Incidence Of Thrombotic Complications Research Articles

Retrospective Comparison of Recombinant Activated Factor VII Versus 4-Factor Prothrombin Complex Concentrate in Cardiac Surgical Patients

ObjectivesTo compare the incidence of postoperative thrombotic complications, transfusion of blood products, and chest tube output in congenital cardiac surgical patients who received either recombinant activated factor VII (rFVIIa) or four-factor prothrombin complex concentrate (4F-PCC) DesignRetrospective analysis SettingTertiary academic hospital ParticipantsPediatric patients who underwent cardiac surgery. InterventionsNone Measurements and Main ResultsData were obtained from the Society of Thoracic Surgeons and the Pediatric Cardiac Critical Care Consortium databases, as well as from manual chart review. Adjusted p-values were obtained from multivariable regression using age (days), surgeon (number), cardiopulmonary bypass time (minutes), and need for deep hypothermic circulatory arrest (yes/no). We included 55 patients in the 4F-PCC group and 89 in the rFVIIa group. The median dose of rFVIIa was 77 mcg/kg (46-88) and the median dose of 4F-PCC was 31 IU/kg (24-43). The incidence of thrombotic complications was 8% in the 4F-PCC group and 30% in the rFVIIa group (adjusted P= 0.023). No difference was reported between the group in terms of chest tube output on day 1 and 2, or transfusion of blood products. Using a sensitivity analysis with propensity matching, the incidence of thrombosis was 10% in the 4F-PCC group (n=38) and 31% in the rFVIIa group (n=39) (P=0.036). No difference was reported in term of bleeding or transfusion. ConclusionsThis retrospective study suggests that the administration of rFVIIa is associated with a higher risk of thrombotic complications when compared to 4F-PCC without benefits in term of bleeding and transfusions.

МЕХАНИЗМЫ ТРОМБО-ВОСПАЛЕНИЯ У ПАЦИЕНТОВ С СИСТЕМНОЙ КРАСНОЙ ВОЛЧАНКОЙ

Introduction. Systemic lupus erythematosus (SLE) is a systemic autoimmune inflammatory disease. According to different authors, the incidence of thrombotic complications in this disease is higher than the average in the population and can be up to 40%. Aim. The aim of the present review is to provide an overview of mechanisms of thrombosis in patients with systemic lupus erythematosus. Material and methods. Analytical review of foreign and native publications in PubMed and eLibrary.ru between 1985-2020. Results and discussion. SLE represents a model of inflammation-induced thrombosis. The hypercoagulability state which characterizes SLE seems to be associated with inflammation-driven alterations of the thrombotic balance. Tissue-nonspecific autoantibodies, as well as cytokines and acute phase proteins induce a proinflammatory endothelial cell phenotype. Platelets are activated following endothelial dysfunction; they participate in inflammatory and thrombotic events occurring in an injured area. One of the possible initiators of the thrombosis process is considered to be an interaction of antiphospholipid antibodies with phospholipids of platelet membranes, endothelium and phospholipid-linked plasma proteins. Local unbalanced thrombin generation leading to hypercoagulability is another source central for thrombosis. Patients with systemic lupus erythematosus show multidirectional disorders of the coagulation system, with predominance of hypercoagulation especially in patients with II-III degree of disease activity. Conclusion. The mechanism of thrombo-inflammation in systemic lupus erythematosus is multifactorial, involving all components of the hemostatic system. Chronic endothelial dysfunction, platelet activation, hypercoagulation, suppression of fibrinolysis reflects an interplay between thrombosis and inflammation. Persisting autoimmune inflammation plays a key role in these abnormalities.

Medullary cavity application of tranexamic acid to reduce blood loss in tibial intramedullary nailing procedures—a randomized controlled trial

