High Risk Of Thromboembolic Events Research Articles

Thromboprophylaxis in gynaecology: a review of current evidence

Key content Thromboembolism is a major cause of preventable morbidity and mortality. Hospital acquired thrombosis (HAT) accounts for 50–60% of all thromboembolic events. As well as effects on patient safety, there are considerable cost implications to both prophylaxis and treatment. While guidance exists on thromboprophylaxis for patients in obstetrics and those undergoing general surgery, there is a paucity of guidance relating to gynaecological practice. Increasing prevalence of risk factors and multimorbidity is paralleled by higher risk of thromboembolic events. Gynaecological surgery presents some unique risk factors for thrombosis. Learning objectives To understand the basic pathophysiology of thrombosis in relation to risk factors particularly relevant to gynaecology and pelvic surgery. To know the current evidence in key areas relevant to gynaecological practice: early pregnancy; day case surgery; minimally invasive gynaecological surgery; open and complex benign gynaecology and gynaecological oncology. To be aware of proposed guidance on risk assessment and prophylaxis in thrombosis as relevant to the gynaecologist based on current evidence. Ethical issues Problems with thromboprophylaxis in high‐risk patients include noncompliance and refusing animal products/injections. Clinicians may be reluctant to institute thromboprophylaxis, most times because of the possible risks of bleeding.

299 LEFT VENTRICULAR APICAL THROMBUS

Abstract LV thrombus is a complication of AMI. It is estimated that 40-60% of patients with large anterior wall MI will develop a LV thrombus. The risk is highest during the first 3 months following AMI. Accurate and timely detection is important as it poses a high risk for thromboembolic events. Advances in technology have improved the detection rate of intracardiac thrombi, but several uncertainties still remain regarding the optimal treatment strategy within daily clinical practice. We report a case of large LV thrombus in a 61-year-old male with extensive anterior wall MI. A 61-year-old man, hypertension, former smoker, subjected to epatic orthotopic transplant for HCC and treated with immunosuppressive therapy (Everolimus), following development of lymphocytic leukemia in fu. He underwent thoracic ct, wich showed a hypodense imaging in the left ventricular apex referable to thrombotic formation large 2cm, with endocardial rim hypointense like ischemic outcomes. The ECG demonstrated Q waves in anterior leads and biphasic T waves in the same leads. The patient was absolutely asyntomatic. A transthoracic echocardiography, showed the apical mass (2×0,9cm) very mobile and akinesia and thinning of the left ventricol middle-apical wall with apical aneurysmatic evolution. A CMR, confirmed the presence of the thrombus and showed defects at the subendocardial layer of the anterior wall and interventricular septal with also involvement of all the apex; the burden of late gadolinium enhancement (ischemic pattern) extended to the same segment. Coronary angiography showed subocclusion involving the second tract of the left anterior descending (99%) and critical coronary stenosis of the third tract of the right coronary (70%). The thrombus was completely removed surgically through left atriotomy, in prevention of embolization due to the thrombus dimension, the motility and the labile docking station. The histological examination confirmed the thrombotic nature of the mass. International guidelines agree on recommending anticoagulation therapy for patients affected by left ventricular thrombosis. OAC with vitamin K antagonists should be started as soon as LVT is identified, as first-line therapy and parenteral anticoagulation should be discontinued when effective therapeutic range with warfarin has been achieved (INR of 2–3). European and American guidelines stressing the efficacy of parenteral therapy with heparin; there are no randomized trials that have examined the efficacy of VKA anticoagulation compared with parenteral therapy. DOACs are attractive alternatives because of their potential efficacy and safety even though there is no trial that proves the effect of DOACs in LVT. Oral anticoagulation should be discontinued as soon as thrombus resolution has been established. Surgical removal of the LVT is an option for patients with high embolic risk, as in our patient. The high morbidity and mortality of this approach outweigh the benefits of performing surgery solely for the indication of LVT.

