High Risk Of Thromboembolic Complications Research Articles

FEATURE OF CORONAVIRUS DISEASE IN PATIENTS WITH ARTERIAL HYPERTENSION AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Relevance. The combination of coronavirus disease (COVID-19) with arterial hypertension (AH) and chronic obstructive pulmonary disease (COPD) is associated with decreased saturation, general clinical signs of inflammation, coagulopathies and worsens the course and prognosis of the disease. That is why it is important to identify all possible risk factors for complicated pathology for the prevention and timely treatment of this category of patients.
 Objective: to study the feature of coronavirus disease in patients with AH and COPD.
 Materials and methods. A total of 101 patients aged 30 to 80 years with COVID-19 were examined. The first group included 26 people with COVID-19 and COPD (GOLD 2, groups A, B), and the second group included 75 patients with COVID-19 and AH (I-III stages, 1-3 grade). The parameters of the general blood test, biochemical blood test, coagulation testing, D-dimer, C-reactive protein (CRP), and ferritin in the blood were studied.
 Results. Patients with COVID-19 and COPD had higher erythrocyte sedimentation rate (p> 0,05) and leukocytosis (p <0,05), as well as increased concentrations of creatinine (p < 0,05) and urea (p < 0,01) that indicates the presence of renal pathology. Patients with COVID-19 and AH had significantly lower prothrombin time (p < 0,05) and international normalized ratio (p < 0,05), as well as a higher prothrombin index (p <0,05), which indicates the benefits of the procoagulant properties of blood in this category of patients. The level of D-dimer (p> 0,05), CRP (p> 0,05), and ferritin (p <0,05) was higher in patients of the 2nd group, which indicates a more severe course of coronavirus disease, as well as more high risks of thromboembolic complications.
 Conclusions. The features of coronavirus disease in patients with hypertension indicate a more severe course of the pathology and a high risk of thromboembolic complications, as evidenced by the procoagulant properties of blood and a high level of D-dimer, CRP, and ferritin. According to the data of clinical and laboratory examinations in patients with COPD and COVID-19, there was a significant increase in creatinine, urea, and leukocytosis, which may indicate the addition of renal pathology.

Ocular manifestations of COVID-19 infection

The most common eye disease associated with SARS-CoV-2 infection is conjunctivitis. COVID-19 also predisposes to other manifestations and complications in the organ of vision, often very unusual or not suspected of viral etiology. Since patients infected with SARS-CoV-2 have a higher risk of thromboembolic complications, they may experience such far-reaching consequences as, for example, occlusion of a vein or central retinal artery. The paper presents cases of SARS-CoV-2 infection with ophthalmic symptoms.

Sequential low molecular weight heparin and rivaroxaban for venous thromboprophylaxis in pelvic and acetabular trauma.

Patients with pelvic trauma are at high risk of thromboembolic complications, but effective methods of prophylaxis are still to be accepted widely. The incidence of venous thromboembolism (VTE) has been reported to be as high as 61%, which represents the commonest cause of morbidity and mortality in this cohort. New oral anticoagulants are now available and may be used instead of LMWH injections for extended prophylaxis. Rivaroxaban has not been comprehensively considered in the previous pelvic and acetabular trauma literature, but its known benefits include increased patient compliance, especially in the minority of patients who are unable to self-administer injections, and that it does not require monitoring. All patients referred to our pelvic trauma service between 2015 and 2020 were considered for this study, exclusion criteria involved those patients who had contraindications to rivaroxaban, those who were referred to our service but were never managed at our centre and those managed by other teams (e.g. neurosurgery). Operative patients were initially managed with LMWH until 24h post-operatively when they started rivaroxaban. Conservatively managed patients started Rivaroxaban straight away. Data were collected on demographics, injury mechanism, fracture classification and clinically relevant VTE and bleeding events up until 3months post discharge. The overall incidence of VTE was 2%. These represented 3 DVTs and 3 PEs, and occurred in patients who were managed operatively. No major bleeding events were observed. There were two minor bleeding events, both occurring in patients who were managed conservatively with rivaroxaban alone, and they did not require further intervention. 90% of patients surveyed expressed preference for oral prophylaxis. Reported compliance with rivaroxaban was 100%. Our data show that this VTE regimen protocol is safe and effective in this group of injured patients and is at least non-inferior to the standard prophylaxis of LMWH alone.

