Aggressive Anticoagulation Therapy Research Articles

Investigation the Role of Calcium and Vitamin D3 And Some Biochemical Parameters in Patients with Renal Failure of Renal Failure

Coronavirus Disease 2019 is a primarily respiratory illness that can cause thrombotic disorders. Elevation of D-dimer is a potential biomarker for poor prognosis in COVID-19, though optimal cutoff value for D-dimer to predict mortality has not yet been established. This study aims to assess the accuracy of admission D-dimer in the prognosis of COVID-19 and to establish the optimal cutoff D-dimer value to predict hospital mortality. Clinical and laboratory parameters and outcomes of confirmed COVID-19 cases admitted to four hospitals in Kathmandu were retrospectively analyzed. Admitted COVID-19 cases with recorded D-dimer and definitive outcomes were included consecutively. D-dimer was measured using immunofluorescence assay and reported in Fibrinogen Equivalent Unit (μg/ml). The receiver operating characteristic curve was used to determine the accuracy of D-dimer in predicting mortality, and to calculate the optimal cutoff value, based on which patients were divided into two groups and predictive value of D-dimer for mortality was measured. D-dimer levels were higher in COVID-19 patients and were related with markers of inflammation, and after treatments, D-dimer levels decreased which was synchronous with hsCRP levels in patients with good clinical prognosis. Also, the low correlation between Padua VTE score and D-dimer levels weakened the role of D-dimer in the prediction of thrombosis.The abnormal changes of D-dimer and inflammatory factors suggest that aggressive anticoagulant therapy might be needed.

Risk factors for intracardiac thrombus in peripartum cardiomyopathy: a retrospective study in China.

Peripartum cardiomyopathy (PPCM) are more vulnerable to intracardiac thrombus than other types of cardiomyopathies, although explicit anticoagulant strategy is not sure. Too aggressive anticoagulation therapy can lead to severe bleeding events. Hence, we want to construct a risk stratification model for intracardiac thrombus in PPCM patients. A total of 159 suspected PPCM cases were initially screened, whereas 123 confirmed cases were enrolled in the final analysis. The study population was randomly assigned as derivation group (N=83) and validation group (N=40). The derivation cohort was utilized to develop the model, and the validation cohort was used to internal validate the discriminatory ability of the model. Formation of intracardiac thrombus was detected in 22 patients. After adjusted by multivariable logistic regression analysis, left ventricle ejection fraction (LVEF, OR 0.772, 95% CI 0.665-0.897, P=0.001), haemoglobin levels (OR 1.050, 95% CI 1.003-1.099, P=0.038), and thrombocyte counts (OR 1.018, 95% CI 1.006-1.029, P=0.003) were identified as risk factors independently associated with intracardiac thrombus and were finally included in the tentative risk stratification model with a C-indexes of 0.916 (95% CI: 0.850-0.982, P<0.001). A score of ≤7 was regarded as low risk, 8-10 defined intermediate risk, and ≥11 defined high risk in our model. Internal validation showed good discriminatory ability of the model with a C-indexes of 0.790 (95% CI: 0.644-0.936, P=0.017). In our retrospective study, impaired LVEF, elevated haemoglobin levels, and high thrombocyte counts were regarded as independent risk factors for intracardiac thrombus in PPCM. A risk stratification model derived from these risk factors, which was economic and easily applicable in clinical practice, could rapidly and accurately identify PPCM patients with higher-risk of intracardiac thrombus.

Spontaneous thrombus formation in native aortic root in patients with hypoplastic left heart syndrome: clinical presentation, treatment, and outcomes.

We report a neonate who presented with spontaneous thrombus formation in the native aortic root after Norwood palliation for hypoplastic left heart syndrome. Thrombus formation led to myocardial ischaemia due to decreased coronary blood flow with electrocardiographic signs of ischaemia and elevated cardiac enzymes. Aggressive thrombolysis and anticoagulation therapy were major contributors to successful outcome.

