The management of antithrombotic therapy in patients undergoing endoscopic surgery for benign prostatic hyperplasia (BPH) remains challenging due to competing risks of thromboembolism and perioperative bleeding. This meta-analysis evaluated perioperative outcomes among patients undergoing endoscopic prostate procedures while continuing antiplatelet (APT) or anticoagulant (AC) therapy compared with patients not receiving antithrombotic treatment. Literature search was conducted on 17th September 2025 including PubMed, Medline, Embase, and Scopus database, to identify comparative studies evaluating perioperative outcomes of endoscopic prostate procedures in patients on versus off APT/AC therapy were identified. Data were pooled using random-effects models to estimate mean differences (MD) or odds ratios (OR) with 95% confidence intervals (CI). Fifteen studies comprising 6091 patients (1900 on APT/AC, 4191 controls) were included. Operative time, postoperative hemoglobin decrease, catheterization duration, and continuous bladder irrigation time were comparable between groups across all surgical modalities. However, bleeding-related complications were significantly more frequent among APT/AC users undergoing transurethral resection of the prostate (TURP) (OR 1.90, 95% CI 1.05-3.41, p = 0.03) and enucleation (OR 2.91, 95% CI 1.71-4.93, p < 0.0001), particularly in the AC subgroup (OR 4.80, p = 0.0002). Enucleation also carried higher odds of bleeding requiring surgical hemostasis (OR 3.69, 95% CI 1.73-7.84, p = 0.0007) and acute urinary retention (OR 1.36, 95% CI 1.04-1.77, p = 0.02) among antithrombotic users. Conversely, photoselective vaporization (PVP) demonstrated comparable rates of transfusion, hemostasis, and urinary complications regardless of APT/AC therapy. Hospital stay was marginally longer after TURP and PVP among APT/AC users (p < 0.05). Continuation of antithrombotic therapy during PVP appears safe, with perioperative outcomes comparable to those of non-antithrombotic patients. Conversely, its ongoing use-especially AC-significantly increases bleeding risks following TURP and enucleation. PVP may therefore represent the preferred modality for high-risk patients requiring uninterrupted antithrombotic therapy. Clinical decision-making should balance individual thromboembolic risk against anticipated bleeding risk, with multidisciplinary input when appropriate.

A focused literature review assessed whether starting therapeutic anticoagulation (AC) during or soon after hospitalisation for sepsis-induced new-onset atrial fibrillation (AF) affects stroke or bleeding risk. Four observational studies were identified. None demonstrated a significant reduction in stroke risk with AC, and one large study found a paradoxical increase in stroke among patients taking anticoagulants. Bleeding risk was not consistently increased, and one study reported reduced mortality with AC. Overall, current evidence does not support the routine use of AC for stroke prevention in patients with sepsis-induced new-onset AF. A randomised controlled trial is needed to clarify the role of AC in this population.

ABSTRACT Background Little is known about the familiarity and implementation of anticoagulation (AC) stewardship on a global scale. Therefore, we aimed to identify current AC stewardship patterns globally. Methods An international survey was electronically distributed to individuals involved with AC as a practitioner, researcher, or administrator between June and September 2024. Results A total of 985 responses (790 United States [U.S.]/195 non‐U.S.) representing 65 countries/regions and 50 U.S. states. Most respondents were physicians (51.9%) or pharmacists (24.2%). 93.7% felt AC safety was a serious concern in their country; 90.5% were at least moderately familiar with the term AC stewardship. Only 52.1% have an AC stewardship program for hospitalized, ambulatory, or both patient populations. Most (73.4%) felt their organization does a good job implementing clinical guidelines/protocols for AC stewardship, most commonly for direct oral anticoagulants (DOACs) (37.0%), low molecular weight heparin (LMWH) (36.5%), intravenous unfractionated heparin (IV UFH) (35.9%), and warfarin (34.3%). Most commonly tracked quality measures were AC reversal (38.5%), rates of major bleeding (33.1%), number of international normalized ratios (INRs) &gt; 5 (32.8%), and warfarin time in therapeutic range (31.4%). 82.2% felt their organization's leadership supports AC stewardship with dedicated resources, including dedicated time to complete AC stewardship (51.1%), dedicated AC stewardship positions (56.5%), and financial support for training (36.3%). Conclusion Respondents were familiar with the term AC stewardship, and many organizations have a supportive leadership structure in place for AC stewardship activities, but only half of the respondents felt they have an AC stewardship program in place. Many organizations have not implemented systematic care that includes the use of common clinical guidelines or protocols, and they are not tracking common quality measures. Opportunities exist for further development of AC stewardship services worldwide.