PurposeStudies have shown an average postoperative hidden blood loss (HBL) of 473.29 ml and an average Hb loss of 16.71 g/l after intramedullary nailing. Reducing HBL has become a primary consideration for orthopaedic surgeons.MethodsPatients with only tibial stem fractures who visited the study clinic between December 2019 and February 2022 were randomized into two groups using a computer-generated form. Two grams of tranexamic acid (TXA) (20 ml) or 20 ml of saline was injected into the medullary cavity before implantation of the intramedullary nail. On the morning of the surgery, as well as on days one, three and five after surgery, routine blood tests and analyses of CRP and interleukin-6 were completed. The primary outcomes were total blood loss (TBL), HBL, and blood transfusion, in which the TBL and HBL were calculated according to the Gross equation and the Nadler equation. Three months after surgery, the incidence of wound complications and thrombotic events, including deep vein thrombosis and pulmonary embolism, was recorded.ResultsNinety-seven patients (47 in the TXA group and 50 in the NS group) were analyzed; the TBL (252.10 ± 10.05 ml) and HBL (202.67 ± 11.86 ml) in the TXA group were significantly lower than the TBL (417.03 ± 14.60 ml) and HBL (373.85 ± 23.70 ml) in the NS group (p < 0.05). At the three month postoperative follow-up, two patients (4.25%) in the TXA group and three patients (6.00%) in the NS group developed deep vein thrombosis, with no significant difference in the incidence of thrombotic complications (p = 0.944). No postoperative deaths or wound complications occurred in either group.ConclusionsThe combination of intravenous and topical TXA reduces blood loss after intramedullary nailing of tibial fractures without increasing the incidence of thrombotic events.

Resumption of anticoagulant therapy after major bleeding and the risk of negative events in patients with atrial fibrillation (based on REGistry of Long-term AnTithrombotic TherApy-2 - REGATA)

It is necessary to strive to resume anticoagulants for patients with atrial fibrillation who have a high risk of thrombosis after the development of large bleeding. Due to the fact that death in these patients is caused not by a recurrence of fatal bleeding, but by the development of stroke in case of refusal of anticoagulant therapy. To evaluate the effect of the resumption of anticoagulant therapy on the risk of recurrence of major bleeding, thrombosis and death in patients with atrial fibrillation who have suffered major bleeding. To evaluate the frequency of bleeding, thrombosis and death in patients with atrial fibrillation after major bleeding according to prospective follow-up data for one year. The recurrence rate of major bleeding after the resumption of therapy was 21.7% per year. The frequency of fatal bleeding was 2.2%. In the anticoagulant withdrawal group, the incidence of thrombotic complications (ischemic stroke and myocardial infarction) was significantly higher compared to patients who resumed therapy. The frequency of death from all causes was significantly higher in the group of patients who did not resume anticoagulant therapy. Half of the deaths were due to cardiovascular causes. The presence of more than 5 points of the Charlson Comorbidity Index was a predictor of the development of the sum of all adverse events. The resumption of anticoagulant therapy after the development of major bleeding in patients with atrial fibrillation reduces the risk of thrombosis and death at a cost, while increasing the risk of recurrence of non-fatal bleeding.

A multicenter retrospective study evaluating the impact of desmopressin on hematoma expansion in patients with antiplatelet-associated intracranial hemorrhage

IntroductionAntiplatelet medications interfere with hemostasis which can contribute to increased risk of hematoma expansion and potentially worse outcomes in patients presenting with intracranial hemorrhages (ICH). Current Neurocritical Care Society guidelines recommend desmopressin (DDAVP) in patients with antiplatelet-associated ICH with evidence limited by small cohorts. Materials and methodsPatients were included in our multi-center, retrospective study if they had computed tomographic (CT) scan confirmed ICH and were taking antiplatelet medications. Patients were excluded if hospital length of stay was <24 h, administered DDAVP dose was <0.3 μg/kg, no follow-up head CT scan was performed within the first 24 h after baseline, major neurosurgical intervention was performed in between CT scans, or the injury was an acute on chronic ICH. The primary outcome was incidence of hematoma expansion (defined as >20 % increase from baseline). Secondary outcomes were incidence of thrombotic complications within 7 days, largest absolute decrease in serum sodium within the first 24 h, and patient disposition. ResultsAmong the 209 patients included in the study, 118 patients received DDAVP while 91 did not. The frequency of hematoma expansion was similar between patients who received DDAVP and those who did not (16.1 % vs 17.6 %; P = 0.78). No difference in secondary outcomes was observed between the two groups. ConclusionsThese findings in conjunction with recently published literature may suggest minimal benefit or harm with DDAVP treatment. However, further study could elucidate any potential impact on long-term function outcomes.