Abstract 10806: The Association of Hemoglobin Drop with In-Hospital Outcomes in Covid-19 Patients

Background: Bleeding events can be critical in hospitalized patients with COVID-19, especially those with aggressive anticoagulation therapy. Objective: We aimed to investigate whether hemoglobin drop associated with increased risk of acute kidney injury (AKI) and in-hospital mortality among patients with COVID-19. Methods: This retrospective study was conducted by review of the medical records of 6,683 patients with laboratory confirmed COVID-19 hospitalized in the Mount Sinai Health system between March 1 st , 2020 and March 30 th 2021. We compared patients with and without hemoglobin drop &gt;3g/dL during hospitalization within a week after admissions, using inverse probability treatment weighted analysis (IPTW). Outcomes of interest were in-hospital mortality and AKI which was defined as increased of creatine 1.5 times or 0.3mg/dL. Results: Of the 6,683 patients admitted due to COVID-19, 750 (11.2%) presented with a marked hemoglobin drop. Patients with hemoglobin drop were more likely to receive therapeutic anticoagulation within two days after admissions. Patients with hemoglobin drop had higher crude in-hospital mortality (40.8% versus 20.0%, P&lt;0.001) as well as AKI (51.4% versus 23.9%, P&lt;0.001) compared to those without. IPTW analysis showed that hemoglobin drop was associated with higher in-hospital mortality compared to those without (odds ratio (OR) [95% confidential interval (CI)]: 2.21 [1.54-2.88], P&lt;0.001) as well as AKI (OR [95% CI]: 2.79 [2.08-3.73], P&lt;0.001). Finally, the smooth spline curve showed the association of hemoglobin drop and adjusted odds ratio for in-hospital mortality, which reflected the association of hemoglobin drop and in-hospital mortality (Figure). Conclusions: Hemoglobin drop during COVID-19 related hospitalizations was associated with a higher risk of AKI and in-hospital mortality. Figure Legends: Smooth spline curve of the association of hemoglobin drop and adjusted odds ratio of in-hospital mortality.

Outcomes of Radial Versus Femoral Approach in Patients with St Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Abstract Aim of the work To compare transradial and transfemoral approaches in 1ry and rescue PCI for STEMI. Methods This prospective observational study was done at Alexandria University Hospital and International Cardiac Center from January 2020 to August 2020 by recruiting every patient had met our inclusion criteria (the third universal definition of MI) admitted to the coronary care unit after doing primary or rescue PCI 200 patients were involved. Exclusion criteria were (Thrombophilia and thrombocytopenia, known hematological abnormalities, and patients with known sever peripheral vascular disease. Randomization made by a computer-generated program into two equal parallel groups that were randomly assigned to either Radial access approach or femoral access approach for primary or rescue PCI. Chest pain to time of first medical contact (FMC), and the procedural time were computed. Coronary angiography and PCI procedure were described including materials used and the intra-procedure complications. MACE (Major Adverse Cardiac Events) or other hemodynamic complications were documented. All the patients were contacted for follow up to 6 months after the procedure by interviewing with the patients via telephone or the responsible physician to determine the outcomes procedure. Results The distribution of demographic variables and risk factors were similar among 200 patients in the radial and femoral groups. There had been significant differences between the groups concerning the primary end point MACE after 6 months in favor of radial group patients with p value (0.004), there was significant deference between the two studied groups concerning the total bleeding complication with higher risk in femoral group 11% compared to radial group 3% with P value (0.02). Despite the nearly equal mean time from pain to FMC (9.01 hours in radial group and 9.2 hours in femoral group), the total procedural time was significantly longer in radial group compared to femoral group with (p value 0.037). However the rate of non-culprit vessel revascularsation was significantly higher in radial group 17% compared to 6% in femoral group with p value of (0.015). In-hospital stay was significantly shorter in the radial group patients P value (0.02). Conclusion Transradial approach is safe, and effective with a high procedural success rate as the transfemoral approach but with lower risk for bleeding vascular complications and other access site complications as hematoma especially for patients where aggressive antiplatelet and anticoagulation therapy is needed, or patients who are expected to suffer from access site complications as those who need rescue PCI. Transradial approach has major additional advantages of decreasing the incidence of MACE compared to transfemoral approach. Transradial approach has another advantages of decreasing the in hospital stay.

