Embolic Complications Research Articles

CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION: HOW TO DIAGNOSE? A CASE REPORT

Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a pulmonary embolism (PE) complication that is a primary cause of pulmonary hypertension (PH) and may lead to right heart failure and significant mortality especially when left untreated. Although CTEPH is the only cause of PH that is curable without needing to resort to lung transplant, it is often misdiagnosed due to the absence of diagnostic instruments and the absence of specific presenting symptoms. This also complicates the process of distinguishing between acute thromboembolic disease and the acute embolic event worsening of undiscovered CTEPH. Objective A better understanding of CTEPH is crucial, therefore we discuss a diagnosis rare case of CTEPH. Case Description A 44-year-old man presenting with syncope and chest discomfort who had no previous episodes of acute PE. Conclusion Computed Tomography Pulmonary Angiography (CTPA) is a significant test for identifying CTPEH. Oral anticoagulants may provide patients with CTEPH a safe and beneficial life-long treatment.

Untreated Right Ventricle Myxoma with Pericardial Effusion in Young Men: A Case Report

Myxomas are benign cardiac tumors that are mostly found in the left atrium. We present a case of a 20-year-old male patient who presented with worsening dyspnea and signs of right heart failure. The echocardiography shows an untreated giant intracardiac mass in a rare place in the right ventricle, obstructing the blood flow, and massive pericardial effusion. We do a pericardiocentesis first to manage the pericardial effusion. Pericardiocentesis was done in different normal locations due to ascites permagna. Nevertheless, our patient needs emergency surgical excision as soon as possible to prevent sudden death caused by obstruction, embolic, and other complications.

Clinical-radiological-pathological correlation in chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and potentially life-threatening complication of acute pulmonary embolism. It is characterised by persistent fibro-thrombotic pulmonary vascular obstructions and elevated pulmonary artery pressure leading to right heart failure. The diagnosis is based on two steps, as follows: 1) suspicion based on symptoms, echocardiography and ventilation/perfusion scan and 2) confirmation with right heart catheterisation, computed tomography pulmonary angiography and, in most cases, digital subtraction angiography. The management of CTEPH requires a multimodal approach, involving medical therapy, interventional procedures and surgical intervention. This clinical-radiological-pathological correlation paper illustrates the diagnostic and therapeutic management of two patients. The first had chronic thromboembolic pulmonary disease without pulmonary hypertension at rest but with significant physical limitation and was successfully treated with pulmonary endarterectomy. The second patient had CTEPH associated with splenectomy and was considered unsuitable for surgery because of exclusive subsegmental lesions combined with severe pulmonary hypertension. The patient benefited from multimodal treatment involving medical therapy followed by multiple sessions of balloon pulmonary angioplasty. Both patients had normalised functional capacity and pulmonary haemodynamics 3-6 months after the interventional treatment. These two examples show that chronic thromboembolic pulmonary diseases are curable if diagnosed promptly and referred to CTEPH centres for specialist treatment.

Clinical correlates of circulating small dense low-density lipoproteins in acute infective endocarditis.

Infective endocarditis (IE) is a complex thrombo-inflammatory disorder, the pathogenesis of which involves a multifaceted interplay between vascular damage and bacterial virulence factors. This study aimed to assess the prognostic role of small dense low-density lipoprotein (sdLDL) cholesterol in patients with IE and its correlation with various disease-related features. A cohort of 198 patients with definite IE was included in this study. Clinical, laboratory, and echocardiographic parameters were meticulously analyzed, with a specific focus on comorbidities. sdLDL levels were measured using stored plasma samples obtained upon admission during the acute phase of the disease. The median level of sdLDL was 24mg/dL [with an interquartile range of 17.9-35.2mg/dL], and this value showed a statistically significant positive correlation with LDL/HDL cholesterol and triglycerides (p < 0.01 for all). Furthermore, a remarkable inverse correlation between C-reactive protein and D-dimer levels was observed (p < 0.0001). Univariate analysis revealed that patients with sdLDL levels ≤ 24mg/dL had 2.75 times higher odds of in-hospital mortality (95% Confidence Interval:1.08-6.98, p = 0.031). In addition, nonsurvivors had significantly lower median sdLDL levels (19.7 vs. 26.0mg/dL, p = 0.041). Lower sdLDL levels were also associated with embolic complications, larger vegetation size, and positive blood cultures for Staphylococci (p = 0.019, p = 0.022, and p < 0.001, respectively). Low circulating sdLDL levels in the acute phase of IE were significantly correlated with unfavorable clinical outcomes. These results suggest that the sdLDL level may serve as an important marker of disease severity in IE and may represent a link between vascular damage, embolic complications, and disease progression.