Haematology department nurses training makes a positive shift in reduction of in-hospital cardiac mortality

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Due to general profile of emergency hospital it is lacking of regular specific training courses for nurses. Haematology department is the one that has a great number of complications after immunosuppressive and chemo-therapy that is why skills in acute cardiovascular care are crucial for haematology healthcare professionals. Training of basic skills of management of acute cardiac events for nurses that work with haematological patients should be considered as routine practice in order to improve patients’ care. Purpose Science is not a study, but an observation of what is around us, therefore we made a registry of acute cardiovascular events over the hospital departments and defined a need for acute cardiovascular training for nurses in haematology department. Methods Data analysis of 1 year observational study of acute cardiac events at emergency hospital was done. Nurses of haematology department were specifically instructed to provide first aid and contact internal medicine doctor on duty in case of signs of cardiovascular events in patients with acute lymphoblastic leukemia that were under 21-st day of chemotherapy due to high risk of thromboembolic complications. Among 573 cases, 110 cases were cardiovascular events diagnosed and managed at haematology department by emergency care multidisciplinary team of internal medicine doctor on duty and haematology nurses. For statistical analysis Microsoft Excel v.2019 was used. Results At haematology department of emergency hospital we detected 110 cases of cardiovascular events. Among them 50 cases of ST-elevation myocardial infarction (STEMI) treated in the first 10 minutes of the episode with successful outcome, 45 cases of ischemic stroke, only 5 of which were lethal due to severity of neurologic disorders, 15 cases of pulmonary embolism with successful outcome. Conclusion Training on acute cardiovascular care for haematology department nurses was beneficial and contributed to lower hospital mortality.

RISK OF THROMBOSIS IN PATIENTS WITH GYNECOLOGICAL CANCERS OF VARYING EXTENT

The tumour process in the female reproductive organs is known as a trigger for the development of thromboembolic complications. Tumour growth, surgery, anticancer therapy, venous catheters and physical inactivity contribute to the risk of thrombosis. There are numerous instances when even under adequate thromboembolism prevention patient may develop deep vein thrombosis resulting in further thrombi migration throughout the body. Such migration can lead to lethal outcome and, unfortunately, nullifies all treatment measures carried out as well as results in significant economic losses. Viewing the problem in a whole requires constant monitoring of blood parameters in dynamics with the interpretation and evaluation of the findings obtained. The purpose of this study is to compare blood parameters of gynaecological patients with a tumour process in the reproductive organs, who are undergoing treatment, have already undergone surgery or have sought medical assistance for the first time.
 The study included 43 women, who were divided into groups: the control group involved 14 patients; 17 women with cervical cancer; 8 women with the uterine body cancer; 4 women with ovarian cancer. In all groups, except for the control group, the investigations were carried out before the beginning of treatment, during and after the treatment.
 The comparison of the blood indicators in the women during the treatment and in post-operative period following the tumour removal demonstrated insignificant changes in the indices of coagulation system, even when taking into account the measures to prevent thrombogenesis. After the counting, the indices confirmed their statistical significance. All women, except those in the control group, demonstrated an increase in the level of all blood parameters, which are responsible for the formation of blood clots and indicate hypercoagulation. We noticed that the risk of blood clots in the female patients with tumours of the reproductive organs remained high, regardless of the localization of the process and the methods of treatment. It is not known exactly to what extent blood count findings would have changed without prescribing thromboembolism prevention course for gynaecological cancerous patients.
 This study has shown the risk of thrombus formation in gynaecological oncology always remains high. The activation of the blood coagulation system occurs in all patients with cancerous diseases of the female reproductive organs of different localization. Surgical intervention or the anticancer therapy stimulates the blood coagulation function, and preventive treatment with pharmacological and mechanical methods does not make it possible to control these indicators in the first days after the operation. The patients with tumours of the female reproductive organs should be included in the group of patients with a high risk of thromboembolic complications.

Single-center Experience with Venous Thromboembolism Prophylaxis for Obese Burn Patients.

Burn injured patients are at high risk of thromboembolic complications. Morbid obesity further increases this risk. Our objective was to evaluate the efficacy of enoxaparin dosed 40 mg twice daily in achieving prophylactic plasma anti-Xa levels in obese burn patients. A retrospective chart review from November 2018 until September 2019 identified patients who were either ≥100 kg or had a body mass index ≥30 kg/m2 and initiated on enoxaparin 40 mg twice daily for venous thromboembolism prophylaxis. Patients were ≥18 yr of age and received ≥3 sequential doses of enoxaparin with appropriately timed peak plasma anti-Xa levels to monitor efficacy. One hundred forty-eight patients were screened with 43 patients included for analysis. Forty-two percent of the patients did not reach target peak plasma anti-Xa levels (0.2-0.5 IU/ml) on enoxaparin 40 mg twice daily. Patients who did not meet prophylactic target levels were more likely to be male (P < 0.05) and have an increased mean body weight (129 ± 24 kg vs 110 ± 16 kg, P < 0.05). Thirteen out of 18 patients received dosage adjustments with subsequent anti-Xa levels available for follow-up assessment, of which an additional six patients required further dosage adjustment to meet prophylactic goals. Current utilization of a fixed 40 mg twice daily regimen of enoxaparin for venous thromboembolism (VTE) is inadequate to meet target prophylactic peak plasma anti-Xa levels in the obese burn patient population. Dose adjusting enoxaparin to target anti-Xa levels to reduce VTE rates in obese burn patients should be further evaluated.