Cryptogenic stroke. Part 3: atrial cardiopathy and silent atrial fibrillation

Atrial cardiopathy (AC) and silent atrial fibrillation (AF) are potential causes of embolic cryptogenic stroke (embolic stroke of undetermined source, ESUS) timely diagnosis of which can significantly change the direction of secondary prevention and reduce the risk of repeated brain catastrophe. The article discusses clinical and radiological markers of cardioembolism, the concept of atrial cardiopathy, its electrocardiographic, echocardiographic and serum markers, as well as the possibility of drug prophylaxis of recurrent stroke. The most applicable AC features in daily operation are the ECG data (p-wave terminal force in lead V1 > 5000 μV x ms, supraventricular extrasystoles and advanced interatrial block), 24-hour ECG monitoring (≥ 480 supraventricular extrasystoles per 24-hour, paroxysms of supraventricular tachycardia ≥ 20 complexes), transthoracic (diameter of left atrium > 40 mm, index of diameter of left atrium ≥ 3 cm/m2, index of volume of left atrium > 34 ml/m2) and transesophageal echocardiography (spontaneous echo contrast phenomenon, blood flow rate in LA appendage <20 cm/s) and NT-proBNP concentration > 250 pg/ml. An individual, interdisciplinary decision to prescribe an anticoagulant when combined: (1) the presence of structural and functional AC markers, (2) cardioembolic pattern of a cerebral infarction or intracranial artery occlusion by visualization data and (3) high thromboembolic risk and probability of detection of AF on assessment scales (CHA2DS2-VASc, AF-ESUS and C2HEST). The greatest benefit of prescribing anticoagulant therapy can be obtained by patients with recurrent ESUS in whom sufficient secondary prevention and expressed AC, typical cardioembolism imaging pattern and high risk of thromboembolic events have already been achieved.

Risk of Intracranial Hemorrhage with Direct Oral Anticoagulants (DOACs) Versus Low Molecular Weight Heparin (LMWH) in Primary and Secondary Brain Cancers: An up-to-Date Meta-Analysis of Comparative Studies

Introduction Patients with brain tumors, primary or metastatic, are at high risk for thromboembolic events and anticoagulant-associated bleeding. LMWH has been the standard treatment for many years. Recently, DOACs are more frequently used in cancer patients. However, such patient populations have been under-represented in anticoagulation trials. As such, there continues to be concerns regarding their safety in patients with primary and metastatic brain cancers especially with respect to intracranial hemorrhages (ICH). There are no trials in brain cancers comparing the safety of DOACs to LMWH in a head-to-head manner. This meta-analysis was conducted to compare the relative risk (RR) of ICH of DOACs to that of LMWH in patients with brain cancers. Methods A review of the medical literature was conducted using online databases. Inclusion criteria consisted of English language, diagnosis of primary brain cancers (PBC) or metastatic brain cancers (MBC), comparative studies using anticoagulation with LMWH versus DOACs, and studies that reported the incidence of ICH. A meta-analysis using the fixed effects and random effects models was conducted. Results Four retrospective comparative studies with a total of 488 patients were included. Three studies reported on ICH incidence of DOACs versus LMWH in PBC and MBC separately and one reported on ICH incidence in MBC only. DOACs were found to have significantly lower RR of all types of ICH in patients with PBC (RR=0.18, 95%CI 0.05-0.62) and a borderline significant lower RR in MBC (RR=0.66, 95%CI 0.41-1.08) than LMWH. However, there was no significant difference between DOACs and LMWH with respect to major ICH in patients with MBC. Conclusions This is the first meta-analysis to show that DOACs is associated with lower relative risk of all ICH compared to LMWH in patients with primary and metastatic brain cancers. In the absence of randomized clinical trials, it represents the most compelling data supporting the use of DOACs to treat thromboembolic events in these patient populations.

Abstract 11401: Silent Brain Infarct on MRI Predicts Clinical Stroke/ Transient Ischemic Attack in Mitral Stenosis

Introduction: Mitral stenosis (MS) is associated with a high risk of cardio-embolic events. However, current recommendations for initiating anti-coagulant therapy in patients with MS is limited to patients with atrial fibrillation (AF),atrial thrombi or those with a prior stroke. In patients with moderate to severe MS who are in sinus rhythm there are no firm recommendations for anti-coagulation despite a known higher risk of thromboembolic events. Moreover there is limited data on the prevalence of silent brain infarcts (SBI) in patients with MS. This study evaluated prevalence and predictors of silent and clinical stroke in MS. Methods: A total of 211 patients with moderate to severe MS (mitral valve area ≤ 1.5 cm2) were recruited in the study and were followed up over a7 year period. Patients with existing left atrial clot(s) or prior valvular intervention were excluded from the study. All patients underwent clinical examination, ECG, echocardiogram, and brain MRI on a 1.5T machine. A 24-hour Holter was performed on patients in sinus rhythm. Results: Among 211 patients, 87(41.2%) were male and 140 (66.3%)were in sinus rhythm. Moderate to severe mitral regurgitation and/or aortic regurgitation was present in 31 (14.7%) and 30 (14.2%)patients respectively. SBI was seen in 44 (20.9 %) patients [26 (18.6%)in sinus rhythm and 18(25.4%) in AF]. Female gender (OR 2.3 95% CI 1.01-5.1, p = 0.043), poorer NYHA functional class (Class II OR 16, 95%CI 4.1-62.8, p=0.001; Class III OR 4.1 95%CI 1.2-13.8, p = 0.024),AF (OR 3.8 95%CI 1.6-8.9 p = 0.002) and aortic regurgitation (OR 3.7 95%CI 1.3-10.4 p = 0.011)were associated with increased risk of SBI. Seventeen patients (8%) were lost to follow up. Among 194patients who completed follow up, clinical stroke/TIA occurred in 15 (7.7%) patients. SBI on MRI was associated with a higher risk of clinical stroke/TIA on follow up on multivariate analysis (OR 3.7 95%CI1.26-10.9, p=0.018). Conclusions: Silent brain infarction is present in a significant minority of patients with MS and is predictive of clinical stroke/TIA on follow up.