Liver transplantation for cirrhosis complicated by non-tumor thrombosis of mesenteric portal system

Aim. To develop a universal technology of thrombectomy from the veins of the mesenteric portal system and to evaluate the outcomes of liver transplantation for cirrhosis combined with non-tumorous portal vein thrombosis.Materials and methods. Immediate and long-term results of 309 transplantations in patients with liver cirrhosis of various etiologies were studied. In 46 cases (14.9%), transplantation was performed in patients with liver cirrhosis and concomitant thrombosis in the veins of the mesenteric portal system. Results. A versatile method of thrombectomy, depending on the degree of thrombosis in the veins of the mesenteric portal system was proposed (M.A. Yerdel et al., 2000). Mesenteric portal vein thrombosis increased duration of transplantation and volume of intraoperative blood loss as compared to patients without concomitant thrombosis. No statistically significant differences were found in the overall incidence of postoperative complications, hospital mortality and duration of hospitalization of the patients after liver transplantation with concomitant venous thrombosis compared to the patients without thrombosis. The incidence of thrombotic complications, including hepatic artery thrombosis, was significantly higher after liver transplantation supplemented with thrombectomy from the portal vein system. Five-year survival rate of the patients after liver transplantation with concomitant thrombosis in the veins of the mesenteric portal system was 94.9% (median – 40 months), patients without thrombosis in the veins of the mesenteric portal system – 93.2% (median – 60 months).Conclusion. Transplantation in patients with cirrhosis and thrombosis in the veins of the mesenteric-portal system shows good immediate and long-term results in case proper thrombectomy is carried out.

Modification of prophylactic anticoagulation regimen reduces the incidence of thrombotic complications after venous reconstruction.

e16250 Background: Surgical treatment for pancreatic cancer (PC) with venous reconstruction is associated with a high risk of venous thrombosis. The purpose of this study was to analyze the dynamics of the blood fibrinolytic system in the postoperative period in PC patients after venous reconstruction. Methods: The study included patients with PC (T3N0-1M0), mean age 63 years. Patients of the main group (n = 11) underwent pancreaticoduodenal or corporocaudal resection with venous reconstruction (portal and superior mesenteric veins), mesenteric cross-clamping time 7-40 minutes (average 23 minutes). Patients of the control group (n = 11) received similar surgical treatment without venous resection. All patients received postoperative prophylactic anticoagulation: standard nadroparin 0.4 ml once a day in the control group and a modified regimen of nadroparin 0.1 ml per 10 kg of body weight per day in a low bleeding risk in the main group. Levels of tPA, uPA, PAI-1 and suPAR, and tPA-act, uPA-act, and PAI-1-act activity were determined in the blood plasma by ELISA (Technoclone, Austria; R&amp;D Systems, USA) on days 1-3, 5-7 and 8-14 after surgery. Results: No thrombotic complications were registered in the main group during the 30-day observation period, while 2 patients (18.2%) in the control group were diagnosed with distal venous thrombosis on days 10-14. The frequency of hemorrhagic complications was similar in both groups (9.1% vs 9.1%). Levels of PAI-1 decreased by 2.4 times in both groups on days 1-3 after surgery, tPA increased by 1.7 times (p &lt; 0.01), and tPA-act increased in the main group by 2.9 times. On days 5-7, no changes were registered in the control group, while patients of the main group showed decreased tPA-act by 3.2 times and elevated suPAR and PAI-1 by 2.2 times (p &lt; 0.01) and PAI-1-act by 3.6 times. However, levels of PAI-1-act decreased by 2.2 times (p &lt; 0.01) in the main group on days 8-14, and in control group PAI-1 increased by 2.4 times (р &lt; 0.05). Thus, patients in the main group had 2.4 times higher levels of tPA on days 1-3, compared to the control group, and higher suPAR on days 5-7 (by 1.8 times, p &lt; 0.01), PAI-1 and PAI-1-act by 2.0 times (p &lt; 0.01), and higher tPA (by 4.4 times) on days 8-14. Conclusions: The proposed scheme of prophylactic anticoagulation showed its efficacy and safety. It activated fibrinolysis 1-3 days after surgery. Further on, we could observe signs of enhanced prothrombotic and pro-inflammatory state despite the ongoing anticoagulant therapy, which, however, was not manifested by thrombotic complications. Levels of tPA increased significantly by days 8-14 after venous reconstruction and intestinal ischemia, while inhibitor levels remained high, which can be considered a change in the balance towards activation of fibrinolysis and enhancement of anti-inflammatory processes.