Thromboembolic Adverse Drug Reactions in Janus Kinase (JAK) Inhibitors: Does the Inhibitor Specificity Play a Role?

Recent advances in immunology enabled the characterization of several signal transmitting pathways responsible for proper cytokine and chemokine signaling. Among them, Janus kinases (JAKs) are essential components of receptor activation systems. The discovery of JAK kinases enabled the synthesis of JAK kinase inhibitors (JAKi or Jakinibs), which have proven to be efficacious in the treatment of hematologic malignancies and several rheumatological disorders and continue to be investigated in many clinical indications. Blocking multiple cytokines belonging to several cytokine families with a single small molecule may, however, create a potential risk for the patients. Recently, a higher risk of thromboembolic complications, namely, deep vein thrombosis and pulmonary embolism, has been recognized as the main concern during treatment with Jakinibs. At present, it is not entirely clear whether this increased risk is related to direct cytokine blockade, the presence of concomitant diseases in treated patients or other unknown circumstances that work together to increase the risk of this side effect. In this review, we discuss data on the risk of thromboembolic side effects, with special emphasis on the mechanism that may be responsible for this increased risk. Many indirect data indicate that higher thromboembolic risk may be related to the specificity of JAK inhibitor action, such that preferentially blocking one signaling pathway upsets the balance between pro and anti-thrombotic activities.

Safety of Direct Oral Anticoagulants in Central Nervous System Malignancies.

Patients with brain tumors are at high risk for thromboembolic complications and frequently require anticoagulation. Direct oral anticoagulants (DOACs) are a less burdensome treatment for cancer-associated thrombosis with safety and efficacy comparable to those of low molecular weight heparin (LMWH); however, there are few data to support the use of DOACs in patients with brain tumors. The purpose of this study was to better understand the safety profile of anticoagulants in patients with primary and metastatic brain tumors, with particular interest in the safety and efficacy of DOACs. Our hypothesis was that DOACs are as safe and effective as LWMH in this population. This study was conducted through a single-center retrospective chart review of 125 patients with primary and metastatic brain tumors on anticoagulation. Our primary outcomes were major bleeding and intracranial hemorrhage (ICH), with secondary outcomes of minor bleeding and recurrent thrombosis. The rate of major bleeding was 26% in the LMWH group versus 9.6% in the DOAC group (p = .03). The rate of ICH was 15% in the LMWH group versus 5.8% in the DOAC group (p = .09). The severity of ICH in both groups was low with median Common Terminology Criteria for Adverse Events version 5 scores of 2 in the LMWH group and 3 in the DOAC group. The rates of minor bleeding and recurrent thrombosis were low in both groups. Our conclusion is that DOAC use in patients with brain tumors is not associated with increased rates of major bleeding compared with LMWH and is a safe and effective option. IMPLICATIONS FOR PRACTICE: Patients with brain tumors are at high risk for venous thromboembolism and frequently require anticoagulation. Direct oral anticoagulants (DOACs) are less burdensome than low molecular weight heparin (LMWH) for treatment of thromboembolism, but there is concern in the community over increased risk of bleeding. This study provides much-needed objective evidence that there are fewer major bleeding events in patients with brain tumors on DOACs compared to LMWH with similar efficacy. As the paradigm of anticoagulation in patients with cancer shifts from LWMH toward DOACs, this work is particularly meaningful as it suggests DOACs are safe and effective for patients with brain tumors.

Results and features of surgical treatment of lung cancer after previous COVID-19 pneumonia

To evaluate the features of preoperative preparation and postoperative outcomes in patients with lung cancer and previous COVID-19 pneumonia. There were 7 patients with non-small cell lung cancer and previous bilateral viral pneumonia between June 2020 and January 2021. In 3 cases, lung cancer was detected in a hospital for COVID-19 patients. Four patients had persistent structural changes in X-ray images. After appropriate preparation, all patients underwent total resection. At admission, all patients had severe physical and functional exhaustion associated with prolonged hypoxia and adynamia that required preoperative rehabilitation. Considering high risk of thromboembolic complications, we administered anticoagulation throughout the entire perioperative period and after discharge. Surgical treatment included anatomical resection (extended lobectomy). Postoperative complications occurred in 2 cases and were associated with prolonged air discharge through the pleural drainage tube. As we study the consequences of the new coronavirus infection COVID-19, it becomes obvious that a new category of patients requiring specific diagnosis and treatment has emerged.