Administering antithrombotic therapy (ATT) in patients with infective endocarditis (IE) involves a complex balance of bleeding and thromboembolic risks. Data on outcomes beyond the acute phase remain limited. This retrospective single-center cohort study had two aims: first, to describe the use of anticoagulation during the acute phase of left-sided IE; and second, to examine, without inferring causality, how anticoagulation, as used in routine care, correlated with in-hospital and long-term clinical outcomes, including mortality and neurological events. ATT in patients with left-sided IE was assessed retrospectively and categorized into two groups: any therapy that included anticoagulation (AC) and therapy without anticoagulation (No-AC). Two observational periods were analyzed: the in-hospital phase and the period beginning 3months after discharge, when 30% of patients had their ATT modified. Vital and neurological status were obtained by standardized telephone follow-up (mean follow-up time 4.2 ± 3.1years). Log-rank tests, Kaplan-Meier estimates, Cox regression analyses, and matched analyses were used to explore correlations between ATT and these outcomes. A total of 504 hospitalized patients (mean age 65 ± 13years, 25% female) with left-sided IE were included. During inpatient treatment, 83 patients (16%) died, with no relevant difference between AC and No-AC groups. During follow-up, patients in the AC group showed a more favorable value for the combined endpoint of mortality and unfavorable neurological function (P = 0.029) that was driven primarily by higher survival rates (P < 0.001). In Cox regression analyses, higher age, CHA₂DS₂-VA score, EuroSCORE II, Staphylococcus aureus bacteremia, and atrial fibrillation were each linked to a higher hazard of the combined endpoint, whereas AC showed an inverse correlation. Consecutive matched analyses yielded similar results. In this retrospective cohort, anticoagulated patients did not show a higher rate of adverse events during hospitalization and had a lower long-term event rate. These findings represent correlations observed in a non-randomized, single-center setting and may partly reflect differences in underlying risk profiles and treatment selection (confounding by indication and residual confounding). Prospective studies are needed to confirm any causal effects and to define more precisely the role of ATT in patients with IE and elevated cardiovascular risk.

Infective endocarditis (IE) carries high morbidity and mortality, largely from neurological complications. The clinical significance of chronic antithrombotic therapy remains uncertain. We assessed whether baseline antithrombotic therapy influences intracranial hemorrhage (ICH) and mortality in left-sided IE. We analyzed a prospective multicenter cohort (2008-2018) including all patients with definite left-sided IE. Patients were classified at diagnosis as receiving no therapy (NT), antiplatelet therapy (APT), anticoagulation (AC), or combined therapy (CAT). The primary outcome was 30-day ICH; secondary outcomes included ischemic stroke, embolic events, major bleeding, and all-cause mortality. Multivariable logistic and Cox regression models adjusted for confounders. Among 3,236 patients, 182 (5.6%) developed ICH, with the highest incidence in CAT (9.5%) and AC (6.8%). Compared with NT, baseline AC was independently associated with a higher frequency of ICH (adjusted risk ratio [aRR] 1.83, 95% CI 1.16-2.91), with the highest risk observed in CAT (aRR 2.45, 95% CI 1.55-3.87). APT was not associated with ICH. Ischemic stroke rates were similar across groups. CAT independently predicted higher 1-year mortality (adjusted hazard ratio [aHR] 1.21, 95% CI 1.02-1.43). Independent factors associated with ICH were Staphylococcus aureus and Candida spp. IE, extracranial embolism, prior cerebrovascular disease, and septic shock. These findings highlight the value of baseline antithrombotic exposure, together with microbiologic etiology and prior cerebrovascular disease, for early neurologic risk stratification at the time of IE diagnosis, informing neuroimaging decisions and multidisciplinary discussions involving infectious diseases specialists, neurologist, and cardiac surgeons among other specialists.