The frailty-driven predictive model for failure to rescue among patients who experienced a major complication following cervical decompression and fusion: an ACS-NSQIP analysis of 3,632 cases (2011–2020)

BACKGROUND CONTEXTPreoperative risk stratification for patients considering cervical decompression and fusion (CDF) relies on established independent risk factors to predict the probability of complications and outcomes in order to help guide pre and perioperative decision-making. PURPOSEThis study aims to determine frailty's impact on failure to rescue (FTR), or when a mortality occurs within 30 days following a major complication. STUDY DESIGN/SETTINGCross-sectional retrospective analysis of retrospective and nationally-representative data. PATIENT SAMPLEThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all CDF cases from 2011-2020. OUTCOME MEASURESCDF patients who experienced a major complication were identified and FTR was calculated as death or hospice disposition within 30 days of a major complication. METHODSFrailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Baseline patient demographics and characteristics were compared for all FTR patients. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic (ROC) curve analysis. RESULTSThere were 3632 CDF patients who suffered a major complication and 7.6% (277 patients) subsequently expired or dispositioned to hospice, the definition of FTR. Independent predictors of FTR were nonelective surgery, frailty, preoperative intubation, thrombosis or embolic complication, unplanned intubation, on ventilator for >48 hours, cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR, achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883–0.919). CONCLUSIONPreoperative and postoperative risk factors, combined with frailty, yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication regarding the likelihood of FTR after a major complication postoperatively with CDF patients. Future studies may determine the predictive ability of this model in other neurosurgical patient populations.

Fat embolism syndrome in Duchenne muscular dystrophy: Report on a novel case and systematic literature review

We report a non-ambulatory 13-year-old boy with Duchenne muscular dystrophy who experienced severe acute respiratory distress syndrome and cerebral fat embolism following elective soft tissue surgery. Post-surgery radiological examination revealed bilateral femoral fractures and marked osteopenia that were believed to have caused disseminated pulmonary and cerebral fat embolism. The patient had never been on glucocorticoid treatment. Five months post-surgery, he remained in a state of minimal consciousness.A literature review was performed and eleven publications included, providing case reports of a total number of 23 patients with Duchenne muscular dystrophy with fat embolism syndrome. The most common causes were falls from the wheelchair that predominantly resulted in femoral fractures. Median age at the event was around 14 years. Seven patients succumbed to complications of fat embolism. No event was described in the context of surgery. We want to raise awareness that spontaneous unnoticed fractures may occur especially in adolescents with DMD from traumatic injury of large bones and also during elective surgery with a high risk of causing fat embolism with severe sequelae.

Stroke and Bleeding Risks of Endocardial Ablation for Ventricular Arrhythmias

BackgroundRisks of radiofrequency catheter ablation for ventricular arrhythmias include emboli and bleeding complications but data on antithrombotic regimens are limited and guidelines do not specify a systematic approach. ObjectivesThis study sought to assess embolic and bleeding complications in relation to pre-periprocedure and post-periprocedure antithrombotic regimens. MethodsProspective assessment for complications was performed for 663 endocardial radiofrequency catheter ablation procedures in 616 consecutive patients (median age 64 years [Q1-Q3: 54-73 years], 70.3% men, 71.6% with cardiomyopathy, 44.5% with sustained ventricular tachycardia). ResultsThere were 2 strokes (0.3%; 95% CI: 0.0%-0.8%), 1 transient ischemic attack (0.15%), and 2 pulmonary emboli (0.3%). There were 39 bleeding complications (5.9%) including 11 pericardial effusions (1.7%), and 28 related to vascular access (4.2%). Consistent with the prevalence of coronary artery disease (47.5%), atrial fibrillation (30.0%), and prior stroke (10.6%), preprocedure, 464 patients (70.0%) were taking antithrombotic agents including 220 (33.2%) taking aspirin alone (ASA), and 163 (24.6%) taking warfarin or a direct acting oral anticoagulant (DOAC). Preprocedure non-ASA antiplatelet use (OR: 2.846; P = 0.011) and DOAC use (OR: 2.585; P = 0.032) were associated with risk of bleeding complications. Following ablation, 49.8% of patients were treated with ASA 325 mg/d and 30.3% received DOACs or warfarin. New DOAC or warfarin administration was initiated in only 6.6% of patients. Overall, 39.7% of patients continued the same preprocedure antithrombotic regimen. ConclusionsStroke is a rare complication of radiofrequency catheter ablation for ventricular arrhythmia using ASA 325 mg/d as a minimal postprocedure regimen with more potent regimens for selected patients.

Gender disparities in postoperative outcomes following elective spine surgery: a systematic review and meta-analysis.