Thromboembolism in cancer patients. What should anaesthesiologists know

Cancer patients are at high risk of thromboembolic complications (deep vein thrombosis, pulmonary embolism) which increase the morbidity and mortality rates. Τhe thromboembolic risk is further increased perioperatively in cancer surgery, rendering its prevention and management a clinical challenge. International Societies and Experts’ Panels have addressed this issue in an effort to fill in the existing gaps, since evidence is rather limited. Thromboprophylaxis should be given to all patients undergoing cancer surgery. It should include pharmacological agents and should be initiated preoperatively and/or as soon as possible postoperatively. Mechanical prophylaxis alone is not recommended, and should be reserved only for cases where pharmacological thromboprophylaxis is contraindicated. Combined pharmacological/mechanical thromboprophylaxis should be used in high risk patients. The patient risk factors, co-morbidities, procedure type/duration and the surgical bleeding risk should be carefully assessed before deciding the scheme, drugs, dosing and timing of thromboprophylaxis. Low Molecular Weight Heparin (is the preferred agent), Unfractionated Heparin (if creatinine clearance <30 mL/min) and possibly Fondaparinux can be used for thromboprophylaxis. There is no consensus on the use of inferior vena cava filters; they are not recommended as a routine thromboprophylactic measure, but their placement could be considered in patients with pulmonary embolism or lower limb proximal deep vein thrombosis (especially during the first 2–4 weeks), if anticoagulants are contraindicated. The risk of intervention-related adverse effects/complications should be taken into account. Postoperative pharmacological thromboprophylaxis should be maintained for at least 7–10 days. For high risk, major abdominal or pelvic surgery (laparotomy or laparoscopic), thromboprophylaxis should last longer (up to 4 weeks). Patients facing a high risk for both thrombosis and major bleeding should receive mechanical thromboprophylaxis first and pharmacological prophylaxis should be added as soon as possible. Early postoperative ambulation should be encouraged whenever possible.

Association between ROTEM Hypercoagulable Profile and Outcome in a Cohort of Severely Ill COVID-19 Patients Under Mechanical Ventilation

Introduction: Recently published data show that COVID-19 is characterized by a hypercoagulable ROTEM profile and decreased fibrinolysis. Multiple reports suggest that severe COVID-19 infection is associated with an increased thromboembolic risk. There are limited data associating a hypercoagulable ROTEM profile and outcomes in the literature. A hypercoagulable ROTEM profile could help identify patients at risk of worse outcome and help target a study population for enhanced anticoagulation therapy or other COVID-19 therapy.Objectives: To determine if early hypercoagulability on ROTEM is associated with a higher risk of thromboembolic complications or worse outcome, in a population of mechanically ventilated COVID-19 patients transferred to a tertiary ARDS/ECMO referral center.Methods: All COVID-19 patients receiving mechanical ventilation at our center between April 3 and June 15, 2020 were assessed with ROTEM. Testing performed included at least ExTEM and FibTEM. Patients were classified as hypercoagulable (HC) or not (nHC) using the following criteria from ROTEM: ExTEM clot formation time (E_CFT)< 40 sec, alpha (∝) angle >79° and, either ExTEM or FibTEM maximum clot firmness (E_MCF or F_MCF) >70mm or >24mm, respectively. Outcomes, assessed at discharge from our ICU, included thromboembolic events (TE: composite of deep vein thrombosis, pulmonary embolism and ischemic stroke), acute kidney injury (AKI: AKIN stage >2 with or without dialysis), duration of mechanical ventilation, requirement for ECMO, and death. Difference between groups was determined using the chi-square or Fisher-exact test for categorical data and a t-test for continuous variables respectively, using p<0.05 as significant.Results: Of 59 patients included, 31 were hypercoagulable (HC) on admission. Mean (SD) age was 52 (14), and SOFA score on admission was high 15 (2). The severity of disease was similar in both groups especially for the cardiac and respiratory SOFA components (Table 1). The composite outcome of TE was not different between the groups (HC 9/31, nHC 6/28, p=0.7). The composite renal outcome was not different (HC 18/31 vs nHC 16/28). Mortality rate (29%, HC 9 vs nHC 8), and the duration of ventilation in survivors (HC 22 vs nHC 22 days) were similar in both groups. Requirement for ECMO support was similar (HC 8 vs nHC 12, p= 0.27). Patients were tested with daily viscoelastic tests and, neither fibrinolysis nor DIC were documented. All patients received TE prophylaxis and 34 received therapeutic intravenous heparin for ECMO (n=20) or TE treatment (n=14). Initial ROTEM were conducted on therapeutic heparin in 22 cases (12 HC, 10 nHC).Conclusion: Our data suggest that in a population of mechanically ventilated patients with severe COVID-19, an early hypercoagulable profile on ROTEM was not associated with an increased risk of thromboembolic events, AKI, prolonged ventilation, ECMO or death during their ICU stay.DisclosuresKarkouti:Octapharma: Research Funding; Canadian blood services: Research Funding.