Introduction: Atrial fibrillation (Afib) is a well-known and significant risk factor for acute ischemic stroke (AIS). Various factors are considered when determining if AIS patient with Afib should be discharged on anticoagulation (AC). Not all are appropriate for AC due to various potential contraindications. At a large geographically diverse Stroke Clinical Network (SCN), composed of one large academic certified comprehensive stroke center (CSC), and seven primary stroke centers (PSCs), a retrospective analysis was conducted to evaluate if there were differences in prescribing AC amongst varying demographics. Methods: The Get With the Guidelines® database was queried for stroke patients discharged from the SCN between 2023-2024 to evaluate AC prescription practices for patients with known Afib. Patients were excluded if they had a hemorrhagic stroke, died during hospitalization, discharged to hospice, left against medical advice, or did not have a documented history or new finding of Afib. Additional data elements collected included age, sex, race, mRS at discharge, NIHSS at presentation, disposition, and if discharging facility was a PSC or a CSC. Categorical variables were compared using chi-squared tests to examine relationships between demographic and medical variables and AC prescribing at discharge. Results: A total of 671 AIS patients met the inclusion criteria. Mean age was 75.1 (SD ± 12.2), 53% were male (353/671), and 64.1% were white (430/671). Of the 671, a total of 83.7% (562/671) were discharged on AC, 13.6% (91/671) were discharged without AC but with a documented contraindication, and overall only 2.7% (18/671) were discharged without AC and no documented contraindication. There was a relationship between being discharged without AC and no documented reason from the PSC compared to those discharged from the CSC (3.8% vs. 0.4%; p &lt; 0.01). There were no other statistically significant differences in patient demographics between the two groups. Conclusions: In conclusion, this large SCN demonstrated high rates of appropriate anticoagulation prescribing, with 83.7% of stroke patients with Afib discharged on AC for secondary stroke prevention. Areas of opportunity remain for patients being discharged from the primary stroke centers. Future studies should focus on identifying barriers to appropriate AC prescribing and those patients’ candidacy for left atrial appendage closure

Antiplatelet and Anticoagulation Use and Outcomes Following Chronic Subdural Hematoma Drainage: Systematic Review and Meta-analysis.

Timing for anticoagulation (AC) initiation in atrial fibrillation (AF) after ischemic stroke (IS) remains uncertain. Previous large studies mostly represented high-income countries, with limited representation of severe stroke and low rates of primary outcomes. We aimed to compare AC initiation at different timeframes in a broader and more diverse population. We searched Medline, Embase, Cochrane, and Clinical Trials for trials and observational studies comparing early versus late AC initiation in AF after IS. The study groups were 0-4, 5-14, and ≥ 15days. Primary endpoints were recurrent IS only and intracranial hemorrhage (ICH). Secondary endpoints included systemic embolism, all-cause mortality, and major bleeding. Sensitivity analysis focused on studies using direct oral anticoagulants and timing categories consistent with our classification. Our meta-analysis included 20 studies with 25,884 patients. Mean NIHSS was 6.14, with at least 3204 severe strokes. IS was similar between groups, but the 0-4days strategy ranked first (P-score = 0.92). Sensitivity analysis showed reduced recurrent IS in the 0-4days group versus the ≥ 15days group (RR, 0.28; 95% CI, 0.12-0.65; P < 0.01). ICH had no difference across all periods, 0-4days versus 5-14days (RR, 1.13; 95% CI, 0.58-2.18; P = 0.14); ≥ 15days versus 5-14days (RR, 0.91; 95% CI, 0.50 to 1.65; P = 0.75); and 0-4days versus ≥ 15days (RR, 0.87; 95% CI, 0.49-1.55; P = 0.63). No differences were observed in all secondary outcomes. Initiating AC 0-4days after IS appears safe and may reduce the risk of recurrent stroke without increasing ICH, even in a more diverse population with higher-bleeding risk.

Risk Factors and Consequences of Bleeding Complications after Transcarotid Artery Revascularization in the Vascular Quality Initiative.

