type of AF permanent 76.6%, 23.4% longstanding persistent), underwent stand alone totally thoracoscopic appendage exclusion. All patinets enrolled after Heart Team evaluation, were screened preoperatively with 3D CT scan, transesophageal echocardiography, spirometry and cerebrovascuar doppler ultrasound. Intraoperative appendage exclusion were guided and confirmed by transesophageal echo. All patients were not on anticoagulation nor antiplatelet therapy at the time of surgery, at discharge and at control visit. Follow up (range 35–1 months) included outpatient visit and CT scan or TEE at 3–6-12 month in all patients to document LAA exclusion. Perioperative mortality and early and late morbidity in addition to freedom from neurological events at follow up were analyzed by chart evaluation and full outpatient neurological examination including including the Questionnaire for Verifying Stroke Free Status (QVSFS) as validated screening tool. Results Mean duration of surgery “skin to skin” was 52.4 minutes; all patients were extubated shortly after the procedure. There were no deaths nor need for blood transfusion or pulmonary procedure related morbidities, only three casea of pericarditis treated with colchicine till complete resolution was documented. On CT or TEE follow up 100% of patients had complete exclusion of the left appendage with minimal residual stumps and no dislodgement of the clip detected. Freedom from neurological events in all patients was documented in absence of anticoagulation or antiplatelet regime from the time of surgery to the time of the follow up visit and questionnaire filling. Conclusion Standalone totally thoracoscopic left appendage clipping is a safe and effective procedure for stroke prevention in patients with permanent and longstanding persistent atrial fibrillation with contraindication to oral anticoagulation. Longer follow up and an European registry are needed to, possibly, confirm this preliminary results. Funding Acknowledgement Type of funding source: None

Characteristic imaging features of neurovascular involvement in primary Sneddon's syndrome: an analysis of 12 cases.

Sneddon's syndrome is a cerebrocutaneous non-inflammatory progressive distal arteriopathy, characterized by livedo racemosa, stroke, and neuropsychiatric symptoms. Our aim was to highlight the characteristic neuroimaging features of Sneddon's syndrome that might be helpful to clinicians in timely diagnosis of this entity. Twelve patients (median age 49years, 11 female) with primary Sneddon's syndrome, diagnosed in last 10years, were analyzed from the perspective of magnetic resonance imaging (MRI) features. In addition, a novel pseudoangiomatosis score was defined for grading angiographic abnormalities (range: 0 to 6). Median interval from the onset of neurological symptoms to diagnosis was 6years. Presentation was with acute stroke in 5, seizures in 3, dementia/speech problems in 2, seizures plus cognitive dysfunction in 1, and chronic progressive hemiparesis in 1. All patients had a typical lesion pattern on MRI. This included multiple (median 3) cortical-subcortical supratentorial and cerebellar non-territorial infarcts, accompanied by multifocal cerebral atrophy. Of note, large territorial infarcts due to cerebral parent artery occlusion, an embolic pattern with multi-territorial involvement on diffusion-weighted imaging, small vessel disease features like severe white matter involvement or lacunar infarcts, and cerebral hemorrhage in the absence of anticoagulation were not observed. MRI lesion severity was not correlated with angiographic arteriopathy severity, clinical stage, or presentation symptoms. Sneddon's syndrome is characterized by highly typical clinico-radiological features. Brain MRI has diagnostic value. By knowing the characteristics of the syndrome, misdiagnosis and potentially harmful treatment can be prevented in this entity that might pose a diagnostic challenge.

ADL-dependency, D-Dimers, LDH and absence of anticoagulation are independently associated with one-month mortality in older inpatients with Covid-19.

Background: To assess factors associated with one-month mortality among older inpatients with Covid-19.Results: The mean age was 78 ± 7.8 years, 55.5% were men, CT scan lung damage was observed in 76% of the patients (mild 23%, moderate 38%, extensive 22%, and severe 7%). The mortality rate was 26%. Dependency/Activities of Daily Living (ADL) score ≤ 5/6, D-Dimers, LDH, and no anticoagulation by reference for curative were independently associated with one-month mortality. A score derived from the multivariate model showed good calibration and very good discrimination (Harrell’s C index [95%CI] = 0.83 [0.79-0.87]).Conclusion: ADL-dependency, high serum levels of D-Dimers and LDH and the absence of anticoagulation were independently associated with one-month mortality among older inpatients with Covid-19.Methods: 108 consecutive older inpatients aged 65 and over with Covid-19 confirmed by RT-PCR and/or typical CT chest scan were prospectively included in a French single-centre cohort study from March to April 2020. A systematic geriatric assessment was performed. Covariates were lymphocyte count, serum levels of albumin, C-Reactive Protein, D-Dimers and Lactate Dehydrogenase (LDH), anticoagulation level, and exposure to the hydroxychloroquine and azithromycin combined therapy. Cox uni- and multivariate proportional-hazard regressions were performed to identify predictors of one-month mortality.

