Contraindications For Anticoagulation Therapy Research Articles

Antithrombotic therapy in patients with non-valvular atrial fibrillation and high risk of stroke after successful endovascular left atrial appendage occlusion

Aim. To assess the antithrombotic therapy after left atrial appendage occlusion (LAAO) with the Watchman device (WD) and Amplarzer Cardiac Plug (ACP) for stroke prevention in patients with nonvalvular atrial fibrillation (AF) with contraindications for long anticoagulation therapy.Methods. 200 consecutive patients with nonvalvular AF and contraindications to oral anticoagulation therapy with contraindications for long anticoagulation who undergone LAAO implantation using WD (n=108; WD group) and ACP (n=92; ACP group) were enrolled into this study. Antithrombotic therapies were prescribed after successful LAAO implantation according to indications. Patients were followed at 45 days, 3, 6 and 12 months after enrollment. At each follow-up visit the data regarding clinical events and healthcare utilization were collected. Transesophageal echo (TEE) was perfomed at 45 days and 6 months after successful LAAO implantation. The efficacy end point was the composite of transit ischemic attack (TIA)/stroke, device thrombosis and procedure-related death.Results. During the follow-up TIA/stroke has occurred in 4.8% of patients in the WD group with no such events in ACP group (4.8% vs 0%, p=0.062). These patients had 4 or more points on the CHA2 DS2 -VASc, and they were prescribed various combinations of antithrombotic therapy, except warfarin, while patients from the WD group with 4 or more points on the CHA2 DS2 -VASc score taking warfarin had no thromboembolic events. Device thrombosis during TEE at 45 days after successful LAAO implantation was confirmed in 3 patients (2,9%) with WD with no such events in ACP group (2.9% vs 0%, p=0.251). The efficacy end point events in all groups were 4.6%: 8 events in WD group (7.6%) and 1 case in ACP group (1.1%). One patient in the ACP group died in 6 weeks after LAAO implantation. No autopsy was performed; therefore, the exact cause of death was not determined (p=0.038). Survival rate showed significantly higher rate events in WD group versus ACP group (p=0.027).Conclusion. Any combinations of antithrombotic therapy could be prescribed to patients with contraindications for anticoagulant therapy and high risk of stroke who undergone successful (LAAO) implantation with Amplatzer Cardiac Plug. It’s possible to cancel oral anticoagulants in this patient. Patients aged 70 and older with a CHA2 DS2 -VASc >4 and a history of stroke are recommended to take warfarin after successful Watchman Device implantation.

Role of the vena cava filter at the present stage of treatment of acute venous thrombosis

The article is a review of the literature on the problem of surgical prophylaxis of venous thromboembolic complications, namely insertion of a vena cava filter. Today, there are a number of recommendations that differently display indications for insertion of a vena cava filter. The contradictions in the indications for insertion of a vena cava filter are based on a lack of evidence base both on the possibility of protection from pulmonary embolism with the help of surgery and the justification for this surgery. The analysis of the efficiency and safety of the vena cava filters, both permanent and removable, is carried out. Currently, only one indication for inserting a vena cava filter is recognized by all recommendations: the presence of contraindications for anticoagulant therapy in a patient with deep vein thrombosis and/or pulmonary embolism.

Does percutaneous left atrial appendage closure affect left atrial performance?