The association of hemoglobin drop with in-hospital outcomes in COVID-19 patients.

BackgroundBleeding events can be critical in hospitalized patients with COVID-19, especially those with aggressive anticoagulation therapy.AimWe aimed to investigate whether hemoglobin drop was associated with increased risk of acute kidney injury (AKI) and in-hospital mortality among patients with COVID-19.DesignRetrospective cohort studyMethodsThis retrospective study was conducted by review of the medical records of 6,683 patients with laboratory confirmed COVID-19 hospitalized in the Mount Sinai Health system between March 1st, 2020 and March 30th 2021. We compared patients with and without hemoglobin drop >3 g/dL during hospitalization within a week after admissions, using inverse probability treatment weighted analysis (IPTW). Outcomes of interest were in-hospital mortality and AKI which was defined as serum creatine change of 0.3 mg/dL increase or 1.5 times baseline.ResultsOf the 6,683 patients admitted due to COVID-19, 750 (11.2%) patients presented with a marked hemoglobin drop. Patients with hemoglobin drop were more likely to receive therapeutic anticoagulation within two days after admissions. Patients with hemoglobin drop had higher crude in-hospital mortality (40.8% versus 20.0%, P < 0.001) as well as AKI (51.4% versus 23.9%, P < 0.001) compared to those without. IPTW analysis showed that hemoglobin drop was associated with higher in-hospital mortality compared to those without (odds ratio (OR) [95% confidential interval (CI)]: 2.21 [1.54-2.88], P < 0.001) as well as AKI (OR [95% CI]: 2.79 [2.08-3.73], P < 0.001).ConclusionsHemoglobin drop during COVID-19 related hospitalizations was associated with a higher risk of AKI and in-hospital mortality.

New method of hepatic artery reconstruction after its injury or resection.

e16221 Background: Restoration the hepatic arterial blood flow is required in traumatic or iatrogenic damage to the hepatic artery and its branches, as well as in the planned resection of the hepatic artery with subsequent reconstruction. Various ways have been proposed to solve this problem: ligation of the hepatic artery and its branches, which is associated with an extremely high mortality rate, reaching 70%, and the need for extensive liver resections; portal vein arteriolization; transposition of the splenic artery with its severe complications (heart attack, abscess) or hepatic artery replacement sometimes are not available and imply aggressive anticoagulant therapy, which is often challenging after extensive oncological interventions. Prosthetic vascular grafts are associated with a high risk of infection. We propose replacement of the common hepatic artery defect by transposition of the left gastric artery and end-to-end anastomosis between the proximal end of the left gastric artery and the distal end of the hepatic artery. Methods: The proposed method was applied in 7 cancer patients - 4 cases of iatrogenic damage to the common hepatic artery in lymph node dissection of the hepatoduodenal ligament and 3 resection of the common hepatic artery with tumor infiltration. The mean age of patients was 53 years. 2 patients had surgery for gastric cancer, 5 - pancreatic cancer. Results: The vascular reconstruction lasted for 17 minutes. No thrombotic complications of the reconstruction area or liver necrosis in the postoperative period were registered. The main advantages of this method were the absence of synthetic materials or deficit blood supply to neighboring organs, and no need for extensive mobilization of the great vessels in other areas (renal artery, abdominal aorta). Conclusions: The proposed method for reconstruction of the hepatic artery allows performing a simple and adequate restoration of the hepatic arterial blood flow, reduced time of the vascular stage of the surgery and reduced incidence of postoperative complications associated with the vascular stage - reduced time of liver ischemia and reduced risk of thrombosis in the reconstruction area.

Use of Low-Molecular-Weight Heparin and Peak anti-Xa Monitoring In Severe SARS-CoV-2 Disease: A Brief Report.