Utility of routine follow-up imaging in patients with small paraflacine and/or paratentorial hemorrhages

ObjectiveImaging follow-up for acute intracranial hemorrhage has followed the same protocols despite differences in clinical progression and outcome associated with bleed in different compartments. We evaluated isolated, small parafalcine and paratentorial subdural hemorrhages to determine the necessity of routine imaging follow up. MethodsWe conducted a retrospective review of all patients presenting to the Emergency Department who were found to have an isolated parafalcine and/or paratentorial subdural hemorrhage, and obtained follow up imaging over the course of 3 years. Subsequent imaging was reviewed to assess for changes in hemorrhage size and the average number of studies performed; clinical data was reviewed for changes in patient status and any intervention if performed. Results95 patients were identified with isolated parafalcine and/or paratentorial hemorrhage that were evaluated with multiple follow-up imaging studies. The average initial subdural hemorrhage thickness was 3.5 mm, with all smaller than 1 cm. The average number of subsequent imaging studies performed was 2.7. All patients received follow up imaging despite remaining neurologically stable. 96 % of the patients had stable to decreased size off hemorrhage on follow up exams. The remaining 4% had a slight increase on the second imaging study but, stabilized without any intervention. Anticoagulation use had no correlation with increase on subsequent imaging. ConclusionSmall isolated parafalcine and/or paratentorial hemorrhage in a neurologically stable patient and absence of anticoagulation does not require scheduled routine follow-up imaging.

Tensile strength, growth factor content and proliferation activities for two platelet concentrates of platelet-rich fibrin and concentrated growth factor

Background/purposePlatelet-rich fibrin (PRF) can be obtained by centrifuging fresh blood in the absence of anticoagulants. Varying the centrifugation speeds may produce tougher and richer concentrated growth factors (CGF). This study examines tensile strength, growth factor content, and the potential of CGF and PRF in promoting periodontal cell proliferation. Materials and methodsBlood (40 mL/subject) was collected from 44 healthy subjects. PRF and CGF were prepared by centrifuging at 3000 rpm and switching speeds ranging within 3000 rpm, respectively. Fibrin strip was prepared and its tensile strength was measured. Transforming growth factor beta 1 (TGF-β1), platelet-derived growth factor BB (PDGF-BB), and epidermal growth factor (EGF) in the residual serum and fibrin clots were determined by enzyme-linked immunosorbent assay, and their effects on the proliferation of hFOB1.19 osteoblasts and human gingival fibroblasts were evaluated by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide assay. ResultsCompared with PRF, tensile strength of CGF was significantly higher. Concentrations and amounts of PDGF-BB and EGF in CGF were significantly higher than those in PRF. Osteoblast number was significantly higher in the cultures with fetal bovine serum (FBS, 10%) and with PRF or CGF fibrin clots (5%, 10%, and 50%) compared to that without FBS. Moreover, osteoblast number in CGF, regardless of the preparation of 10% and 50%, was significantly greater than that in PRF. Similar findings were also observed for gingival fibroblasts among the various subjects. ConclusionVarying centrifugation speeds can modify the tensile strength and biological activities of platelet fibrin clots.

427 Utilisation of 320-slice Computed Tomography (CT) to Determine Association Between Prosthesis Geometry and Leaflet Thrombosis (LT) following Transcatheter Aortic Valve Replacement (TAVR)

CT-defined LT following TAVR is a recognised condition. The association between CT-assessed prosthesis geometry and LT is unclear. 117 patients that received intra-annular TAVR prosthesis and post-procedure TAVR-CT were included. LT was defined as hypo-attenuated leaflet-thickening with ≥50% restricted leaflet motion on 4-dimensional CT. Prosthesis expansion [(actual prosthesis area)/(expected prosthesis area)x100%] and eccentricity [(max–min diameter)/(max diameter)x100%] was measured at prosthesis inflow, annulus and outflow. Implant depth was the average distance between inflow and nadir of cusps. Commissural alignment was the average angle between native and prosthesis leaflet commissures; significant commissural misalignment was defined as commissural alignment >30°. Prevalence of LT was 13.7% [13/93 cases (14.0%) of Lotus and 3/24 cases (12.5%) of Sapien 3 valves]. Baseline (age, STS-score, cardiac risk factors) and procedural (access-site, post-dilation, valve-repositioning) characteristics were similar in both groups. None of the patients with LT were on anticoagulation therapy (0.0% vs 22.8%,p<0.01). There were no differences in actual prosthesis area, perimeter or eccentricity at separate prosthesis levels. Patients with LT had reduced annulus expansion (89.3±9.8% vs 94.6±8.3%,p=0.02), lower implant depth (6.9±1.5mm vs 4.9±1.5mm,p<0.01) and more significant commissural misalignment (81.3% vs 48.5%,p=0.02). To exclude anticoagulation bias, analysis was repeated only in non-anticoagulated patients (94/117 patients) and the previous significant findings were similar in this cohort. Patients with LT had reduced annulus expansion, lower implant depth and greater commissural misalignment on CT assessment. These findings were not affected by presence or absence of anticoagulation. These factors may be important considerations during pre-procedural TAVR planning.