A European consensus statement on the use of four-factor prothrombin complex concentrate for cardiac and non-cardiac surgical patients.

Modern four-factor prothrombin complex concentrate was designed originally for rapid targeted replacement of the coagulation factors II, VII, IX and X. Dosing strategies for the approved indication of vitamin K antagonist-related bleeding vary greatly. They include INR and bodyweight-related protocols as well as fixed dose regimens. Particularly in the massively bleeding trauma and cardiac surgery patient, four-factor prothrombin complex concentrate is used increasingly for haemostatic resuscitation. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology performed a systematic literature review on four-factor prothrombin complex concentrate. The available evidence has been summarised for dosing, efficacy, drug safety and monitoring strategies in different scenarios. Whereas there is evidence for the efficacy of four-factor prothrombin concentrate for a variety of bleeding scenarios, convincing safety data are clearly missing. In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25IU.kg-1 . This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available. In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5IU.kg-1 ) should be considered. A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.

Does the CHA2DS2-VASc scale sufficiently predict the risk of left atrial appendage thrombus in patients with diagnosed atrial fibrillation treated with non-vitamin K oral anticoagulants?

The CHA2DS2-VASc scale does not include potential risk factors for left atrial appendage thrombus (LAAT) formation such as a form of atrial fibrillation (AF) and impaired kidney function. The real risk of thromboembolic complications in AF patients is still unclear as well as an optimal anticoagulant treatment in males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.The aim of this study was to compare the predictive value of the CHA2DS2-VASc scale and other scales to estimate the risk of LAAT formation in AF patients treated with non-vitamin K oral anticoagulants (NOACs) and to assess the prevalence of thrombi in patients at intermediate risk of stroke.The observational study included consecutive patients with a diagnosis of non-valvular AF treated with NOACs, admitted to 3 high-reference institutions between 2013 and 2018. All individuals underwent transoesophageal echocardiography before cardioversion or ablation.Out of 1163 enrolled AF patients (62.1% male, mean age 62 years) the LAAT had been detected in 50 individuals (4.3%). Among patients with LAAT, 1 patient (2.0%) was classified as a low-risk category, 9 (18.0%) were at intermediate-risk, and 40 (80.0%) were at high risk of thromboembolic complications according to CHA2DS2-VASc scale. All patients were treated with NOACs: 51.0% rivaroxaban, 47.1% dabigatran, and 1.9% apixaban.Patients at intermediate stroke-risk with detected LAAT had higher R2CHADS2 score (2.1 ± 1.2 vs 1.2 ± 0.8, P = .007), higher CHA2DS2-VASc-RAF score (6.4 ± 4.4 vs 3.7 ± 2.6, P = .027) and more often had an estimated glomerular filtration rate below 56 mL/min/1.73 m2 (44.4% vs 13.2%, P = .026) compared to patients without LAAT. The receiver operating characteristics revealed that the CHA2DS2-VASc-RAF scale had better predictive ability to distinguish between patients with and without LAAT in the study group than CHA2DS2-VASc (P = .0006), CHADS2 (P = .0006) and R2CHADS2 scale (P = .0140).The CHA2DS2-VASc scale should be supplemented with an assessment of renal function and form of AF to improve stroke risk estimation. The application of additional scales to estimate the risk of LAAT might be especially useful among males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.

A Delphi consensus on the management of oral anticoagulation in patients with non-valvular atrial fibrillation in Spain: ACOPREFERENCE study.

To evaluate the level of agreement between cardiologists regarding the management of oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (NVAF) in Spain. A two-round Delphi study was performed using an online survey. In round 1, panel members rated their level of agreement with the questionnaire items on a 9-point Likert scale. Item selection was based on acceptance by ≥66.6% of panellists and the agreement of the scientific committee. In round 2, the same panellists evaluated those items that did not meet consensus in round 1. A total of 238 experts participated in round 1; of these, 217 completed the round 2 survey. In round 1, 111 items from 4 dimensions (Thromboembolic and bleeding risk evaluation for treatment decision-making: 18 items; Choice of OAC: 39 items; OAC in specific cardiology situations: 12 items; Patient participation and education: 42 items) were evaluated. Consensus was reached for 92 items (83%). Over 80% of the experts agreed with the use of DOACs as the initial anticoagulant treatment when OAC is indicated. Panellists recommended the use of DOACs in patients at high risk of thromboembolic complications (CHA2DS2-VASc ≥3) (83%), haemorrhages (HAS-BLED ≥3) (89%) and poor quality of anticoagulation control (SAMe-TT2R2 >2) (76%), patients who fail to achieve an optimal therapeutic range after 3 months on VKA treatment (93%), and those who are to undergo cardioversion (80%). Panellists agreed that the efficacy and safety profile of each DOAC (98%), the availability of a specific reversal agent (72%) and patient's preference (85%) should be considered when prescribing a DOAC. A total of 97 items were ultimately accepted after round 2. This Delphi panel study provides expert-based recommendations that may offer guidance on clinical decision-making for the management of OAC in NVAF. The importance of patient education and involvement has been highlighted.