Increased risk of venous thrombosis in breast cancer patients receiving chemotherapy treatment after COVID-19.

e24106 Background: Immune suppression and coagulopathy development in cancer patients receiving chemotherapy determines a high incidence of complications, including venous thrombosis, and mortality from COVID-19 infection. There are still no explicit data on managing cancer patients when anticancer treatment is resumed after coronavirus disease. According to clinical guidelines for the prevention of venous thromboembolic complications in cancer patients receiving chemotherapy, patients with breast cancer are classified as having a low risk of these complications and do not require prophylactic anticoagulation. The purpose of this study was to assess the parameters of the blood coagulation system and the frequency of venous thrombosis in breast cancer patients with chemotherapy resumption after coronavirus disease. Methods: The study included 30 patients receiving anticancer medical therapy for breast cancer after COVID-19. Anticancer treatment was resumed no earlier than 4 weeks after clinical recovery, absence of SARS-CoV-2 RNAs in nasopharyngeal swabs, infiltrative lung damage according to a chest CT scan, exclusion of venous thrombosis by a lower extremity venous ultrasound. Control group included 20 breast cancer patients without a history of COVID-19. Stage I tumors were registered in 26.6% in the main group vs 15% controls; II - 40% vs 60%; III - 20% vs 15%. Some patients were diagnosed with distant metastases (stage IV- 13.3% vs 10%). Results: Initially, before chemotherapy resumption in the main group, half of the patients had elevated levels of fibrinogen and D-dimer compared with the control group (66.7% vs. 35%, p &gt; 0.05). After a cycle of chemotherapy, a significant difference in the coagulation system parameters was noted (73.3% vs 30%). A lower extremity venous ultrasound after the end of the therapy cycle in the main group showed venous thrombosis in 3 patients (catheter-related n = 2, distal vein thrombosis of the lower extremities n = 1), while no venous thrombotic complications were detected in the control group (10% vs. 0%). Conclusions: Breast cancer patients after coronavirus disease 2019 have hemostasis abnormalities and higher risk of venous thrombosis, and the resumption of anticancer treatment increases the incidence of thrombotic complications. COVID-19 should be considered an additional risk factor of venous thrombosis in cancer patients and requires reconsideration of indications for prophylactic anticoagulation when resuming anticancer treatment for patients with breast cancer.

Development and validation of capillary zone electrophoresis and high-performance liquid chromatography methods for the determination of oral anticoagulant edoxaban in pharmaceutical tablets.

The incidence of thrombotic complications in SARS-CoV-2 infections has become a global concern; thus, anticoagulants are an integral part of the treatment. Edoxaban (EDX) is an oral anticoagulant suitable for pharmacologic thromboprophylaxis. Herein, two novel analytical methods for EDX determination in tablets are developed and validated using capillary zone electrophoresis (CZE) and high-performance liquid chromatography (HPLC). Operating conditions such as the electrolyte's concentration and pH value, injection time, volume, and the capillary temperature, were optimized. The methods were successfully validated by establishing the linearity, intra- and inter-day precisions (relative standard deviation [%]), accuracy, and robustness. Adequate separation of excipients and degradation products of EDX generated by stress degradation conditions demonstrated the stability-indicating capability of the methods. The analytical procedures were linear in the range of 25-125µg/ml (r>0.999), with the limits of detection and quantification of 3.26 and 10.87µg/ml for CZE and 0.740 and 2.78µg/ml for HPLC. Although both methodologies are suitable for determining EDX in tablets, CZE provides a greener alternative due to low-cost analysis using less organic solvents and minimizing waste generation.

Thrombotic complication in non-hospitalized COVID-19 patients: An underestimated phenomenon?

Thrombotic complications are quite frequent during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, especially during severe disease and in hospitalized patients. The incidence of thrombotic complications in mild disease is not clear and probably few cases have been identified. We reported a case of a 60-year-old man with no previous history admitted to our unit for splenic infarct and a floating clot into the descending aorta without signs of severe disease. Several mechanisms to clarify prothrombotic state have been described. However, the exact prevalence of thromboembolic phenomenon is probably underestimated. There is no consensus about the treatment and the indications for preventing these complications in non-hospitalized patients. Thrombotic events should be suspected also in healthy patients with symptoms suggestive for coronavirus disease infection but without severe COVID-19 pneumonia. Further analysis should be performed to stratify the risk in nonhospitalized patients and the indications for prophylactic treatment.