In 2019, a novel coronavirus was identified in Wuhan, China. This strain was classified as a pandemic in early 2020 by the World Health Organization (WHO), rapidly reaching millions of cases worldwide and overwhelming intensive care units. One distinct feature identified in severe SARS-CoV-2 is abnormal and complex coagulation and hematologic abnormalities, including significantly elevated D-dimer and fibrin/fibrinogen values possibly increasing morbidity and mortality in this patient population. Aggressive anticoagulation therapy with appropriate peak anti-Xa level monitoring has produce satisfactory results at our institution. Our intent is to present a case series of our strategy to highlight the benefits of this approach.

Overview of Upper Airway Management During COVID-19 Outbreak: Head and Neck Surgeon's Perspective: Comment.

Overview of Upper Airway Management During COVID-19 Outbreak: Head and Neck Surgeon's Perspective: Comment.

A Comparison of the Incidences of Venous Thromboembolism after Total Hip Arthroplasty between the Direct Anterior Approach and the Direct Lateral Approach, Especially in the Early Period after Introduction of the Direct Anterior Approach.

Objective To compare the incidence of venous thromboembolism (VTE) after total hip arthroplasty (THA) using the direct anterior approach (DAA) with that using the direct lateral approach (DLA). In addition, patient background characteristics and the incidence of VTE were compared between the first half and the latter half of the period after introducing DAA and against DLA. Method This was a retrospective, multicenter study involving 109 patients (116 hips) who had undergone primary unilateral THA. Thirty-six hips underwent THA using DAA and 80 hips underwent THA using DLA. Patient information including sex, age, and preoperative diagnosis was collected. The incidence of VTE was compared between DAA and DLA. Moreover, the patients who underwent THA using DAA were divided into 2 groups (first half and latter half groups), and sex, age, body mass index (BMI), and surgical time were compared between the 2 groups. Moreover, the incidence of VTE was compared among the 3 groups (first half of DAA, latter half of DAA, and DLA). Results The incidence of VTE in the DAA group was significantly higher than that in the DLA group (p=0.014). The incidence of VTE in the first half group was significantly higher than in the latter half group and the DLA group (p=0.035 and p=0.001, respectively), and there was no difference in the incidence of VTE between the latter half group and the DLA group (p=0.923). Surgical time was significantly longer in the first half group than in the latter half group (p=0.046). Conclusions In the first half of the period after introducing the DAA, more VTEs occurred than in the DLA. It may be important to shorten the surgical time in the early stage of introducing the DAA, and aggressive anticoagulation therapy may be required until the surgeon becomes familiar with the procedure.

Management of free-floating thrombus in the arch of the aorta in a case of upper limb ischemia

Floating thrombus in a nonaneurysmal and nonatherosclerotic arch of the aorta is an extremely rare event with potential catastrophic complications. There is a risk of both systemic and cerebral embolization. We present a case of floating thrombus in the arch of the aorta who presented with left upper limb advanced ischemia. Confirmation of the diagnosis was done by computed tomography angiogram. His upper limb symptoms were relieved with thrombectomy, supported by medical line of treatment. For floating thrombus in the arch of the aorta, he was started on aggressive anticoagulation therapy, and there was significant resolution after 4 weeks and complete resolution after 3 months of the treatment. We report our experience with a very rare condition and make a proposal for therapeutic interventions.

Sub-acute anterior myocardial infarction due to the discontinuation of warfarin in a patient with aortic valve prosthesis: what is the best treatment

Acute myocardial infarction (MI) is a common entity in patients due to the atherosclerotic plaque rupture or coronary embolism. We present a patient who had a mechanical aortic valve and was admitted to the hospital for a sub-acute anterior ST elevation myocardial infarction due to the discontinuation of warfarin. In case of persistent thrombus formation despite aggressive antithrombotic and anticoagulant therapy, thrombus aspiration, angioplasty and stenting should be preferred rather than conservative approach.

FRI0473 A Rare but Life-Threatening Presentation of BehÇEt's Disease: Intra-Cardiac Thrombus

BackgroundBackground: Behçet's disease (BD) is a chronic, multisystemic disorder characterized by recurrent oral aphtous ulcers, genital ulcers and ocular inflammation. Vasculitis and thrombotic events are the most important causes of...