P0213CHRONIC KIDNEY DISEASE AND ATRIAL FIBRILLATION: RISK OF COMPLICATIONS

Abstract Background and Aims The assessment of the thromboembolic risk (TE) and transient ischemic attacks (TIA) in patients with chronic kidney disease (CKD) in combination with atrial fibrillation (AF) and the effect of complex treatment, including rivoraxaban. Method The study included 28 patients, 16 men and 12 women, average age - 57.8 ± 6.9 years. Patients with 3rd stage CKD (GFR 30-50 ml/min) associated with various forms of non-valve AF were examined. All patients were at high risk according to the classification of stroke risk stratification. The risk of thromboembolic complications was assessed using the CHA2DS2-VASc scale. Depending on the form of AF, patients with CKD were divided into 2 groups: with paroxysmal AF and CKD (n = 9) and persistent AF and CKD (n = 19). The average age in the 2 groups was 52.7 ± 6.4 and 58.4 ± 7.4 years, respectively. A history of 11 patients (39.3%) had ischemic stroke and TIA. All patients underwent echocardiography and transesophageal echocardiography (TE EchoCG). The peak blood flow velocity was a quantitative reflection of the hemodynamic state of left atrium (LA). Hemoglobin, creatinine, eGFR (CKD-EPI) and coagulogram were also monitored. Results According to the results of TE echocardiography, the size of the LA in patients with stage 3 CKD and paroxysmal AF is less than in the group of persistent AF (43.7±2.8 mm and 48.6±5.8 mm, respectively, p&amp;lt;0.05). The average value of the peak blood flow velocity was reduced in all patients - 34.88±10.59 cm/sec, in the presence of thrombosis this parameter significantly decreased - 24.3±2.49 cm/sec (p&amp;lt;0.001). Atrial thrombi were detected in 10 patients (35.7%). Spontaneous echocardiographic contrast (SEC) was found in 7 people (25%). We found that in patients with a thrombus in the auricle of the LA ejection fraction (EF) was significantly lower than in patients without thrombi. The average score on the CHA2DS2-VASС scale was 5. A higher incidence of a thrombus in the auricle of the LA was revealed in patients with persistent AF than paroxysmal AF (7 and 3, respectively). Only 15 patients (53.6%) received oral anticoagulants (OAC) on an outpatient basis, and 2 (7.1%) took aspirin. In the hospital, everyone was prescribed rivoraxaban in a dose of 15 mg once a day. After 4 weeks of treatment with rivoraxaban, from 7 patients with a revealed SEC during repeated TE echocardiography, the disappearance of SEC was observed in 4 patients (57%). In 6 patients (60%) was revealed thrombus lysis in the LA. In 16 (57.1%) patients was noted an increase in GFR above 50 ml/min. Coagulogram values in all patients throughout the observation were within normal limits. Conclusion TE echocardiography allows to distinguish among patients with stage 3 CKD and AF group with a high risk of stroke and TIA. The use of rivoraxaban for 4 weeks allows lysis of blood clots in the auricle of the LA in 60% of patients, and the disappearance of the SEC effect in 57% of cases. This allows us to recommend rivoraxaban for the treatment of patients with AF, especially with a high risk of thromboembolic complications.

Percutaneous Ventricular Assist Device Exclusion: Institutional Case Series and Review of Literature