Abstract Aim To evaluate thrombosis and bleeding outcomes associated with anticoagulation (AC) and/or antiplatelet (AP) strategies following portal or superior mesenteric vein resection during pancreatectomy. Method A systematic search of MEDLINE, Embase, Scopus, Cochrane, and Web of Science was conducted up to May 2025, following PRISMA guidelines. Studies reporting postoperative AC/AP use and outcomes after pancreatectomy with venous resection were included. Data were extracted on prophylaxis regimen, reconstruction type, thrombosis, and bleeding. Studies were stratified into five groups: AC-only, AP-only, AC+AP, mixed, or no prophylaxis. Due to heterogeneity, a descriptive synthesis was performed. Group comparisons were assessed using chi-square tests. Results Sixty studies comprising 4,664 patients were included. Median thrombosis rates were lowest in the AP-only group (2.3%) and highest in the AC+AP group (15.4%, p &amp;lt; 0.001). AC-only strategies showed a moderate thrombosis rate (9.6%). Bleeding complications were low (range 3.5–6.1%) across all groups, with no significant difference (p = 0.18). Higher thrombosis rates were consistently seen in patients undergoing segmental venous resection with interposition grafts, especially synthetic or allogeneic. In contrast, primary suture or patch repairs were associated with lower thrombosis risk. The elevated thrombosis in the AC+AP-group likely reflects its selective use in complex reconstructions and high-risk patients, along with intensified surveillance detecting more symptomatic and asymptomatic thromboses. Variability in surveillance protocols and outcome definitions limited direct comparisons. Conclusions No strategy proved clearly superior. Prophylaxis should be tailored to resection strategy, reconstruction type, and individual risk. Standardized definitions and prospective studies are needed to guide evidence-based practice.

Impact of Antiplatelet and Anticoagulation Therapy on Hemodialysis Reliable Outflow Graft Patency.

Novel leukocytapheresis method using highly concentrated sodium citrate solution for the manufacturing of tisagenlecleucel.

Background: Direct current cardioversion (DCCV) is a standard intervention for restoring sinus rhythm in atrial fibrillation (AF). Left atrial appendage closure (LAAC) devices provide an alternative to anticoagulation (AC) for stroke prevention in select AF patients, but their effectiveness in mitigating thromboembolic complications during and after DCCV remains uncertain. This study evaluates the outcomes of DCCV in patients with LAAC devices in those receiving AC and those who are not. Methods: This was a retrospective observational cohort study using de-identified electronic health records from the TriNetX Research Network, including 103 healthcare organizations across the United States. The study included patients who underwent DCCV at least 6 months after LAAC device implantation. Patients with prior stroke, transient ischemic attack (TIA), hypertrophic cardiomyopathy, deep vein thrombosis, or pulmonary embolism were excluded. The primary exposure was AC use from 1 day prior to 1 month post-DCCV. The primary thromboembolic outcome was a composite of stroke, TIA, and arterial thromboembolism. The primary bleeding outcome was a composite of gastrointestinal, intracranial, genitourinary, and other bleeding events. Follow-up time was 1 year. Propensity score matching (1:1) was used to control for confounders including age, sex, hypertension, heart failure, ischemic heart disease, and diabetes. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated. Results: Of 1,295 patients identified, 925 received AC and 370 did not. After propensity score matching, 364 patients remained in each group. The mean age was 73.6 ± 8.1 years and 62% were male. At 1 year, the composite thromboembolic event rate was 3.3% in the AC group and 3.8% in the non-AC group (RR 0.86; 95% CI 0.40–1.83; p=0.690). Bleeding events occurred more frequently in the AC group (18.7%) than in the non-AC group (12.9%) (RR 1.45; 95% CI 1.03–2.04; p=0.033). Conclusions: In patients with LAAC devices undergoing DCCV, the omission of routine periprocedural AC did not increase thromboembolic risk but was associated with fewer bleeding complications. Selective use of AC may be appropriate, especially when a stable device seal is confirmed. Further prospective studies are warranted to define standardized management protocols.