Cardiorenal Outcomes Among Patients With Atrial Fibrillation Treated With Oral Anticoagulants

Direct oral anticoagulants (DOACs) have progressively replaced vitamin K antagonists (VKAs) for stroke prevention in patients with nonvalvular atrial fibrillation (AF). DOACs cause fewer bleeding complications, but their other advantages, particularly related to kidney outcomes, remain inconclusive. We studied the risks of chronic kidney disease (CKD) progression and acute kidney injury (AKI) after DOAC and VKA administration for nonvalvular AF. Retrospective cohort study. Cohort study of Swedish patients enrolled in the Stockholm Creatinine Measurements (SCREAM) project with a diagnosis of nonvalvular AF during 2011-2018. Initiation of DOAC or VKA treatment. Primary outcomes were CKD progression (composite of >30% estimated glomerular filtration rate [eGFR] decline and kidney failure) and AKI (by diagnosis or KDIGO-defined transient creatinine elevations). Secondary outcomes were death, major bleeding, and the composite of stroke and systemic embolism. Propensity score weighted Cox regression was used to balance 50 baseline confounders. Sensitivity analyses included falsification end points, subgroups, and estimation of per-protocol effects. We included 32,699 patients (56% initiated DOAC) who were observed for a median of 3.8 years. Their median age was 75 years, 45% were women, and 27% had an eGFR <60mL/min/1.73m2. The adjusted HRs for DOAC versus VKA were 0.87 (95% CI, 0.78-0.98) for the risk of CKD progression and 0.88 (95% CI, 0.80-0.97) for AKI. HRs were 0.77 (95% CI, 0.67-0.89) for major bleeding, 0.93 (95% CI, 0.78-1.11) for the composite of stroke and systemic embolism, and 1.04 (95% CI, 0.95-1.14) for death. The results were similar across subgroups of age, sex, and baseline eGFR when restricting to patients at high risk for thromboembolic events and when censoring follow up at treatment discontinuation or change in type of anticoagulation. Missing information on time in therapeutic range and treatment dosages. Among patients with nonvalvular AF treated in routine clinical practice compared with VKA use, DOAC use was associated with a lower risk of CKD progression, AKI, and major bleeding but a similar risk of the composite of stroke, systemic embolism, or death.

Perioperative Hypercoagulability in Free Flap Reconstructions Performed for Intracranial Tumors.

Patients with intracranial tumors have a higher risk of thromboembolic events. This risk increases at the time of surgical intervention. We have noted an anecdotal increase in perioperative flap thrombosis in patients undergoing free tissue transfer for intracranial tumor resection. This study aims to formally evaluate this risk. A multi-institutional retrospective chart review was performed of patients who underwent free tissue transfer for scalp/cranial reconstruction. Perioperative thrombosis and free flap outcomes were evaluated. The 209 patients who underwent 246 free tissue transfers were included in the study. The 28 free flap scalp reconstructions were associated with intracranial tumors, 19 were performed following composite cranial resections with associated dural resection/reconstruction, and 199 were performed in the absence of intracranial tumors (control group). There was a significantly higher incidence of perioperative flap thrombosis in the intracranial tumor group (11/28, 39%) when compared to controls (38/199, 19%) (p= 0.0287). This was not seen when scalp tumors extended to the dura alone (4/19, 21%, p= 0.83). Therapeutic anticoagulation used for perioperative thrombosis (defined as intraoperative or in the immediate postoperative phase up to 5 days) was associated with a lower risk of flap failure, although this was not statistically significant (p= 0.148). Flap survival rates were equivalent between flaps performed for intracranial pathology (93.3%) and controls (95%). There is an increase in perioperative flap thrombosis in patients with intracranial tumors undergoing free tissue scalp reconstruction. Anticoagulation appears to mitigate this risk. This recommendation is based on level 3 evidence (retrospective case-control studies, systematic review of retrospective studies, and case reports) Laryngoscope, 133:1103-1109, 2023.