Several studies have described disparities between male and female patients following spine surgery, but no pooled analyses have performed a robust review characterizing differences in postoperative outcomes based on gender. The purpose of this study was to broadly assess the effects of gender on postoperative outcomes following elective spine surgery. Between November 2022 and March 2023, PubMed, MEDLINE, ERIC, and Embase were queried using artificial intelligence-assisted software for relevant cohort studies. Cohort studies with a minimum sample of 100 patients conducted in the United States since 2010 were eligible. Studies related to trauma, tumors, infections, and spinal cord pathology were excluded. Independent extraction by multiple reviewers was performed using Nested Knowledge software. A fixed- or random-effects model was used if heterogeneity among included studies in a meta-analysis was < 50% or ≥ 50%, respectively. Risk of bias was assessed independently by multiple reviewers using the Newcastle-Ottawa Scale. Pooled effect sizes were calculated for readmission, nonroutine discharge (NRD), length of stay (LOS), extended LOS, reoperation, mortality, all medical complications (individual analyses for cardiovascular, deep venous thrombosis/pulmonary embolism, genitourinary, neurological, respiratory, and systemic infection complications), and wound-related complications. For each outcome, two subanalyses were performed with studies that used either center-based (single- or multi-institution) or high-volume (national or state-wide) databases. Across 124 included studies, male patients had an increased incidence of mortality (OR 0.54, p < 0.0001) and all medical complications (OR 0.80, p = 0.0114), specifically cardiovascular (OR 0.68, p < 0.0001) and respiratory (OR 0.76, p = 0.0008) complications. Female patients were more likely to experience a wound-related surgical complication (OR 1.16, p = 0.0183). These findings persisted in the high-volume database subanalyses. Only center-based subanalyses showed that female patients were at greater odds of experiencing an NRD (OR 1.18, p = 0.0476), longer LOS (SMD 0.23, p = 0.0036), and extended LOS (OR 1.28, p < 0.0001). Males are more likely to experience death and medical complications, whereas females were more likely to face wound-related surgical complications. At the institution level, females more often experience NRD and longer hospital stays. These findings may better inform preoperative expectation management and provide more detailed postoperative risk assessments based on the patient's gender.

First-in-human study of the CAPTIS embolic protection system during transcatheter aortic valve replacement.

Stroke and other clinically significant embolic complications are well documented in the early period following transcatheter aortic valve replacement (TAVR). The CAPTIS device is an embolic protection system, designed to provide neurovascular and systemic protection by deflecting debris away from the brain's circulation, capturing the debris and thus avoiding systemic embolisation. We aimed to study the safety and feasibility study of the CAPTIS complete cerebral and full-body embolic protection system during TAVR. A first-in-human study investigated the safety, feasibility and debris capturing ability of CAPTIS during TAVR. Patients were followed for 30 days. The primary endpoints were device safety and cerebrovascular events at 72 hours. Twenty patients underwent TAVR using balloon-expandable or self-expanding valve systems. CAPTIS was successfully delivered, positioned, deployed, and retrieved in all cases, and TAVR was successfully completed without device-related complications. No cerebrovascular events were observed. High numbers of debris particles were captured in all patients. The use of the CAPTIS full-body embolic protection system during TAVR was safe, and it captured a substantial number of debris particles. No patient suffered from a cerebrovascular event. A randomised clinical trial is warranted to prove its efficacy.

Symptom-related screening programme for early detection of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the SYSPPE study

BackgroundChronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). We aimed to evaluate the impact of a symptom screening programme to detect CTEPH...

Efficacy and Safety of Recombinant Thrombopoietin Combined with Immunosuppressive Therapy for Primary Treatment of Severe Aplastic Anemia: A Single-Center, Open-Label, Randomized, Clinical Trial