Background: Atrial fibrillation (AF) is the most common arrhythmia, and studies have reported increased risk of heart failure and sudden cardiac death (SCD). However, the proportion of SCDs with AF due to hemorrhage is unknown because these studies presumed cardiac/arrhythmic causes without autopsy; these are now considered presumed SCD (pSCD) by international consensus. Research Question: To determine autopsy-defined causes of sudden death in victims with AF and on anticoagulant (AC) therapy in San Francisco (SF) County. Methods: POST SCD is an ongoing prospective study using autopsy and clinical records to adjudicate arrhythmic vs. non-arrhythmic causes among 1,120 incident pSCDs aged 18-90 years meeting WHO criteria in SF County from 2/1/2011-1/1/2024. For rate calculations, 525 (i.e., every incident) pSCDs in the initial cohort (2/1/2011-3/1/2014) were used, with at-risk person-years estimated from US census and AF prevalence data. For analysis of causes, 595 additional pSCDs (incident cases approximately every third day) were added from the extended cohort (3/1/2014-1/1/2024). A composite of intracranial, gastrointestinal, or other hemorrhage was classified as hemorrhagic sudden deaths. Clinical records were used to identify AF and atrial flutter (AFL) diagnoses and AC or antiplatelet (AP) use. Results: Of 1,120 total pSCDs, 78 (7%) had a diagnosis of AF/AFL; these cases were older than those without AF/AFL (70 vs 58 years, p&lt;0.01) and 31/63 cases with CHADS2-VASC≥2 (49%) were appropriately prescribed AC. Using an estimated AF prevalence of 4.48% in SF County, 3-year age-adjusted incidence rate ratio (IRR) of hemorrhagic sudden death for individuals with AF/AFL was 3.6 (95% CI 2.9-4.4, p&lt;0.01) vs those without AF/AFL. pSCDs with AF/AFL were more likely to die of arrhythmia secondary to cardiomyopathy (18.4% vs 8.9%, p=0.01) but not hemorrhagic sudden death (p=0.57). However, pSCDs who were prescribed AC/AP were twice as likely to have hemorrhagic sudden death vs those not on therapy (6.9% vs 3.5%, p=0.03). Conclusion: In this 13-year countywide postmortem study of sudden deaths, individuals with AF/AFL had an over-3-fold higher age-adjusted incidence of hemorrhagic sudden death. AC or AP therapy was associated with a two-fold higher risk of hemorrhagic cause of sudden death. Because sudden deaths in AC trials for AF were presumed cardiac, the real-world risk of hemorrhagic death was likely underestimated and thus changes the risk-benefit calculus of AC for AF.

Background: AF is a common comorbidity in patients with liver cirrhosis and may negatively impact both quality of life and prognosis. The management of AF in this population is complex due to cirrhosis-related disruptions in hemostasis, which increase the risk of both thrombosis and bleeding. These competing risks make decisions regarding anticoagulation therapy particularly challenging. This study aimed to evaluate the impact of anticoagulation on outcomes among patients with cirrhosis and coexisting AF. Research Question: Does anticoagulation use affect mortality, complications, or resource utilization in hospitalized patients with liver cirrhosis and atrial fibrillation? Methods: We conducted a retrospective cohort study using data from the National Inpatient Sample (NIS) from 2016 to 2021. Adult patients hospitalized with liver cirrhosis were identified using ICD-10 diagnostic codes. Among these, individuals with coexisting AF were selected and categorized by current or long-term use of anticoagulation (AC). The primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), total hospital charges (THC), ICU utilization, mesenteric ischemia, portal vein thrombosis, venous thromboembolism (deep vein thrombosis [DVT] and pulmonary embolism [PE]), acute myocardial infarction/angina (AMI), cardiac arrest, and bleeding complications (transfusion, gastrointestinal bleeding, intracranial hemorrhage). Multivariable regression analyses were performed adjusting for patient demographics, comorbidities, and hospital characteristics. Results: The study included 11,140 patients with cirrhosis and AF, of whom 2,417 (21.70%) received AC. AC use was associated with reduced in-hospital mortality (adjusted odds ratio [aOR] 0.75; 95% CI, 0.58–0.98; P=0.03), ICU admission (aOR 0.65; 95% CI, 0.50–0.84; P&lt;0.01), AMI (aOR 0.71; 95% CI, 0.54–0.95; P=0.02), and GI bleeding (aOR 0.75; 95% CI, 0.62–0.90; P&lt;0.01). No significant differences were found in LOS, THC, mesenteric ischemia, portal vein thrombosis, DVT/PE, cardiac arrest, transfusion, or intracranial hemorrhage. Conclusion: In hospitalized patients with cirrhosis and AF, AC therapy was associated with reduced mortality, ICU use, AMI, and GI bleeding, without increased risk of other major complications. These findings support the safety and benefit of AC in this population and underscore the need for individualized risk assessment rather than default avoidance due to cirrhosis