Safety and effectiveness of direct oral anticoagulants in patients with nephrotic syndrome: a report of 21 cases

BackgroundNephrotic syndrome (NS) is associated with increased risk of thromboembolic events (TE) adding to the morbidity and mortality. International guidelines recommend prophylactic anticoagulation in patients with NS and high risk of TE, but no studies have identified the optimal type of anticoagulation in NS. We aimed to assess the effectiveness and safety of direct oral anticoagulant (DOAC) by analyzing the thromboembolic and bleeding events in NS patients prescribed DOAC as primary prophylaxis to prevent TE or as treatment for TE occurring in relation to NS.MethodsWe performed a single-center, retrospective study including patients with NS, a plasma albumin less than 25 g/L and prophylactic anticoagulation treatment with DOAC at the Department of Renal Medicine at Aarhus University Hospital, Denmark from July 2016 to June 2021. Patients treated with DOAC as thromboprophylaxis for other indications than NS were excluded. Baseline characteristics and outcomes, including TE, bleeding and other adverse effects associated with DOAC were obtained from medical records.ResultsWe identified 268 patients treated with DOAC of which 21 patients with NS were included in the study. Nineteen patients were prescribed DOAC as thromboprophylaxis and two patients received DOAC due to previous TE, which was considered associated with the NS. The type of DOAC prescribed was apixaban (n = 10) and rivaroxaban (n = 11). No patients experienced TE during DOAC treatment, while five patients had a minor bleeding episode. Patients who experienced bleeding episodes were older (median 62 vs 51 years), more often female (80%) and had been on DOAC for a longer period (204 days vs 47 days). Neither the HAS-BLED score nor GN-risk-score predicted the risk of minor bleedings in this population.ConclusionsIn this case series, no new TE and only minor bleeding complications were observed among adult NS patients treated with DOAC.

EP08.02-070 High Incidence of Peridiagnosis Thromboembolic Events In Patients with BRAF Mutant Lung Cancer

A higher risk of thromboembolic events (TEE) has been recently reported in patients (pts) with non-small-cell lung cancer (NSCLC) harboring ALK or ROS1 gene rearrangements (incidence rate 20-30%). BRAF mutations have been described in 4% of NSCLC. Whether pts with BRAF mutant NSCLC show higher risk of TEE is unknown. We aimed to describe the incidence, characteristics and time of onset of TEE in pts with advanced BRAF mutant NSCLC.

Testosterone Pellet Use in Transgender Men.

We assessed the efficacy and short-term adverse effects of testosterone pellet use in transgender men to broaden therapeutic options. We conducted a retrospective study of 30 transgender men who started testosterone pellets between 2018 and 2020. Testosterone pellets were started at dosages 675-825 mg per cycle and dose was adjusted according to testosterone levels obtained 1 to 6 months post-testosterone pellet insertion. Pharmacokinetics of testosterone pellet in transgender men was similar to those in cisgender men. Total testosterone levels reached a peak in 1 month and remained in the therapeutic range for ∼4 months in the range of 300-800 ng/dL. After switching over to testosterone pellets, 100% of patients continued to achieve amenorrhea and deepening of their voice. Most of the patients noticed increased hair growth in androgen-dependent regions (96.3%) and improved libido (70%). Adverse events were notable for a rate of polycythemia that was unexpectedly high at 46.67%. Pellet extrusion was found in 13.33% of patients. There was a low rate of pellet site hematoma (6.67%) and cellulitis (3.33%). No thromboembolic or cardiovascular events occurred in any of the patients. This study reveals that testosterone pellets are a reasonable alternative to other testosterone modalities in transgender men but would use caution in patients with a history of polycythemia or higher risk for thromboembolic events.

Incidence, risk factors, and evolution of venous thromboembolic events in patients diagnosed with pancreatic carcinoma and treated with chemotherapy on an outpatient basis