Standard immunosuppressive therapy (IST) combined with eltrombopag is the first-line treatment regimen for severe aplastic anemia patients who are ineligible for allo-hematopoietic stem cell transplantation (allo-HSCT). However, there was no second-generation TPO receptor agonist available in China before 2019, and only a first-generation TPO preparation was available for clinical treatment. Although rhTPO and eltrombopag act on different receptor binding sites, the differentiation pathways are similar, so rhTPO can theoretically also stimulate hematopoietic stem cells and promote hematopoietic recovery in AA. In 2015, we used rhTPO combined with IST as the first-line treatment for SAA. The results showed that the OR and quality of response in the rhTPO group were significantly higher than those in the control group. Multivariate analysis showed that the application of rhTPO was an independent prognostic factor affecting the efficacy of IST. Based on these results, we performed a single-center, randomized, open-label, parallel-controlled clinical trial to assess the hematologic response rate and long-term safety 3, 6, and 12 months after treatment. The study was conducted between 2015 and 2019 with 188 patients with primary SAA who were randomly assigned to the control or rhTPO group (95 with IST alone and 93 with rhTPO). For rhTPO, 15000 IU was administered subcutaneously starting on day 14 after p-ATG administration and then once every other day for a total of 14 injections. The median age of the 93 patients in the rhTPO group was 33 years (range 16-67). These included 58 patients with SAA and 35 patients with very severe aplastic anemia (VSAA), which were comparable to the control group. There were no significant differences in baseline clinical parameters between groups. No significant differences were observed in the overall hematologic response rates at 3, 6, and 12 months between the rhTPO and control groups (3 months: 40.9% vs 41.1%, P = 0.979; 6 months: 52.7% vs 52.6%, P = 0.994; 12 months: 65.6% vs 63.2%, P = 0.782, respectively). The median time of platelet transfusion independent was 49 (0-376) days in the rh-TPO group and 47 (0-195) days in the control group, which was not different between the two groups ( P = 0.757). The median time of RBC transfusion independence was 47 (5-404) days and 49 (0-295) days, respectively ( P = 0.592). The median follow-up time was 64 (1.3-86.2) months. The 5-year overall survival was 86.4% (95% confidence interval [CI], 77.2-92.0%) in the rh-TPO group and 84.1% (95% CI, 74.5-90.3%, P = 0.898) in the control group. The 5-year event-free survival was 51.7% (95% CI, 41.0-61.5%) and 54.1% (95% CI, 43.5-63.6%, P = 0.947) in the two groups, respectively. No significant differences were observed in the relapse rate and clonal evolution rate between the two groups (11.5% vs. 11.7%, 4.3% vs.3.2%, repectively). Subcutaneous rhTPO injection was well tolerated by patients, with no significant adverse effects other than mild localized pain at the injection site. The patients in the rhTPO group did not have concomitant thrombotic or embolic complications; moreover, reticulo-fibrillary or collagen fibrillary hyperplasia in bone marrow was not detected in any patients at three and six months after IST. Ten patients had anti-TPO antibodies at the end of TPO treatment, with no positive anti-TPO antibodies. In conclusion, our study is the only prospective randomized controlled clinical trial in China of rhTPO combined with IST for the treatment of SAA, with no difference in the hematologic response rate of the 28-day rhTPO combination regimen compared to standard IST; however, we did confirm the safety of rhTPO at this dose. Further clinical studies are required to determine the most effective dosage and duration of rhTPO treatment.

The Additional Value of Activated Clotting Time-Guided Heparinization During Interventions for Peripheral Arterial Disease.

Unfractionated heparin is widely used to lower the risk of arterial thromboembolic complications (ATECs) during interventions for peripheral arterial disease (PAD), but it is still unknown which heparin dose is the safest in terms of preventing ATECs and bleeding complications. This study aims to evaluate the incidence of complications during interventions for PAD and the relation between this incidence and different heparinization protocols. A retrospective analysis of a prospective multicenter cohort study was performed. Between June 2015 and September 2022, 355 patients who underwent peripheral interventions for PAD were included. All patients who were included before July 2018 received 5000 international units (IU) of heparin (group 1). Starting from July 2018, all included patients received an initial dose of 100 IU/kg, with potential additional heparin doses based on activated clotting time (ACT) values (group 2). Data on ACT values and complications within 30 days post-procedurally were collected. In total, 24 ATECs and 48 bleeding complications occurred. In group 1, 8.7% (n=11) of patients suffered from ATEC, compared with 5.7% (n=13) in group 2. Thirteen percent of patients (n=17) in group 1 had a bleeding complication, compared with 14% (n=31) in group 2. Arterial thromboembolic complications were more often found in patients with peak ACT values of <200 seconds, compared with ACT values between 200 and 250 seconds, 15% (n=6) versus 5.9% (n=9), respectively, p=0.048. Patients with peak ACT values >250 seconds had a higher incidence of bleeding complications compared with an ACT between 200 and 250 seconds, 24% (n=21) versus 9.8% (n=15), respectively, p=0.003. Forty-four percent of patients (n=23) in group 1 reached a peak ACT of >200 seconds, compared with 95% (n=218) of patients in group 2 (p=0.001). ATEC was found in 6.8% (n=24) and bleeding complications in 14% (n=48) of patients who underwent a procedure for PAD. There was a significantly higher incidence of ATECs in patients with a peak ACT value <200 seconds, and a higher incidence of bleeding complications in patients with a peak ACT value >250 seconds. The findings obtained from this study may serve as a basis for conducting future research on heparinization during procedures for PAD, with a larger sample size. Heparin is administered during arterial interventions for peripheral arterial disease (PAD) to decrease the risk of arterial (thrombo)embolic complications (ATEC) during or shortly following surgery. The effect of heparin is unpredictable in the individual patient, and the optimal dosage of this anticoagulant has not yet been established. Using the activated clotting time (ACT), the anticoagulatory effect of heparin can be monitored periprocedurally. Previous research on the incidence of both ATEC and bleeding complications, or on the optimal dosage of heparin administration, is scarce. This study aims to investigate the incidence of ATEC and bleeding complications between 2 different dosage protocols of heparin-a standard bolus of 5000 IU or ACT-guided heparinization-and thereby provide clarity on the optimal dose of heparin during peripheral arterial interventions for PAD.