Background: Left ventricular thrombus (LVT) is a known and serious complication of myocardial infarction (MI) and cardiomyopathy, associated with systemic embolism including stroke. The standard management includes anticoagulation (AC) to prevent thromboembolic complications. However, when a patient simultaneously presents with an acute ischemic stroke, initiating AC poses a significant clinical dilemma due to the potential for hemorrhagic conversion (HC). Case: A 56-year-old male with type 2 diabetes, presented with altered mental status, speech difficulty, and slurred speech. Vital signs were stable on admission. Labs showed hyperglycemia and elevated high-sensitivity troponin (peak: 3359 ng/L). EKG revealed sinus tachycardia at 109 bpm, T wave inversions in Leads 3, avF and inferior Q waves. Imaging consistent with an acute infarction in the posterior left MCA territory without hemorrhage. Transthoracic echocardiography demonstrated severely reduced ejection fraction (25–30%) with regional wall motion abnormalities and a well-defined apical thrombus. Cardiology diagnosed non-ST elevation MI with decompensated heart failure and LVT. Heparin infusion was started and was closely monitored due to very high risk of HC. Neurological status remained stable on heparin and then transitioned to apixaban prior to discharge. The patient remained neurologically stable and discharged with plans for outpatient coronary angiography and follow-up with neurology and cardiology. Methods: Case report highlighting complexities of balancing ischemic prevention and bleeding risk in concurrent LVT and middle cerebral artery infarct. Results: This case required balancing the high embolic risk of untreated LVT against the risk of HC of a large-vessel stroke. The team employed a multidisciplinary approach involving cardiology, neurology, and critical care to guide timing and selection of AC. Heparin used initially for its short half-life and reversibility, then transitioned to apixaban for long-term management. Conclusion: In patients with concurrent LVT and acute ischemic stroke, AC timing must be cautiously individualized. This case supports a multidisciplinary, stepwise approach—delaying initiation during the highest risk period, using short-acting agents first, and considering direct oral AC's when clinically appropriate. As evidence for DOAC use in LVT continues to evolve, this case adds to the growing support for their safety and efficacy in select high-risk patients.

Description of Case: A 47-year-old female with history of thrombophilia (PAI-1 4G/4G genotype), Barlow syndrome with native leaflet repair then mechanical mitral valve (MV) replacement on warfarin, and previous stroke due to MV thromboembolism, presented with more than 24-hour onset of expressive aphasia. CT head showed showed acute ischemic stroke (AIS) in left parietal lobe with left middle cerebral artery (MCA) distal occlusion on CTA-head despite warfarin use and therapeutic INR-2.5. Within hours of admission, she had neurological deterioration and brain MRI demonstrated new left frontal-temporal intracranial hemorrhage (ICH) with cerebral herniation. She emergently received 4F-PCC/vitamin K, underwent decompression craniectomy. TTE showed MV severe stenosis. TEE (Figure 1) confirmed MV thrombus, similar embolic mechanism to prior AIS. To balance the concomitant high risks of strokes given mechanical MV thrombus requiring uninterrupted anticoagulation (AC) and ICH recurrence with AC, she was started on low-dose heparin infusion without bolus day 8. Transcranial Doppler (TCD) (Figure 2) was utilized to determine risk of cerebral embolization from MV thrombus via detection of microemboli or high-intensity transient signals (HITS) within bilateral MCA. Although patient anticoagulated with heparin, we detected 16 HITS in 15 mins of embolic monitoring suggesting high risk of recurrent ischemic stroke. AC was switched to enoxaparin at 1mg/kg twice daily and repeated TCD-emboli on day 15 showed continued AIS risk with 11 HITS even with a therapeutic anti-Xa level of 0.7 (goal 0.6-1.0). Enoxaparin dosage increased guided by emboli monitoring until HITS resolved. She was discharged to stroke rehab with plan to bridge to warfarin (INR goal 3.5-4.0) after 4 week. At one-month follow-up, she remained on warfarin 10mg daily with therapeutic INR and free of recurrent AIS or ICH. Discussion: Microembolic signals detected on TCD can be used as biomarkers to predict stroke risk and guide therapeutic interventions. Our patient was at risk of further ICH after decompressive hemicraniectomy but without anticoagulation she had high risk of embolic stroke from mechanical MV thrombus. TCD emboli monitoring played a pivotal role in guiding the timing of AC initiation and determining the therapeutic dose to reduce risk of both recurrent emboli and hemorrhagic complications.