BackgroundPancreatic carcinoma is one of the tumors associated with a higher risk for thromboembolic events, with incidence rates ranging from 5% to 41% in previous retrospective series. Patients and methodsWe conducted a retrospective study in eleven Spanish hospitals that included 666 patients diagnosed with pancreatic carcinoma (any stage) between 2008 and 2011 and treated with chemotherapy. The main objective was to evaluate the incidence of venous thromboembolic events (VTE) in this population, as well as potential risk factors for thrombosis. The impact of VTE on mortality was also assessed. ResultsWith a median follow-up of 9.3 months, the incidence of VTE was 22.1%; 52% were diagnosed incidentally. Our study was unable to confirm the ability of the Khorana score to discriminate between patients in the intermediate or high risk category for thrombosis. The presence of VTE proved to be an independent prognostic factor associated with increased risk of death (HR 2.39, 95% CI 1.96–2.92). Symptomatic events correlated with higher mortality than asymptomatic events (HR 1.72; 95% CI, 1.21–2.45; p = 0.002), but incidental VTE, including visceral vein thrombosis (VVT), negatively affected survival compared to patients without VTE. Subjects who developed VTE within the first 3 months of diagnosis of pancreatic carcinoma had lower survival rates than those with VTE after 3 months (HR 1.92, 95% CI 1.30–2.84; p<0.001). ConclusionsPancreatic carcinoma is associated with a high incidence of VTE, which, when present, correlates with worse survival, even when thrombosis is incidental. Early onset VTE has a particularly negative impact.

Acute arterial thrombosis in patients admitted with COVID-19 infection: Clinical experience

Background: Acute limb arterial thrombosis (LAT) is defined as a sudden reduction in arterial supply to the extremity to a degree that affects its viability. Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]) have unbalanced coagulation profiles and are prone to thromboembolic events. Prompt diagnosis of LAT and appropriate urgent intervention, whenever possible, can help decrease morbidity and mortality among these patients and increase the chance of limb rescue. Therefore, this was the stimulus for this study, where based on our clinical experience, we aimed to identify the prevalence and analyze the outcomes of acute LAT in patients admitted with COVID-19 in Baghdad, Iraq. Methods: This study included 135 patients admitted with COVID-19, aged 35–70 years. During admission, these patients were referred to the consultation vascular surgeons because of ischemic changes in their limbs. History, demographics, clinical history, and laboratory tests were collected from all the patients. Vascular Doppler ultrasound and CT angiography were performed in some patients (especially those with re-thrombosis) to finalize the diagnosis and to plan for vascular intervention. Appropriate therapeutic anticoagulants were immediately initiated and once the diagnosis of LAT was established, surgical intervention (under local anesthesia), including thrombo-embolectomy and revascularization, was performed. After postoperative management and anticoagulation were completed, post discharge followup was the final step. Results: The mean age of the enrolled patients was 55.3 ± 7.8 (range 35.1–70.9) years, 86 (63.7%) were males. The mean number of days after the initial COVID-19 manifestation was 22 (16–28). The mean serum levels of D-dimer, CRP, and ferritin were high (795.8 ng/mL, 49.1 mg/mL, and 994.7 ng/mL, respectively). The prevalence of associated risk factors including diabetes, hypertension, and ischemic heart diseases was relatively high. Two-thirds of the patients with LAT had involvement of lower limbs and mostly (69.6%) on the left side. The men represented more than half of the patients affected by LAT in their lower limbs. Re-thrombosis was encountered in 29.6% of the patients, mostly women. Of the total 135 patients with LAT, 14 (10.4%) underwent surgical amputation on presentation to surgical wards or afterwards, however; and unfortunately, 13 (9.6%) of the total patients with LAT died. Most of the recorded mortality among the patients with LAT occurred during hospitalization for COVID-19, nine (75%), regardless of their etiologies. Conclusions: COVID-19 is associated with a high risk of thromboembolic events including LAT. Those with blood group A tend to develop more “re-thrombotic events” than other groups. Even with the successful prescription of prophylactic anticoagulants, young and otherwise healthy cases may be prone to LAT. In patients with COVID-19 and owing to their hypercoagulable state, the surgical intervention of LAT might be harder and more challenging than anticipated. Cardiovascular surgeons and physicians should consider the benefits of extended postoperative anticoagulant administration.

Thromboembolic Complications in COVID-19 Patients Hospitalized in Italian Ordinary Wards: Data from the Multicenter Observational START-COVID Register.