The efficacy and safety of direct oral anticoagulants compared with low-molecular-weight heparin for venous thromboembolism prophylaxis after surgical resection of primary lower extremity bone or soft-tissue sarcoma.

The incidence of postoperative venous thromboembolism (VTE)and wound complications is greater after sarcoma resection. We sought to identify differences in postoperative VTE and bleeding complications with direct oral anticoagulants (DOACs)versus low-molecular-weight heparin (LMWH)following resection of lower extremity primary bone or soft tissue sarcoma. We retrospectively identified 2083 patients from the PearlDiver database who underwent resection of primary bone or soft tissue sarcoma of the lower extremity from January 2010 to October 2021 and prescribed LMWH or DOAC within 90-days postoperatively. The primary outcomes were comparison of postoperative incidence and odds of deep venous thrombosis(DVT), pulmonary embolism(PE), and bleeding complications within 90-days following resection. Patients prescribed DOACs had a greater odds of DVT (odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.06-2.41;p = 0.024) and PE (OR: 3.38;95% CI: 1.96-5.86;p < 0.001) within 90-days following resection of bone sarcoma when compared withthe LMWH cohort. Patients undergoing resection of soft tissue sarcomas also had greater odds DVT (OR: 1.65;95% CI: 1.09-2.49;p = 0.016) and PE (OR: 2.62;95% CI: 1.52-4.54;p < 0.001) in the DOAC cohort. There was no difference in the odds of bleeding complications. This study demonstrated an increased incidence and odds of VTE, but not bleeding complications, when using DOACs versus LMWH after primary bone or soft tissue sarcoma resection. Level III.

Acute infections and inflammatory biomarkers in patients with acute pulmonary embolism

Abstract Background Although pneumonia is considered a common complication of acute pulmonary embolism (PE), the true incidence of infections after PE and the effect of infections on patient outcome are insufficiently studied. Purpose To investigate incidence and prognostic impact of acute infections and inflammatory biomarkers in patients with acute PE. Methods Consecutive PE patients enrolled in a prospective single-centre registry between 09/2008 and 02/2019 were studied. We excluded patients with (1) missing C-reactive protein (CRP) measurements at the time of PE diagnosis, (2) cardiopulmonary resuscitation as the presenting symptom, and (3) other acute cardiopulmonary or infectious disease responsible for the clinical presentation. We evaluated the incidence and impact of infections requiring antibiotic treatment and of inflammatory biomarkers (CRP and procalcitonin [PCT]) on the primary study outcome (hemodynamic insufficiency or in-hospital all-cause death) and the duration of the in-hospital stay. Results We analysed data from 749 patients (age 69 [interquartile range (IQR) 56-78] years). The primary study outcome occurred in 65 (8.7%) patients. Of 26 (3.4%) patients who died during the in-hospital stay, 17 (65.4%) deaths were due to PE and 6 (23.1%) due to infections. During the first 7 days after PE 347 (46.3%) patients required antibiotic treatment; in 79.6% due to pneumonia (Figure). On multivariate logistic regression analyses, antibiotic treatment increased the risk for the primary outcome with an OR of 3.12 (95% confidence interval [CI] 1.70-5.74), similar to an increase in one risk class of the ESC 2019 risk stratification algorithm (OR 3.45 [95% CI 2.24-5.30]). Furthermore, patients requiring antibiotic treatment had a longer duration of in-hospital stay compared to patients with no antibiotic treatment (11.0 vs. 7.0 days, p&amp;lt;0.001). At presentation, the majority of patients (86.4%) had CRP elevations above the upper limit of normal (median 33.5 [IQR 11.4-71.2] mg/l) and 34.2% had elevated PCT levels (median 0.05 [IQR 0.03-0.10] µg/l). CRP &amp;gt;124 mg/l and PCT &amp;gt;0.25 µg/l predicted the main study outcome with &amp;gt;90% specificity and odds ratios (OR) of 4.64 (95% CI 2.52-8.21) and 6.88 (95% CI 3.48-13.59), respectively. Furthermore, the predictive value associated with elevated inflammatory markers was independent of established risk factors for early mortality such as elevated troponin and the simplified Pulmonary Embolism Severity Index (sPESI). Conclusion Clinically relevant infections requiring antibiotic treatment occurred in almost half of patients with acute PE and carried a similar prognostic effect as an increase in one risk class of the ESC 2019 risk stratification algorithm. Furthermore, elevated levels of CRP and PCT were independent predictors of adverse outcome.Indications for antibiotic treatment