Hemolacria in a Patient with Severe Systemic Diseases

Hemolacria is a rare phenomenon of bloody tears caused by various ocular and systemic conditions, as well as psychological, pharmacologic, and idiopathic etiologies. Hemolacria is typically a benign process; however, serious systemic associations can exist. It is predominantly unilateral and self-limiting, but because of limited literature, its prevalence and predilection toward a specific gender, race, or age is not known. An 82-year-old Caucasian male presented for an emergent eye examination with an acute onset of hemolacria of the right eye (OD). Patient medical history was extensive with coronary artery disease, atrial fibrillation, lipidemia, insulin-dependent diabetes, uncontrolled hypertension, and untreated severe renal failure. Before the incident, patient medication included warfarin, 81 mg of aspirin, insulin, glipizide, and blood pressure regime with which the patient was noncompliant. The patient was forwarded to urgent care to address his stage 2 hypertension and referred for a medical evaluation, which included a complete blood count, an International Normalized Ratio, a prothrombin time, and a glycated hemoglobin. Spontaneous resolution of the hemolacria occurred within 24 hr after evaluation and restoration of blood pressure to normal range. Before follow-up, the patient died because of kidney failure. After a review of pertinent laboratory results and literature, the etiology of this patient's hemolacria could be attributed to either uncontrolled hypertension, chronic renal failure, aggressive anticoagulant therapy, and/or diabetes. An extensive literature review of documented etiologies and management is included.

Cardiovascular Biomarkers in ACS: State of the Art 2012

In the setting of an acute coronary syndrome cardiac troponins are well established for the diagnosis of myocardial infarction. In particular, diagnostic protocols using high-sensitivity troponin assays are being recommended for earlier diagnosis of MI by the European Society of Cardiology (ESC) guidelines on the management of ACS without ST segment elevation. In addition to accurate detection of myocardial necrosis, cardiac troponins give complementary information on short- and long-term prognosis and facilitate the identification of patients who derive benefits from a more aggressive anticoagulation and/or early invasive therapy versus conservative therapy. Other cardiac biomarkers may help to improve earlier diagnosis or improve risk stratification. Their role is currently under investigation. The present state-of-the-art paper gives an overview on the role of cardiac troponins including recent recommendations on the use of high-sensitivity assays from the third version of the Joint ESC/ACCF/AHA/WHF infarct definition “Universal MI definition” and the ESC guidelines. In addition, an overview on the role of novel cardiac biomarkers in earlier diagnosis or risk stratification is provided.

Manual aspiration thrombectomy for cerebral venous sinus thrombosis

BackgroundHydration and anticoagulation are the standard of care for cerebral venous sinus thrombosis (CVST) but some patients remain refractory to medical management and warrant more aggressive therapy. Here we present...

Abstract 3070: Assessment of Manual Aspiration Therapy for the Treatment of Sinus Thrombosis

Objective: While hydration and anticoagulation is typically the standard of care for cerebral venous sinus thrombosis, some patients remain refractory to medical management and continue to deteriorate. In these instances a number of more aggressive endovascular techniques have been reported to remove clots and restore blood flow in the venous sinuses. These techniques include direct thrombolysis, angioplasty, and various methods to disrupt and aspirate clot. Here we present the technique of endovascular transvenous manual aspiration thrombectomy (MAT) in five patients. Methods: We reviewed the records of five patients with medically refractory cerebral venous sinus thrombosis who received transvenous MAT. Presentation, technique, and outcome were evaluated. Results: Out of the five cases reviewed presentation included vomiting, dehydration, mental status changes, headaches, and acute motor deficits. On imaging three of the five patients had hemorrhage, edema, and mass effect present before treatment, while two had edema only. All of the patients reviewed were treated with anticoagulation therapy, intravenous heparin or subcutaneous lovenox, for a minimum of 24 hours. However, all of the patients continued to deteriorate despite early and aggressive medical anticoagulation therapy. All of the patients demonstrated rapid and progressive worsening of their neurological exam pre-operatively, including lack of arousal, pathological posturing, and expansion of secondary hemorrhages. This rapid deterioration warranted aggressive intervention, making the patients candidates for endovascular therapy. Direct thrombolysis with tPA was utilized with MAT via a distal access catheter(DAC) in all but one patient in which tPA was not used due to concern for hemorrhage. Aspiration of the superior sagittal sinus, transverse sinuses, straight sinus, and internal jugular were all included in this series. Catheters included the 0.070, 0.057, and 0.044 DAC and the 0.054 Penumbra microcatheter. Revascularization was achieved in all instances. One patient presented and remained neurologically devastated. She died 5 days after treatment. All other patients experienced improvement in their neurological examinations and were eventually discharged from the hospital in stable condition. Conclusions: Endovascular transvenous MAT is a feasible and effective revascularization technique to treat patients with cerebral venous sinus thrombosis.