Background Coronavirus disease 2019 (COVID-19) infection causes acute respiratory insufficiency with severe interstitial pneumonia and extrapulmonary complications; in particular, it may predispose to thromboembolic disease. The reported incidence of thromboembolic complications varies from 5 to 30% of cases. Aim We conducted a multicenter, Italian, retrospective, observational study on COVID-19 patients admitted to ordinary wards, to describe the clinical characteristics of patients at admission and bleeding and thrombotic events occurring during the hospital stay. Results The number of hospitalized patients included in the START-COVID-19 Register was 1,135, and the number of hospitalized patients in ordinary wards included in the study was 1,091, with 653 (59.9%) being males and 71 years (interquartile range 59–82 years) being the median age. During the observation, two (0.2%) patients had acute coronary syndrome episodes and one patient (0.1%) had an ischemic stroke; no other arterial thrombotic events were recorded. Fifty-nine patients had symptomatic venous thromboembolism (VTE) (5.4%) events, 18 (30.5%) deep vein thrombosis (DVT), 39 (66.1%) pulmonary embolism (PE), and 2 (3.4%) DVT+PE. Among patients with DVT, eight (44.4%) were isolated distal DVT and two cases were jugular thrombosis. Among patients with PE, seven (17.9%) events were limited to subsegmental arteries. No fatal PE was recorded. Major bleeding events occurred in nine (1.2%) patients and clinically relevant nonmajor bleeding events in nine (1.2%) patients. All bleeding events occurred among patients receiving thromboprophylaxis, more frequently when treated with subtherapeutic or therapeutic dosages. Conclusion Our findings confirm that patients admitted to ordinary wards for COVID-19 infection are at high risk for thromboembolic events. VTE recorded among these patients is mainly isolated PE, suggesting a peculiar characteristic of VTE in these patients.

PB2303: THROMBOCYTOPENIA IN COVID-19 PATIENTS ON ECMO SUPPORT

Background: Thrombocytopenia is a common complication of COVID-19 (coronavirus disease 2019). The possible mechanisms include decreased platelet production, increased platelet destruction, and consumption. According to studies, thrombocytopenia indicates a poor prognosis and increased mortality in COVID-19 patients. Meanwhile, thrombocytopenia is often complicated in ECMO (extracorporeal membrane oxygenation) due to shearing force in the circuit and heparin-induced thrombocytopenia (HIT). COVID-19 patients who are managed on ECMO are at high risk of developing thrombocytopenia and life-threatening bleeding. Aims: Venous thromboembolism prevention is critical in managing COVID-19 patients. The balance between bleeding secondary to thrombocytopenia and thromboembolic prophylaxis is challenging. ECMO support also increases the risk of thrombocytopenia. Our retrospective observation study reports the incidences of thrombocytopenia and major bleeding events in twenty-three COVID-19 patients who were managed with ECMO. Methods: We retrospectively reviewed the data of twenty-three patients who were diagnosed with COVID-19 and managed on ECMO. Thrombocytopenia is defined by platelet level lower than 150,000/uL. Incidences of thrombocytopenia and related complications were recorded and analyzed. Results: Twenty-three adult patients who were diagnosed with COVID-19 received ECMO support. The mean age of patients was 45-year-old and mean body mass index (BMI) was 31.29. Seventeen patients were males, and eleven patients had at least one of the following pre-ECMO comorbidity: ten (43.5%) patients had hypertension, eleven (47.8%) patients had type 2 diabetes and four (17.3%) patients had hyperlipidemia. None of the patients were active smokers or had chronic lung disease when admitted. Anticoagulation was initiated on the day of admission. Twenty-one (91.3%) patients developed thrombocytopenia and HIT was excluded. Eighteen (78.3%) patients had hemorrhage requiring transfusion, with the gastrointestinal tract being the most common site. Other bleeding sites included brain, chest, tracheostomy area and cannulation site. Thromboembolic prophylaxis was held for active bleeding or platelet count threshold of < 30,000/uL. The overall mortality rate was 70.0%. Image:Summary/Conclusion: Based on our data, the incidence of thrombocytopenia was 91.3% in ECMO-managed COVID-19 patients; 78.3% patients developed hemorrhage requiring transfusion. Given the high risk of thromboembolic events in COVID-19 patients, anticoagulation is recommended to all hospitalized COVID-19 patients unless there is active bleeding, previous bleeding history within three days or platelet count is lower than 30,000 cells/uL. However, anticoagulation further increases the risk of bleeding in the setting of thrombocytopenia, which may lead to sudden deterioration and death. Further investigation into the mechanisms, implications, and management of thrombocytopenia will lead to significantly improved outcomes and prognosis for COVID-19 patients who are managed on ECMO.

Thromboprophylaxis and anticoagulation for inpatients with COVID-19 in 2022 and beyond

In spring 2020, small observational studies suggested that COVID-19 was associated with a high risk for thromboembolic events, mainly within the venous compartment (VTE) as pulmonary embolism (PE) and deep venous thrombosis in patients managed in intensive care units (ICU). Despite lack of data from randomized clinical trials, guidelines on thromboprophylaxis and anticoagulation (AC) rapidly emerged with recommendations on thromboprophylaxis for most patients hospitalized with COVID-19 and intermediate or therapeutic dose AC for ICU patients, endorsed by international societies.

Global outflow angle influences silent ischemic events in coil embolization for unruptured distal anterior cerebral artery aneurysms.