Medical Management of Retained Inferior Vena Cava Filters

Background Venous thromboembolism (VTE) is a common and often fatal medical event. VTE management often includes inferior vena cava filter (IVCF) placement when anticoagulation fails or is contraindicated. Controversial indications for IVCF placement include adjunctive treatment for deep vein thrombosis (DVT) without pulmonary embolism (PE) and VTE prophylaxis for high-risk patients (Deyoung and Minocha, 2016; Ho et al., 2019). Numerous device-associated mechanical and medical complications have been described (Ayad et al., 2019) and guidelines recommend early retrieval (Morales et al., 2013). There is limited evidence, however, to guide anticoagulation practices while IVCFs are retained. We aimed to characterize IVCF placement, retrieval, and interim medical management at our institution. Methods Retrospective chart review was performed for all patients who underwent IVCF placement at the University of Virginia Medical Center from January to December 2016. Data were collected from time of IVCF placement until either IVCF removal or 18 months post-placement, whichever occurred first. Indication for IVCF placement, baseline patient characteristics, IVCF complications, anticoagulation regimens, and bleeding and clotting events were identified. Baseline characteristics were recorded for all patients. Patients who did not survive the admission during which the IVCF was placed, underwent IVCF removal prior to discharge, or lacked adequate outpatient records during the period of IVCF retention were excluded from the event analysis cohort. Results IVCFs were placed in 140 patients during the study period (Table 1). A majority of patients were admitted to a surgical service, frequently following trauma (49 patients, 35%). IVCFs were placed for several indications, most commonly diagnosed VTE with a contraindication to anticoagulation (70 patients, 50%) and prophylaxis for high risk of VTE (44 patients, 31%). By the end of the study period, 88 patients (63%) had confirmed IVCF removal while 35 patients (25%) retained the IVCF for a clinical consideration. 33 patients (24%) lacking an adequately documented period of outpatient IVCF retention were excluded from the event analysis. Of the 107 patients included in the event analysis cohort, 76 patients (71%) underwent IVCF removal. Removal occurred &gt;60 days after placement in 82% of these cases and median time to removal was 95 days (Table 2). Outpatient follow up and anticoagulation management varied widely, though 75 patients (70%) received a therapeutic dose anticoagulant during the period of IVCF retention and only 15 patients (14%) were not exposed to either a prophylactic or therapeutic dose anticoagulant. 50 patients (47%) had at least one regimen change. Bleeding and/or clotting events occurred for 15 patients (14%, Table 3). All 8 bleeding events occurred during anticoagulant exposure. Patients were exposed to a therapeutic dose anticoagulant during 4 of the 6 observed major or clinically relevant non-major bleeding events. Of the 12 observed clotting events, 8 occurred in the absence of anticoagulation. Isolated DVT was the most common clotting event (8 events in 7 patients, 7%) and IVCF thrombus was observed in 2 patients (2%). Bleeding and clotting events were observed in patients with a wide range of indications for IVCF placement, including patients whose IVCFs were placed prophylactically. Conclusions The optimal medical management of retained IVCFs is uncertain. This retrospective study characterizes IVCF placement, removal, and interim medical management for a diverse patient population at a single institution. Outpatient follow up varied widely and anticoagulant exposure during IVCF retention was inconsistent. Despite considerable anticoagulant exposure across the cohort, major bleeding events were infrequent. Thrombotic events, often in the absence of anticoagulation and potentially preventable, were more common. Standardization of medical management during IVCF retention would likely benefit this heterogeneous patient population at high risk of both bleeding and thrombotic complications. Ongoing statistical modeling for the study cohort will seek to inform anticoagulant decision making by assessing for associations between anticoagulant exposure and these clinical events. Disclosures No relevant conflicts of interest to declare.