Surgical left ventricular assist device (LVAD) explantation is associated with increased risk of perioperative mortality (9.2%), myocardial infarction (10.8%), stroke (4.9%), and postexplant infections (4.3%).1 Minimally invasive surgical strategies have been explored, but still expose patients to risks associated with blood transfusion and myocardial trauma during dissection of adhesions.2 Percutaneous LVAD exclusion can potentially avoid perioperative complications associated with surgical exclusion. In this case series, we examined our institutional experience and reviewed published data for risks and benefits associated with percutaneous LVAD exclusion. A total of four patients underwent percutaneous LVAD exclusion between 2011 and 2018 at our institution. Subsequently, we performed a systematic review of all reported cases of percutaneous LVAD exclusion published in Pubmed/Medline between the years 2011 and 2018 and identified seven additional cases. The cumulative results (n = 11) are presented in Supplemental Table 1 https://links.lww.com/ASAIO/A436. The average age of all patients was 44 ± 17 years, 7 (64%) were men, and 9 (82%) had non-ischemic cardiomyopathy. The average time between LVAD implantation and percutaneous LVAD exclusion was 16 ± 9 months. Majority of the patients underwent percutaneous LVAD exclusion for myocardial recovery (n = 7, 64%); four patients had LVAD-related complications (mainly, pump thrombosis) and were deemed poor surgical candidates for exchange or explant and were not suitable for transplant listing. Either an Amplatzer Vascular Plug II (St. Jude Medical, St. Paul, Minnesota) (n = 8, 73%) or an Amplatzer Septal Occluder (St. Jude Medical, St. Paul, Minnesota) (n = 3, 27%) were used to occlude the VAD outflow or inflow grafts. The type of Amplatzer device used to occlude the grafts was mainly based on operator’s preference. The average disc diameter of Amplatzer device used to occlude the outflow graft of HeartMate II device was 19 ± 2 mm and HeartWare LVAD was 13 ± 1 mm. The majority of implantations occluded the outflow graft (n = 9, 82%), while two cases reported occluding only the inflow graft (n = 2, 18%). The occlusion device was deployed at both proximal and distal portions of the outflow graft in the majority of the cases (n = 7, 64%). All cases reported successful LVAD exclusion. Following implantation, the driveline was excised followed by closing the open end with either Gore-Tex or BioGlue Surgical Adhesive (CryoLife Inc, Kennesaw, Georgia) in most cases. None of the cases reported any procedure related direct complications or death. The average reported postprocedure follow-up was 18 ± 11 months. For postexclusion stroke prophylaxis; majority of patients received warfarin with an INR goal range between 1.5 and 3. Nonetheless, one patient was discharged on daily Aspirin 100 mg only,3 while another did not receive any anticoagulation.4 The reason for using only Aspirin was not clarified by the authors while the patient without anticoagulation had percutaneous LVAD exclusion as a palliative option. However, both patients were reported to be alive without any cerebrovascular complications on long-term follow-up. These two cases suggest that warfarin might not be needed postexclusion for stroke prophylaxis, and further studies are required to validate this observation. Two of the four patients who underwent exclusion due to LVAD-related complications died within 2 weeks of the procedure, whereas the remaining seven patients who underwent exclusion for myocardial recovery were still alive at last reported follow-up. In summary, percutaneous LVAD exclusion appears to be associated with high procedural success and minimal procedural complications, and is potentially, an attractive alternative to conventional surgical exclusion. However, it is worth mentioning a few limitations of our study. First, percutaneous LVAD exclusion can theoretically be associated with higher risk of thromboembolic complications and therefore, necessitates lifelong anticoagulation. Second, the presence of retained LVAD hardware with direct endovascular access also carries the risk of endocarditis. However, neither of the abovementioned complications were reported in our review of these patients. A larger sample size or a longer follow-up period of these cases will be necessary to establish the incidence of the abovementioned potential long-term complications. Lastly, the publication bias also needs to be kept in mind which may have resulted in overestimation of the success rate of percutaneous LVAD exclusion. Prospective studies with larger sample size and longer duration of follow-up are necessary to accurately understand the risk and benefit associated with percutaneous LVAD exclusion. Acknowledgement The authors thank Balsara K., Brinkley M., Wigger M., Menachem J., Punnoose L., and Brown Sacks S. for their valuable clinical contribution.

Thrombophilia as a Risk Factor for Thrombosis

The review article presents a contemporary view on the most common causes of hereditary and acquired thrombophilias and their role in the development of venous and arterial thromboses. The examination of patients in accordance with modern requirements consists in determining the causes and risk factors for blood clot formation, as well as implementing secondary prevention of recurrent thrombosis. Analysis of genetic and acquired hemostatic disorders allows us to identify a group of patients who require long-term anticoagulant therapy and mandatory anticoagulant prophylaxis in cases involving a high risk of thromboembolic complications.