Distal anterior cerebral artery (DACA) aneurysms are rare, and endovascular treatment of these aneurysms is challenging. Thromboembolic events, including silent ischemic events, are one of the most important complications of coil embolization for cerebral aneurysms. The treatment outcomes and predictors of silent ischemic events in coil embolization for unruptured DACA aneurysms were investigated, focusing on the morphological characteristics of aneurysms, especially the inflow angle (IA) and global outflow angle (GOA). A total of 12 patients with 12 unruptured DACA aneurysms, treated with coil embolization at our institute, were retrospectively investigated. Predictors for silent ischemic events were evaluated by comparing diffusion-weighted imaging (DWI)-positive and DWI-negative patients. Silent ischemic events detected on DWI were observed in eight aneurysms (66.7%). Comparison of the morphological characteristics of aneurysms between the two groups showed a significantly smaller GOA in the DWI-positive group than in the DWI-negative group (172.6 ± 17.7° vs. 216.8 ± 16.8°, P < 0.01). A multivariate analysis showed that GOA <195° was a significant predictor of silent ischemic events (P = 0.04; odds ratio: 23.62; 95% confidence interval: 1.11-490.39). A small GOA was a significant predictor of silent ischemic events after coil embolization for unruptured DACA aneurysms. While some patients can be treated safely with minimally invasive coil embolization, it is necessary to consider surgical clipping in patients at high risk of thromboembolic events with coil embolization.

Vitamin-K-antagonist phenprocoumon versus low-dose direct oral anticoagulants (DOACs) in patients with atrial fibrillation: a real-world analysis of German claims data

BackgroundFor stroke prevention in patients with atrial fibrillation (AF), direct oral anticoagulants (DOACs) have been increasingly prescribed instead of vitamin-K-antagonists (VKA). For some patients a lower dosage of DOACs (ld-DOACs) is recommended. Ld-DOAC prescribing seems to be common, although previous studies did not show clear superiority of ld-DOACs over warfarin. In Germany, phenprocoumon is used almost exclusively as VKA. Randomized controlled trials comparing DOACs and phenprocoumon in the general population of patients with AF do not exist. Therefore, we aimed to compare ld-DOACs and phenprocoumon in a real-world setting in Germany.MethodsIn a retrospective observational cohort study, claims data from a group of small to medium-sized health insurance companies were analysed. Risks for the outcomes thromboembolism, death and major bleeding were estimated by Cox regression. Out of 93,685 patients with atrial fibrillation and a first prescription of an oral anticoagulant, 20,179 receiving VKA and 21,724 ld-DOACs (29.6% of all DOAC patients) were included. For the sensitivity analysis phenprocoumon was compared to the five ld-DOAC groups (ld-apixaban, ld-dabigatran, ld-edoxaban, ld-rivaroxaban, and the composite of all ld-DOACs) after propensity-score matching.ResultsPhenprocoumon was associated with statistically significant fewer thromboembolic events (HR = 1.29, 95% CI [1.13, 1.48], p < .001) and deaths (HR = 1.52, 95% CI [1.41, 1.63], p < .001) and a non-significant higher bleeding risk (HR = 0.89, 95% CI [0.79, 1.00], p = .051) than composite ld-DOAC. Regarding the subgroups, only patients with ld-apixaban had a statistically significant higher risk for thromboembolic events (HR = 1.42, 95% CI [1.21, 1.65], p < .001) and a lower bleeding risk (HR = 0.75, 95% CI [0.65, 0.86], p < .001). Ld-apixaban, ld-edoxaban, and ld-rivaroxaban were associated with a higher risk of death. The sensitivity analysis confirmed these associations.ConclusionPhenprocoumon seems to be superior to ld-DOACs for patients with AF. As a hypothesis phenprocoumon might turn out to be the wiser choice for high-risk patients with AF as compared to ld-DOACs, especially regarding thromboembolic events and death. Therefore, RCTs comparing ld-DOACs with phenprocoumon are needed.