The impact of Covid-19 on mortality and clinical characteristics in hospitalized patients with peripheral artery disease in the year 2020

Abstract Background The Covid-19 pandemic developed its full destructive capacity and caused over 6.6 million confirmed deaths worldwide in the year 2020. This retrospective study aimed to examine the effects of Covid-19 on the mortality and clinical characteristics of peripheral artery disease (PAD) patients because these chronically ill patients are at risk for arterial embolic vascular complications and a fatal outcome. Methods and results From a German nationwide registry of 2020 all patients hospitalized with PAD (n=173.075) were compared in four different groups. The first group had no additional diabetes mellitus type 2 or Covid-19 (n=110.531), the second diabetes mellitus but no Covid-19 (n=59.991), the third diabetes mellitus and Covid-19 (n=1497) and the fourth no diabetes mellitus but Covid-19 (n=1056). Mortality rates in all PAD patients without Covid-19 were low and ranging between 1.1-3.6%, depending on PAD classification. However, PAD patients with Covid-19 had significantly higher mortality rates of 11.1-12.6%. Clinical characteristics and the Charlson- comorbidity index surprisingly revealed that PAD patients with Covid-19 but without diabetes mellitus presented more complications such as higher rates of stroke (1.4%), cardiogenic shock (3.3%), chronic kidney failure with GFR &amp;lt; 15 ml/min (10.5%) and prolonged ventilation time &amp;gt;48 hours (4.4%). Conclusion Covid-19 massively increased death rates in PAD patients in the year 2020. Neither disease severity of different stages of PAD nor additional diabetes mellitus had an effect on in-hospital mortality. One explanation of this finding might be that the risk for arterial embolism increases after a Covid-19 infection and thus leads to higher mortality rates in PAD patients, who are in danger for vascular/embolic complications. Our study reveals the importance of preventing the spread of Covid-19 disease, especially in the case of patients with atherosclerotic diseases.

Investigation of Plasminogen Activator Inhibitor-1 (PAI-1) 4G/5G promoter polymorphism and other thrombophilia genes in patients with acute pulmonary embolism

Abstract Background Venous thromboembolism (VTE) is a serious threat to life and health, commonly known as the silent killer. Recent study has found that VTE is a polygenetic disease and more than 60% of deep vein thrombosis risk is influenced by genetic factors [1]. PAI-1 is a serine protease with negative feedback to fibrinolysis, activating and inhibiting coagulation [2]. The aim of this study was to elucidate the clinical impact of the PAI-1 4G/5G polymorphism and other thrombophilia in patients with acute PE. Methods A total of 58 subjects with acute PE and 60 healthy controls, were recruited in Institute of Cardiology. The accuracy of the RT-PCR method for detecting F5 G1691A (FVL) and PAI-1 4G/5G polymorphisms was evaluated by using sequencing method as the gold standard. Moreover, the association of the PAI-1 4G/5G polymorphism with susceptibility, treatment efficacy and recurrence status were explored. Eventually, we evaluated the association with inherited thrombophilia genes, such as the coagulation Factor V Leiden, prothrombin G20210A, FGB-455 G/A and methylenetetrahydrofolate reductase C677T and 1298 A/C. Results It was noted that the vast majority of patients with acute PE (87.9%) present polymorphism in the PAI-1 gene (29.3% homozygous (4G/4G) and 58.6% heterozygous (5G/4G)). Eleven patients out of 58 (19% of patients) showed factor V Leiden mutation and 19 patients out of 58 (32,7% of patients) showed mutation in FGB-455 G/A (2 homozygotes); MTHFR C677T gene mutation was found in 55,2%, while prothrombin 20210A gene mutation was presented in 6 patients (10.3% of patients). Nine patients (15,5% of patients) presented with chronic complication of VTE and 38.7% of patients showed recurrent pulmonary embolism. More than a half of patients (51.9%) had multiple gene mutation and only one presented with mutations in three studied genes. It showed a significant difference in the occurrence of other thromboses in the body and significant increase in the recurrence of pulmonary embolism and residual complications in these patients. It was also observed that individuals with the 4G/5G genotype had lower neutrophil counts and neutrophil-to-lymphocyte ratio (NLR) than the 5G/5G genotype. Furthermore, it was underlined that the patients with the 5G/5G genotype were more likely to achieve complete recanalization compared to the 4G/4G genotype. Individuals carrying the 5G/5G genotype were more likely to develop a recurrence-free status as compared to those with the 4G/4G or 4G/5G genotypes. PAI-1 antigen levels in the VTE group were significantly higher than those in the HC group. Conclusion The PAI-1 4G/5G polymorphism has potential value in assessing the prognosis of patients with VTE. This study has laid the foundation for the application of PAI-1 4G/5G polymorphism in the personalized management and monitoring of patients with VTE. According to this study results PAI-1 4G/5G polymorphism could be included in laboratory testing panel of thrombophilia.