Abstract Background: Percutaneous left atrial appendage (LAA) occlusion may be an alternative therapy for atrial fibrillation (AF) patients with contraindication for anti-coagulation therapy. However, the influence of LAA occlusion on left atrial (LA) performance has not been studied. Objective: Our aim was to evaluate the influence of percutaneous LAA occlusion device on LA function by transthoracic echocardiography plus speckle-tracking echocardiography (STE). Methods: We included 16 patients undergoing percutaneous LAA closure with adequate echocardiographic window for the study of LA mechanics. Transthoracic echocardiography was performed before and after the procedure. LA volumes were calculated using the biplane method, and LA mechanics were assessed using STE. The analysis focused on the LA reservoir phase strain and strain rate. Results: Seventy-five percent of patients had permanent atrial fibrillation. Embolic and bleeding risk scores used were CHA2DS2-VASc [median of 4-5] and HAS-BLED [median of 2-3]. Major bleeding (62%) was the most common indication for the procedure. Percutaneous LAA closure was performed successfully in all patients, without major complications. No differences were found in maximum LA volume (44 ± 11 vs. 46 ± 13 mL/m2; p = 0.54), minimum LA volume (32 ± 8 vs. 37 ± 14 mL/m2; p = 0.09) or LA emptying fraction (26 ± 17 vs. 21 ± 14%; p = 0.33) before and after the procedure. Similarly, no differences were noted in left atrial strain (13.7 ± 11.1 vs. 13.0 ± 8.8%; p = 0.63) or strain rate (1.06 ± 0.26 vs. 1.13 ± 0.34 s-1; p = 0.38) in the reservoir phase. Conclusions: Our data suggest that percutaneous LAA closure does not affect LA reservoir function.

TCT-767 Long-term Outcomes Following Percutaneous Left Atrial Appendage Closure with the Amplatzer Cardiac Plug Device in Patients with Non-Valvular Atrial Fibrillation and Contraindications for Anticoagulation Therapy

TCT-767 Long-term Outcomes Following Percutaneous Left Atrial Appendage Closure with the Amplatzer Cardiac Plug Device in Patients with Non-Valvular Atrial Fibrillation and Contraindications for Anticoagulation Therapy

Retrievable inferior vena cava filters in trauma patients: factors that influence removal rate and an argument for institutional protocols

BackgroundTrauma patients at risk for pulmonary embolism, but with contraindications for anticoagulation therapy, often have retrievable inferior vena cava filters (RIVCF) placed. This study evaluated factors associated with the recovery rate of the device (RIVCFs) with the goal of developing an institutional protocol to ensure timely removal. MethodsThis was a case-control study of 88 trauma patients who underwent RIVCF placement at a level 1 trauma center between 2006 and 2010. ResultsThe overall retrieval rate was 58%, declining from 89% in 2006 to 50% in 2009. Factors independently associated with filter nonretrieval included increasing age, increase in number of providers, comorbidity, hospital discharge from the intensive care unit, and discharge to a long-term acute care facility or skilled nursing facility. In 2010, a protocol was implemented and the retrieval rate increased to 73%. ConclusionsIn a large institution where a number of providers may be responsible for filter management, implementation of a protocol appears to improve retrieval rates.

Surveillance Study of Temporary IVC Filters placed in Patients with VTE and Contraindications for Full Dose Anticoagulant Therapy

To study the circumstances surrounding the use of IVC filters in our institution we collected medical information from all patients with IVC filters placed between January 1, 2006 and December 31, 2007 in our institution. During this time, 247 IVC filters were placed and we are reporting preliminary data of 50 of those patients. Of these patients, 8 (16%) had permanent filters placed (Vena tech™) and 42 (84%) had retrievable filters (Gunther Tulip filters). In most of the cases, the indication for the IVC filter was the inability to use full dose of anticoagulants in patients with acute DVT secondary to active bleeding, requiring immediate surgery or very high risk of bleeding due to different circumstances (such a recent intracranial bleed or traumatic intra-abdominal hemorrhage). Most of the patients were trauma patients. Thus, 30 of the patients had neurosurgical injuries, 13 had orthopedic injuries requiring urgent surgery, 5 had intra-abdominal injuries and 2 were medical patients with DVT and contraindications for anticoagulant therapy. Of the filters deployed, 12 (24%) were inserted after developing thrombosis despite the use of prophylactic dose of anticoagulants. Once the filter was inserted, surveillance Doppler studies revealed propagation of the clots in 7 (14%) patients. Of these 7 patients 2(29%) of them were receiving low dose enoxaparin and 5 (71%) were receiving no anticoagulants at all. In addition, there were 12 patients with DVT and contraindication to full dose anticoagulation who were treated with prophylactic dose of enoxaparin. Of these 12 patients, 10(83%) had stability or resolution of the thrombus and 2(17%) showed propagation. Twenty patients were given no anticoagulation after diagnosis of DVT, of them, 15(75%) had resolution or stabilization of the clots and 5(25%) experienced propagation. Most of the patients were eventually treated with full dose enoxaparin followed by warfarin for a minimum of 3 months. All IVC filters were inserted by intervention radiologists at our institution. Deployment was done uneventfully in all cases. The retrieval of all filters was done between 4 and 8 weeks of the time of insertion. By then, most of the patients were taking warfarin. This drug was held 3 evenings before the procedure and restarted 8–12 hours after the procedure. Enoxaparin at a dose of 40 mg SQ daily was use for bridging before and after the retrieval of the IVC filters. Of all temporary filters, only 11 (26%) were retrieved. IVC filter could not be retrieved despite attempting it in 1 (2%) of patients. The reason for this was that the filter had embedded in the intima of the IVC. Additionally, 1(2%) patient required two attempts to successfully remove the filter IVC filters as there was residual thrombus at the filter site the first time. IVC retrievable filters were effective in preventing pulmonary embolism in 49 (98%) of patients. The only patient with a pulmonary embolism was a neurosurgical patient that was not treated with anticoagulants and the clot extended to the filter. Excessive bleeding occurred in 2(4%) of all patients resulting in discontinuation of anticoagulants. IVC filters are safe and constitute a reasonable intervention to prevent pulmonary embolism in patients with contraindications for anticoagulation. Although, many temporary filters are placed they are often not retrieved. Low dose enoxaparin in patients with IVC filter and contraindication for full dose anticoagulants is associated to low risk of bleeding and seems to prevent proximal propagation of the clots. We expect to have all data from the 247 patients collected by the time of the Meeting.