Invited commentary

Sanchez Munoz-Torrero and the RIETE investigators report that older patients with acute deep vein thrombosis (DVT) have a higher mortality from bleeding than pulmonary embolism (PE) in the first 3 months. Although point estimates are low, their observations may be surprising to most readers. Their findings reaffirm prior observations that major bleeding events from anticoagulation, particularly vitamin K antagonists (VKAs), occur early in the course of therapy. This robust database has provided enormous insight into the outcome of patients with DVT and PE. Most recurrences follow the initial event, that is, patients presenting with PE will have PE as a recurrent event, and those presenting with DVT recur with DVT. That was also the case in these patients. The authors also showed that the diagnosis of DVT carries an early mortality ranging from 6% to 11% in patients ≥60 years of age. The majority of the fatalities that were observed occurred beyond the first week of therapy; therefore, one would assume that the majority of the patients were being treated with a VKA. Two factors on multivariate analysis were found to correlate with fatal PE: chronic lung disease and malignancy. However, eight factors were associated with fatal bleeding: age (upper decades), low body weight, recent major bleeding, renal dysfunction, bilateral DVT, cancer, immobility ≥4 days, and prior venous thromboembolism. Aside from renal dysfunction, low body weight, and recent major bleeding, it is difficult to integrate the bleeding risk factors to modify clinical care. The authors tabulated outcome events by decade of life in Table II. The most impressive discrepancy in mortality occurred in the patients ≥80 years of age, where major/fatal bleeding occurred in 3.6% vs thrombotic events in 1.7%. Eleven percent of this age group died within this 3-month window. It is reasonable to assume that all major bleeding will be clinically apparent and therefore accurately recognized. However, that is not the case with fatal PE. To fulfill the definition of fatal PE, the patients must have experienced an objectively confirmed PE followed by death within 10 days. Therefore, sudden unexplained deaths, which more commonly would occur out of the hospital, would not be recorded as a fatal PE by the authors' definition. As they recognized, the rate of fatal PE may be underestimated. This is not to detract from the value of this report nor the importance of the RIETE registry. The authors observe that in older patients, the risk of fatal bleeding exceeds the risk of fatal PE in patients presenting with acute DVT. Clinicians might assume that less aggressive anticoagulation therapy with VKAs might be indicated. Unfortunately, that cannot be substantiated by observations from a prior randomized trial.1Kearon C. Ginsberg J.S. Kovacs M.J. Anderson D.R. Wells P. Julian J.A. et al.Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism.N Engl J Med. 2003; 349: 631-639Crossref PubMed Scopus (732) Google Scholar It will be interesting to observe how guideline writing committees respond to the important observations reported by the RIETE investigators. Effects of age on the risk of dying from pulmonary embolism or bleeding during treatment of deep vein thrombosisJournal of Vascular SurgeryVol. 54Issue 6PreviewThe risk of patients dying of pulmonary embolism (PE) or bleeding during the treatment of deep vein thrombosis (DVT), and whether these risks are influenced by patient age, has not been thoroughly studied. Full-Text PDF Open Archive

Hematologic Complications Associated with Ventricular Assist Devices (VAD's) in 13 Children From a Single Center