Abstract 18878: Right Heart Valves Affected by Cancer-Related Non-Bacterial Thrombotic Endocarditis as Potential Cause of Pulmonary Embolism

Background: Ca-NBTE primarily affects the mitral valve (MV) and aortic valve (AV), with rare involvement of the right heart valves. Premortem descriptions of this condition are limited to a few case reports. This study presents an initial clinical series focusing on patients with Ca-NBTE specifically affecting their right heart valves. We describe the underlying cancers, types of valve lesions, and associated embolic complications. Patients and Methods: A electronic search of medical records (March 31, 2002, to June 30, 2022) was followed by a manual review to identify adult patients with echocardiographically detected NBTE, active cancer, and no infectious endocarditis or lupus anticoagulant/antiphospholipid antibodies. Results: Out of 115 identified patients with Ca-NBTE (mean age 63.2±9.7 years, 66.1% female), there were 8 cases (7.0%) affecting right heart valves (mean age 64.5±12.1 years, 3 females) with underlying cancer: pancreatic (n=3), lung (n= 2), genitourinary (n=1), gastric (n=1) and neck sarcomatoid carcinoma (n=1). TV was affected in 8 patients and PV in one case; 4 patients had Ca-NBTE limited only to PV, 2 patients had MV and TV, 1 patient had mitral, aortic and TV, and 1 patient with pancreatic cancer had all four valves affected by NBTE. 5 patients had embolic complications to the brain with one patient in that group also experiencing emboli to the kidney and spleen. Out of 4 patients with NBTE limited to TV, two still had brain emboli, one had only pulmonary embolism, and one patient had no embolic complications. Conclusion: Around 7% of Ca-NBTE cases involve the right heart valves, with half of these cases limited to the TV. The cancer profile in these cases resembles that seen in left heart valve involvement.

Abstract 12823: As Anticoagulation Use Increases, Embolic Events Downtrend in Atrial Fibrillation Hospitalizations

Background: Direct oral anticoagulants and Left atrial appendage closure (LAAC) were approved for use in 2010 and 2015, respectively. Data on temporal changes in stroke prevention strategies and rates of embolic complications in atrial fibrillation (AF) in the 2010s decade are limited. Aims: Describe trends in long-term anticoagulation (AC), LAAC use, and in-hospital AF associated ischemic stroke (IS), transient ischemic attacks (TIA), and systemic embolic events (SEE) between 2010 and 2019. Methods: The national inpatient database was used to identify patients with AF from 2010 to 2019. Data were divided into 2 eras: 2010-2014 and 2015-2019. Results: A total of 40,787,136 inpatients with AF were identified: prevalence increased from 18,594,372 in 2010 to 2014 (46%; mean [SD] age 75.5 [12.0] years; 50.3% male) to 22,192,764 in 2015 to 2019 (54%; mean [SD] age 75.1 [11.8] years; 52.5% male). There was a marked increase in long-term AC use (27.2% to 40.2%; P=0.001) and rates of percutaneous LAAC procedures (0.01% to 0.6%; P &lt;0.001) from 2015 to 2019. IS rates among patients with AF increased from 2010 to 2014 (3.5% to 3.8%; P=0.04), with no significant temporal change from 2015 to 2019 (P=0.84). TIA rates declined from 2010 to 2014 (1.2% to 1.0%; P=0.017) and continued a downtrend from 2015 to 2019 (0.9% to 0.7%; P=0.002). There was no temporal change in SEE or the composite outcome of all embolic events from 2010 to 2014, followed by a decline from 2015 to 2019 in SEE (0.5% to 0.4%; P 0.012) and all embolic events (5.1% to 4.8%; P 0.026) ( Figure 1 ). Mean rates of major bleeding events increased from 5.7% in 2010-2014 to 9.1% in 2015-2019 (P &lt;0.001). Conclusion: In an inpatient AF population, the composite outcome of all embolic events and specifically SEE downtrend from 2015 to 2019, likely due to increased AC use. Further data assessing the risk-benefit ratio of available therapies for stroke prevention in inpatients with AF - AC and LAAC - are needed to optimize personalized strategies.