The Use of Paired Optionally Retrievable Günther Tulip Filters in Trauma Patients with Anatomical Variants

Inferior vena cava (IVC) filtration is commonly performed to protect against pulmonary embolism in acutely injured patients with contraindications for anticoagulation therapy. Increasingly, optionally retrievable IVC filters are utilized, particularly in younger patients with longer life expectancies. There are well-described anatomical variants that preclude the typical infrarenal deployment of IVC filters. We describe three cases in which trauma patients with congenital anomalies required temporary prophylaxis with IVC filters. One patient had a duplication of the IVC requiring filter deployment in each IVC limb. The second patient had a low inserting accessory left renal vein, and a third patient had a megacava. Both of these patients required filter deployment in each common iliac vein. In each case, a pair of optionally retrievable Günther Tulip filters was deployed and subsequently retrieved.

Percutaneous Left Atrial Appendage Transcatheter Occlusion (PLAATO System) to Prevent Stroke in High-Risk Patients With Non-Rheumatic Atrial Fibrillation: Results From the International Multi-Center Feasibility Trials

These studies were conducted to evaluate the feasibility of percutaneous left atrial appendage (LAA) occlusion using the PLAATO system (ev3 Inc., Plymouth, Minnesota). Patients with atrial fibrillation (AF) have a five-fold increased risk for stroke. Other studies have shown that more than 90% of atrial thrombi in patients with non-rheumatic AF originate in the LAA. Transvenous closure of the LAA is a new approach in preventing embolism in these patients. Within two prospective, multi-center trials, LAA occlusion was attempted in 111 patients (age 71 +/- 9 years). All patients had a contraindication for anticoagulation therapy and at least one additional risk factor for stroke. The primary end point was incidence of major adverse events (MAEs), a composite of stroke, cardiac or neurological death, myocardial infarction, and requirement for procedure-related cardiovascular surgery within the first month. Implantation was successful in 108 of 111 patients (97.3%, 95% confidence interval [CI] 92.3% to 99.4%) who underwent 113 procedures. One patient (0.9%, 95% CI 0.02% to 4.9%) experienced two MAEs within the first 30 days: need for cardiovascular surgery and in-hospital neurological death. Three other patients underwent in-hospital pericardiocentesis due to a hemopericardium. Average follow-up was 9.8 months. Two patients experienced stroke. No migration or mobile thrombus was noted on transesophageal echocardiogram at one and six months after device implantation. Closing the LAA using the PLAATO system is feasible and can be performed at acceptable risk. It may become an alternative in patients with AF and a contraindication for lifelong anticoagulation treatment.