Post-operative atrial fibrillation: not just a transient phenomenon

Abstract Funding Acknowledgements Type of funding sources: None. Background A high proportion of patients undergoing cardiac surgery develop atrial fibrillation (AF) in the immediate post-operative period. To assess whether this translates into long-term AF, studies have used incidence of stroke as a surrogate marker, however the rhythm has not been directly measured. Our study retrospectively reviewed device checks of patients with permanent cardiac devices who underwent cardiac surgery in order to directly measure AF up to 18 months post cardiac surgery. Purpose To assess whether the development AF in the immediate post-operative period relates to the prevalence of longer-term AF after cardiac surgery. Methods Patients who had undergone a coronary artery bypass graft (CABG) or valve surgery between January 2011 and March 2020 and who had a pre-existing device or a device inserted within 1 year after surgery were identified. Patients were excluded if they had a congenital cardiac condition or a diagnosis of AF pre-operatively. Patients were categorised as having AF in the immediate post-operative period if AF was coded in the electronic ICU observation chart, mentioned on the discharge summary, or found in a device check &amp;lt;6 weeks post-surgery. Device checks were analysed up to 18 months post-surgery and AF was confirmed if lasting &amp;gt;6 minutes and documented on atrial electrogram (EGM). Comorbidities and operation details were gathered from institutional surgical database and medical notes. Results 359 patients at our institution met initial criteria. 94 had device checks available and were used for final analysis. Mean follow up duration was 377 days. In total 41 (44%) patients developed AF in the immediate post-operative period. Patients developing post-op AF were older (69 vs. 64 years old, p=0.01) and had a different spread in operation type (CABG only 27% vs. 28%, valve only 51% vs. 68%, combined CABG &amp; valve 22% vs. 4%, p=0.02) but there was no difference in other relevant characteristics (see Table 1). In total, 24 (26%) patients developed longer term AF, with significantly higher proportion in those who developed immediate post-operative AF (see Figure 1). Immediate post-operative AF and hypertension demonstrated a significant association with longer-term AF on univariate regression analysis using a significance value of 0.1. On multivariate analysis only immediate post-operative AF remained significant (odds ratio 3.75 (95% confidence interval 1.38-10.22), p=0.01). Conclusion Developing AF in the post-operative period appears to be an independent predictor of developing clinically significant AF up to 18 months after surgery. This is an important finding in identifying patients who may be at higher risk of thromboembolic events. Further research is required to determine the optimal approach, in particular consideration of anticoagulation in this patient group.

Implant-based versus Autologous Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis.

Background:For women undergoing breast reconstruction after mastectomy, the comparative benefits and harms of implant-based reconstruction (IBR) and autologous reconstruction (AR) are not well known. We performed a systematic review with meta-analysis of IBR versus AR after mastectomy for breast cancer.Methods:We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies from inception to March 23, 2021. We assessed the risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods.Results:We screened 15,936 citations and included 40 studies (two randomized controlled trials and 38 adjusted nonrandomized comparative studies). Compared with patients who undergo IBR, those who undergo AR experience clinically significant better sexual well-being [summary adjusted mean difference (adjMD) 5.8, 95% CI 3.4–8.2; three studies] and satisfaction with breasts (summary adjMD 8.1, 95% CI 6.1–10.1; three studies) (moderate SoE for both outcomes). AR was associated with a greater risk of venous thromboembolism (moderate SoE), but IBR was associated with a greater risk of reconstructive failure (moderate SoE) and seroma (low SoE) in long-term follow-up (1.5–4 years). Other outcomes were comparable between groups, or the evidence was insufficient to merit conclusions.Conclusions:Most evidence regarding IBR versus AR is of low or moderate SoE. AR is probably associated with better sexual well-being and satisfaction with breasts and lower risks of seroma and long-term reconstructive failure but a higher risk of thromboembolic events. New high-quality research is needed to address the important research gaps.

Sometimes Late Is Better Than Never: Implantation of a Cardioverter Defibrillator Years after an Acute Myocardial Infarction —Case Report

Abstract Sustained ventricular arrhythmias that occur early post-myocardial infarction (MI) are generally considered epiphenomena of the MI and are not consistently associated with long-term prognosis. The lack of association with long-term prognosis is more clearly established for early ventricular fibrillation (VF) and polymorphic ventricular tachycardia (PVT). Sustained monomorphic ventricular tachycardia (SMVT), even when it occurs early, however, may reflect a permanent arrhythmic substrate1. Patients with COVID-19 have a high risk of thromboembolic events, and the virus has also been shown to have extensive effects on the cardiovascular system2,3,4. A 62-year-old woman, recently hospitalized for COVID-19 pneumonia, was brought to the emergency department with pulseless SMVT having been successfully resuscitated in the prehospital setting. The patient has a history of an old MI treated with thrombolysis and percutaneous coronary intervention (PCI) that was complicated with early SMVT, but with preserved left ventricular function and without heart failure. The patient underwent implantation of a cardioverter defibrillator (ICD). During the hospitalization, she developed dyspnea and was diagnosed with minor pulmonary embolism. It may be appropriate to consider early SMVT as a predictor of adverse late outcomes that would necessitate rigorous follow-up and maybe an early invasive primary prevention strategy. This case also reflects the possibility of long-term cardiac involvement and increased thromboembolic risk in patients recovering from COVID-19.