Introduction: Clinical trials comparing anticoagulation (AC) therapy with left atrial appendage closure (LAAC) in patients with atrial fibrillation (AF) have shown conflicting results regarding stroke, bleeding, and mortality outcomes. This meta-analysis aims to clarify these discrepancies, with a specific focus on ischemic stroke or systemic embolism, major bleeding, cardiovascular mortality, and all-cause mortality. Methods: We searched PubMed and ClinicalTrials.gov for randomized controlled trials (RCTs) using the terms atrial fibrillation, left atrial appendage closure, anticoagulation, stroke, and major bleeding. Additionally, reference lists from the retrieved studies were reviewed to identify other eligible trials. Four RCTs were identified and included in the meta-analysis. Results: This meta-analysis included 3,116 patients with AF, comprising 1,736 patients in the LAAC group and 1,380 in the AC group. The incidence of ischemic stroke or systemic embolism was comparable between the two groups, with a relative risk (RR) of 1.25 (95% confidence interval [CI]: 0.85–1.83). Although the rate of major bleeding was lower in the LAAC group, the difference was not statistically significant (RR: 0.81; 95% CI: 0.65 to 1.02). In contrast, cardiovascular mortality (RR: 0.67; 95% CI: 0.49 to 0.92) and all-cause mortality (RR: 0.78; 95% CI: 0.64 to 0.96) were significantly reduced in the LAAC group. Conclusions: In patients with AF, LAAC demonstrates a similar risk of ischemic stroke or systemic embolism compared to AC. While major bleeding appears less frequent with LAAC, the difference is not statistically significant. Notably, LAAC is associated with significantly lower cardiovascular and all-cause mortality. Further long-term and real-world studies are needed to better understand the long-term outcomes of both treatment strategies.

Background: Patent foramen ovale (PFO) is a recognized contributor to embolic stroke, especially in hypercoagulable states (HCSs). However, patients with HCSs, including malignancy, were excluded from major PFO closure trials, creating a significant evidence gap. Objectives: This narrative review examines the role of PFO closure in secondary stroke prevention among patients with HCSs, including malignancy. We highlight key studies and current evidence in this understudied population. Methods: A systematic search of PubMed was conducted using pertinent MeSH terms. Due to limited data, a narrative synthesis of the literature was performed. Case Presentation and Narrative Review of Literature: A 43-year-old lady with a history of metastatic breast cancer and recent bilateral pulmonary emboli on anticoagulation (AC), presented with expressive aphasia. MRI brain confirmed a Broca-area infarct. Biopsy of an expansile pelvic mass yielded a diagnosis of ovarian mucinous cystadenocarcinoma. TEE demonstrated a PFO; an embolic stroke driven by hypercoagulability of malignancy was diagnosed. PFO closure was offered for secondary stroke prevention after risk-benefit discussion, as opposed to AC alone. While early trials (CLOSURE I, PC) showed no benefit of closure, subsequent studies (RESPECT, REDUCE, DEFENSE-PFO) favored it in selected patients, but notably, these trials excluded patients with HCSs and malignancy. The benefit of PFO closure in this population thus comes largely from observational data. Abrahamyan et al. found that PFO closure could be safely offered in patients with thrombophilia to prevent recurrent stroke. Liu et al., in their prospective study, noted that among patients with cryptogenic stroke and thrombophilia, PFO closure lowered the risk of recurrence. Similarly, a retrospective study from Greece found benefit from PFO closure in this population. Buber et al. found that among patients with HCSs and stroke, PFO closure offered a five-fold risk reduction from future CVA/TIA. The Society for Cardiovascular Angiography and Interventions (SCAI) guidelines recommend PFO closure in patients with thrombophilia for secondary stroke prevention (conditional recommendation- low certainty of evidence). Conclusions: Data on PFO closure for secondary stroke prevention in HCSs and malignancy are scant, necessitating individualized decision making. Current evidence supports PFO closure, but future studies are needed specifically in this vulnerable population.

The use of anticoagulation on paroxysmal nocturnal hemoglobinuria.