Midterm results of aortic valve replacement with Carpentier-Edwards porcine bioprosthesis

Since 1987 we have been using Carpentier-Edwards porcine bioprostheses for aortic valve replacements in patients of advanced age and those with a contraindication for anticoagulation therapy. The purpose of this study was to provide insight into the midterm results of our series of patients with Carpentier-Edwards porcine bioprostheses in the aortic position. From September 1987 through June 1999, 31 patients underwent aortic valve replacement with Capentier-Edwards porcine bioprostheses. The age of the patients ranged from 21 to 89 (average, 71 ± 11 years old), and 21 patients (67.7%) were 70 years old or older. There were no operative deaths. Three hospital deaths (9.7%) and one nonhospital death (3.2%) took place. The actuarial survival rate of 31 patients was 90.3% at 5 years and 81.3% at 7 years. Valve-related complications were seen in six patients (19.4%). The postoperative Doppler peak gradient of aortic prostheses was less than 30 mm Hg in all groups, irrespective of valve size. In conclusion, the Carpentier-Edwards porcine bioprosthesis affords good durability with a low rate of valve-related complications and reoperation. Furthermore, the postoperative function of the prosthesis was reasonable in the Doppler echo studies.

Treatment of Venous Thromboembolism in Cancer Patients

The management of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients with cancer can be a clinical dilemma. Comorbid conditions, warfarin failure, difficult venous access, and a high bleeding risk are some of the factors that often complicate anticoagulant therapy in these patients. In addition, the use of central venous access devices is increasing but the optimal treatment of catheter-related thrombosis remains controversial. Unfractionated heparin (UFH) is the traditional standard for the initial treatment of venous thromboembolism (VTE) but low molecular weight heparins (LMWHs) have been shown to be equally safe and effective in hemodynamically stable patients. For long-term treatment or secondary prophylaxis, vitamin K antagonists remain the mainstay treatment. However, the inconvenience and narrow therapeutic window of oral anticoagulants make extended therapy unattractive and problematic. As a result, LMWHs are being evaluated as an alternative for long-term therapy. New antithrombotic agents are being tested in clinical trials and may have the potential to replace conventional treatment. The role of inferior vena cava filters in cancer patients remains ill defined but these devices remain the treatment of choice in patients with contraindications for anticoagulant therapy.

Mitral Valve Replacement with the Hancock Bioprosthesis: Five- to Ten-Year Follow-up

One hundred eleven patients undergoing mitral valve replacement, either alone (56) or in conjunction with another type of prosthetic valve, prior to 1975 were evaluated. Hospital mortality was 9.9%. Cumulative follow-up is 505 patient-years (mean, 5.4 years). Seventy patients have been followed between 5 and 10 years. Late mortality for mitral valve replacement alone is 4.3 ± 1.3% per patient-year; actuarial survival is 82 ± 6% at 5 years and 65 ± 11% at 10 years. The incidence of emboli was 3.3 ± 0.9% per patient-year for all patients with bioprostheses (62) and 4.2 ± 1.7% per patient-year for bioprostheses and concomitant mechanical aortic valves (32). In patients with only bioprostheses, two of twelve emboli occurred within the first 6 postoperative months and there were three fatal cerebral emboli (0.8 + 0.5% per patient-year). The incidence of hemorrhagic complications is 4.9 ± 1.9% for anticoagulated patients with bioprostheses and mechanical aortic valves; one hemorrhage was fatal (0.7 ± 0.7% per patient-year). Intrinsic mitral bioprosthesis failure occurred in 10 patients; 2 died. Five patients had valve failure secondary to perivalvular regurgitation (3) or endocarditis (2). Actuarial late survival free from intrinsic mitral bioprosthetic failure was 99 ± 1% at 5 years, 92 ± 4% at 7 years, 70 ± 12% at 9 years, and 61 ± 13% at 10 years. It is unknown at the present time whether the long-term risk of late intrinsic valve failure and reoperation will outweigh the low incidence of emboli and avoidance of anticoagulant-related hemorrhage. Until further information becomes available, the Hancock bioprosthesis is used for mitral valve replacement only in patients older than 60 years or in patients with contraindications for anticoagulant therapy.