Abstract▪2263▪This icon denotes a clinically relevant abstract Introduction:Mechanical circulatory support systems are used for the treatment of end-stage heart failure. In children, extracorporeal membrane oxygenation systems and centrifugal pumps have been used widely in the past, but are only suitable for short term use and intensive care is obligatory. The Berlin Heart is a VAD which is an extracorporeal pulsatile pneumatic system which can be placed as a bridge to transplant or recovery and allows patients to be mobile and to lead an almost normal life. As with placement of any mechanical device, aggressive anticoagulant therapy is needed due to the increased risk of thrombosis and therefore an increased risk of bleeding associated with the treatment. Here we report the complications seen in 13 children on VAD's from a single institution. Methods:Patient medical records were reviewed to obtain the information on complications and associated coagulation test results. Tests of hemostasis and thrombosis were performed in the authors' CAP accredited Coagulation Laboratory at the Children's Hospital of Michigan. Results:Thirteen children with a mean age of 42 months (range 3 weeks to 13 years) received a VAD as a bridge to transplant between 2006 and 2011. There were 7 males and 6 females, 9 were African American and 5 Caucasian. 10/13 patients were on ECMO for a short duration (1–15days) prior to VAD implantation. The duration of VAD implantation varied from 8 days to 8 months. 9/13 eventually received a heart transplant. Anticoagulation was monitored according to the Berlin Heart protocol. There were 4 deaths, all in infants <7months of age. Complications included thrombosis in 7 patients and bleeding in 5, some of whom had both. Time to thrombotic complications varied from day of implant to 14 days post implantation. Thrombotic complications included fibrin deposits in the VAD to strokes. Assessment of risk factors for thrombosis and bleeding showed that 3/10 patients were heterozygous for the MTHFR gene mutation, 1/10 had a low protein S and 2/10 had a low protein C. 5/7 patients with thrombosis had concurrent systemic or respiratory infections. ATIII was monitored and replaced to keep over 70% per protocol recommendations. Reactive thrombocytosis seen in some patients with thrombosis was associated with an increase in MA on thromboelastography despite administration of antiplatelet drugs. Bleeding complications varied from hemopericardium and intracranial hemorrhage to GI bleeding. Anticoagulation was monitored using thromboelastography with platelet mapping (monitoring antiplatelet agents), PTT and unfractionated (UFH level) or low molecular weight heparin levels respectively; UFH levels were found to be more useful for monitoring heparin anticoagulation than PTT. PTT was found to be low secondary to elevated Factor VIII activity resulting in poor correlation to heparin levels. Thromboelastography Platelet mapping assays were used to monitor aspirin and platelet ADP receptor antagonists, but did not correlate with traditional whole blood platelet aggregation studies. Conclusions:While thrombosis and bleeding complications are commonly seen in adult patients on VAD's, pediatric data in this population are limited and monitoring for the complications is inadequate. At our institution, infants who received VAD's had a poor outcome, but larger studies are needed to evaluate if there are complications unique to this age group. Current monitoring strategies are not always successful in predicting the occurrence of complications. Defects in fibrinolysis and increased thrombin generation may predispose to thrombotic manifestations. Tests to detect elevated thrombin generation and evaluation of fibrinolysis using modified thromboelastography may be useful to predict an increase in thrombotic potential which may assist us in improving the outcome. Disclosures:No relevant conflicts of interest to declare.

Mechanisms of Bleeding and Approach to Patients With Axial-Flow Left Ventricular Assist Devices

Axial-flow LVADs have become an integral tool in the management of end-stage heart failure. Consequently, nonsurgical bleeding has emerged as a major source of morbidity and mortality in this fragile population. The mechanisms responsible for these adverse events include acquired von Willebrand disease, GI tract angiodysplasia formation, impaired platelet aggregation, and overuse of anticoagulation therapy. Because of ongoing concerns for pump thrombosis and thromboembolic events, the thrombotic/bleeding paradigm has led to a difficult clinical dilemma for those managing patients treated with axial flow LVADs. As the field progresses, advances in the understanding of the pathological mechanisms underlying bleeding/thrombosis risk, careful risk stratification, and potential use of novel anticoagulants will all play a role in the management of the LVAD patient.