512 Single Center Experience with Venous Thromboembolism Prophylaxis for Obese Burn Patients

Abstract Introduction Burn injured patients are at high risk of thromboembolic complications. Morbid obesity further increases risk for thromboembolic complications. Recent evidence supports the use of anti-Xa guided enoxaparin dosing for the prevention of venous thromboembolism (VTE) in high risk populations. Our objective was to evaluate the efficacy of enoxaparin 40mg twice daily in achieving prophylactic plasma anti-Xa levels in obese burn patients. Methods A retrospective chart review of an ABA-verified burn center from November 2018 until September 2019 identified patients who were either ≥100 kilograms (kg) or had a body mass index (BMI) ≥ 30 kg/m2 and were initiated on enoxaparin 40 mg twice daily for VTE prophylaxis. Patients were included if they were at least 18 years of age and received at least three sequential doses of enoxaparin with appropriately timed peak plasma anti-Xa levels to monitor efficacy. Patient demographics were analyzed, as well as body weight, BMI, and total body surface area (TBSA) burn. Statistical analysis was performed with student’s t-test for continuous data and Fischer’s exact test for categorical data. Results During the study period, 148 patients were screened with 44 patients included for analysis. Forty-one percent of the patients evaluated did not reach target peak plasma anti-Xa levels (0.2–0.5 IU/mL) on enoxaparin 40 mg twice daily. Patients who did not meet prophylactic target levels were more likely to be male (p&amp;lt; 0.05) and have an increased body weight (129 +/- 24 kg versus 112 +/- 17 kg, p&amp;lt; 0.05). Eleven out of 18 patients received dosage adjustments with subsequent anti-Xa levels available for follow-up assessment, of which an additional four patients required further dosage adjustment to meet goal peak plasma levels. Conclusions Current utilization of a fixed 40 mg twice daily regimen of enoxaparin for VTE prophylaxis is inadequate to meet target prophylactic peak plasma anti-Xa levels in the obese burn patient population. Dose adjusting enoxaparin to target peak plasma anti-Xa levels to reduce VTE rates in obese burn patients should be further evaluated. Applicability of Research to Practice This study demonstrates the need for more accurate dosing and evaluation of our dosing practices for VTE prevention. It also demonstrates the importance of having a Burn dedicated pharmacist in facilitating appropriate care.

Impact of pulmonary vein anatomy on cryoballoon isolation results

Aim. To estimate the efficacy of pulmonary veins (PV) cryoballoon isolation in its different anatomical variants.Methods. 230 patients 57 (53; 62) years of age were enrolled in the study in approximately equal proportion of males and females. Up to 1/3 of patients suffered from isolated AF, most of them belonged to the category of high risk of thromboembolic complications. To evaluate the PV anatomical variant, a modified classification of E. Marom et al was used. In groups of cryoballoon and radio-frequency isolation, subgroups of typical and variant anatomy were distinguished. Evaluation of the effectiveness of the intervention was based on the identification of any (symptomatic and asymptomatic) documented episodes of atrial arrhythmias lasting more than 30 seconds during the observation period of 12 months.Results. Comparison of efficacy in typical PV anatomy did not reveal significant differences between cryo and RFA groups, regardless of the type of device used. Subgroup I of generation of cryoballoons showed freedom from AF 83.2%, II generation – 87.5%, RFA group – 82.7% at p = 0.82. At the same time, with PV variant anatomy, the efficiency of cryo isolation with the use of II generation devices was 52.2 versus 85.7% in the RFA group (OR = 0.25; 95% CI 0.09–0.71; p = 0, 02). When analyzing long-term results in cryo and RFA groups depending on the anatomical variant, it was found that with RFA, the presence of a left PV common trunk (collector / vestibule), as well as the presence of additional veins, showed results comparable with the group of typical anatomy. At the same time, in the cryoablation group, the presence of a left common trunk was accompanied by a decrease in efficiency to 23.1 versus 84.9% for typical anatomy (OR = 0.14; 95% CI 0.03–0.6; p = 0.02) and 90% in the presence of additional veins (OR = 0.1; 95% CI 0.01–0.64; p = 0.02). In the presence of a left common trunk, the efficiency of cryoablation using second-generation cylinders was 23.1 versus 82.4% in the RFA group (OR = 0.16; 95% CI 0.05–0.5).Conclusion. The presence of a left PV common trunk leads to a decrease in the effectiveness of cryoablation in the long-term observation period relative to the group of typical anatomy to 23.1 versus 84.9% (OR = 0.14; 95% CI 0.03–0.6) and 82.4% for radiofrequency ablation (OR = 0.16; 95% CI 0.05–0.5). The presence of additional veins of right-sided localization does not affect the effectiveness of the intervention.

Improving the Results of Surgical Treatment of Abscessed Cellulitis of the Fingers and Toes in Patients with a Moderate and High Risk of Thromboembolic Complications Developing

The article presents the experience of low molecular weight heparins usage in outpatient general surgery in compromised patients, namely with abscessed cellulitis of the fingers and toes affected by moderate and high risk of thromboembolic complications developing. The results of the study indicate that the low molecular weight heparins usage in patients with abscessed cellulitis of the fingers and toes affected by moderate or high risk of thromboembolic complications significantly reduces the chances and the probability of purulonecrotic complications in the area of intervention in the early postoperative period (OR = 4.32, RR = 3.60). Also, in this category of patients on the back of low molecular weight heparins usage significantly enhanced chances and probability (OR = 5.60, RR = 4.73) of the favorable treatment outcomes development are observed, consisting in the safekeeping of fingers (toes) and its functional activities.