Abstract 16055: Marantic Endocarditis - A Rare Paraneoplastic Presentation of Ovarian Carcinoma

Introduction: Nonbacterial thrombotic endocarditis (NBTE) or Marantic endocarditis, involves formation of sterile platelet &amp; fibrin thrombi on undamaged cardiac valves &amp; adjacent endocardium. The vegetation is associated with embolization. Case presentation: A middle-aged female without cardiac history presented to the ED with blurred vision &amp; fatigue for 3 days. The patient was afebrile with a BP of 183/97mmHg. Physical examination showed decreased visual acuity in the left eye. The EKG was normal. The patient underwent a CT scan brain that showed suspicion of bilateral occipital strokes. MRI brain revealed multiple small acute infarcts in the bilateral cerebral hemispheres &amp; cerebellum. Blood cultures were negative. Telemetry did not show atrial fibrillation. Given a suspicion of cardioembolic stroke, the patient underwent a transesophageal echocardiogram (TEE) which demonstrated a trileaflet aortic valve (AV) with abnormal irregular thickening of leaflets, concerning for vegetation &amp; moderate-severe aortic regurgitation (AR). figure 1. Our patient was diagnosed with marantic endocarditis based on TEE &amp; serial negative cultures. Apixaban was started. Further workup of the patient revealed bilateral pulmonary emboli. Abdominal imaging revealed a pelvic mass, ultimately diagnosed as clear-cell ovarian cancer. Interval TEE at 3 months demonstrated complete resolution of vegetations with preserved cusp motion &amp; mild AR. A shared decision was made to continue lifelong anticoagulation. Discussion: NBTE commonly involves mitral &amp; AV. Risk factors include trauma, circulating immune complexes, hypercoagulability, malignancy &amp; acute inflammation. Symptoms result from embolization, valve dysfunction, or impaired cardiac function. It is based on imaging after ruling out infectious etiologies. Management is anticoagulation &amp; valve replacement with the treatment of the underlying etiology. Valve replacement prevents future embolic complications.

“Catheter Kissing” Technique to Recanalize Chronic Total Occlusions in Iliac Artery with Wire-Catheter Approach

PurposeTo describe a technique in which two 5-F curved catheters were utilized to facilitate the wire-catheter approach for recanalizing chronic total occlusions (CTOs) in the iliac arteries concurrently affecting the common iliac artery and external iliac artery. MethodsThis was a single-center retrospective analysis involving endovascular recanalization of 17 iliac artery CTOs in 15 patients (mean age: 73.66 years; all men) between January 2019 and October 2022 using the subintimal arterial flossing with antegrade–retrograde intervention technique. With antegrade and retrograde guidewires in the subintimal spaces of CTOs, the location where the two guidewires seemed to overlap was identified as the rendezvous point. Although the two guidewires appeared to be in close proximity, there was no evidence that the bidirectional subintimal channels were connected. If several initial attempts failed, two 5-F multipurpose catheters were introduced to the rendezvous point, followed by twisting, pulling, and pushing maneuvers until the tips of the catheters touched, indicating that the bidirectional subintimal channels were joined. A second wire rendezvous attempt was then employed to create a flossing-type guidewire. Outcome measurements included technical success, rendezvous points, complications, and procedure duration. ResultsAmong this cohort, 80.0% smoked and 66.7% had hypertension. In 11 limbs (64.7%), when initial wire rendezvous attempts failed, the "catheter kissing" technique was employed to successfully recanalize iliac artery CTOs, taking an average of 3.80 ± 1.64 minutes to complete the secondary wire rendezvous. The average length of CTOs was 111.06 ± 9.99 mm, with 7 (41.2%) and 8 (47.1%) cases exhibiting severe calcification and flush occlusion, respectively. The wire rendezvous point for all cases was in EIA and the average time for successful secondary wire rendezvous was 3.80 ± 1.64 minutes. All patients were treated with iliac artery stents. No statistically significant difference was observed between the puncture sites of the common femoral artery and superficial femoral artery in relation to failure of the primary wire rendezvous (p = 0.644). No in-hospital deaths or complications were associated with the procedure, including iliac artery rupture, distal embolization, or access site complications. ConclusionIn patients with extensive iliac artery CTOs, the "catheter kissing" technique may offer an effective and time-efficient recanalization approach, without requiring additional specialized devices. Importantly, the risk of complications remains unchanged even when employing a wire rendezvous in a challenging subintimal space.