Long-term outcomes of coronary artery bypass graft surgery in patients with widespread atherosclerotic lesions of the coronary and peripheral vascular basins (based on the REGATA long-term antithrombotic therapy registry)

Introduction . Multifocal atherosclerosis (MFA) in patients with CHD is a key risk factor for thrombotic complications (TC). There are little data on the long-term prognosis in patients with multivessel CHD combined with carotid artery lesions. Objective . To assess prognostic negative outcomes (thrombosis and bleeding) in patients with CHD and MFA undergoing revascularization procedures – coronary artery bypass graft surgery and, in case of high risk of ischemic stroke, carotid endarterectomy. Materials and methods . A total of 189 patients with stable multivessel coronary artery disease who successfully underwent coronary bypass graft surgery and had concomitant atherosclerosis of the carotid arteries ≥50% were included in the study. The exclusion criterion was chronic use of oral anticoagulants. The choice of antithrombotic therapy after the surgical intervention was determined by the attending physicians. The efficacy endpoint was defined as the sum of TC including cardiovascular death, acute coronary syndrome, ischemic stroke, acute lower limb ischemia, and the need for emergency revascularization of the carotid or coronary basins. BARC bleeding types 2-5 were considered as a safety endpoint. Results . The median follow-up period was 37 months. [MR 25.0; 45.0]. The cumulative incidence of TC was 11.1%, BARC 2-5 bleeding was 4.8%. One or two antiplatelet agents were prescribed at discharge in 87.3% of cases, and in 12.7% – a combination of acetylsalicylic acid (ASA) and oral anticoagulant (OAC) for up to 6 months. The incidence of thrombotic complications was not significantly different in the mono- or dual antiplatelet therapy groups. The combination therapy group (OAC + ASA) was characterized by the highest number of comorbidities. When analyzing the TC for the first 6 months. (before anticoagulant withdrawal) there was no significant difference between the groups of antiplatelet therapy and the combination of ASA and OAC (Log-Rank, p = 0.4669). The proportion of patients who survived the entire follow-up period without developing TC was significantly higher in the group compared to the initial combination therapy group: 0.83 versus 0.50 (Log-Rank, p = 0.0101). Conclusion . Despite complete revascularization, the incidence of TC during the two years of follow-up was high. In the combination therapy group, anticoagulant withdrawal led to an increased incidence of TC.

Evaluation of management strategies in patients with coronary ectasia: a retrospective cohort study

Abstract Background/Introduction Since patients with coronary ectasia have an increased risk of developing myocardial infarction and cardiovascular death, these patients could benefit from a more intensive treatment. Unfortunately, the evidence regarding outcomes with different management strategies is limited, especially with direct oral anticoagulants (DOAC). Purpose To compare clinical outcomes in patients with coronary ectasia based on the selected/chosen treatment strategy. Methods We conducted a retrospective cohort study in patients diagnosed with coronary artery ectasia. They were divided into 3 different groups based on the treatment they received at discharge and we evaluated the main cardiovascular outcomes at one-year follow-up. Results Between 2016 and 2019, 7,579 angiographies were performed, in which 510 patients with coronary ectasia were found (prevalence of 6.72%). Of these patients, 43.9% (n=224) had the diagnosis of STEMI, 21% NSTEMI (n=107), 5.1% unstable angina (n=26), 18.6% chronic stable angina (n=95) and other 11.4% (n=58). The angiographic distribution of the lesions was as follows: left main coronary artery 25.1%, Left descending coronary artery 62.7%, circumflex artery 52.1%, right coronary artery 79.2%. It was possible to obtain the follow-up of 363 patients (71.2%) because 25 died during their hospitalization and data of 122 were not available at the time of analysis. Three groups were formed based on the treatment: (1) Dual Antiplatelet Therapy (DAPT) in 47% (n=174); (2) DAPT + Vitamin K Antagonist (VKA) in 8.5% (n=31); (3) DAPT + DOAC in 6.6% (n=24). The overall MACE rate at 1-year of follow-up was 6.6% (n=15): 11 patients in the DAPT group (6.3%), 1 patient in the DAPT + VKA group (3.2%), and 3 patients in the DAPT + DOAC group (12.5%). During this period, 3 patients died from cardiovascular causes, all of them in the DAPT group. Myocardial infarction occurred in 12 patients, 8 in the DAPT group (4.2%), 1 in the DAPT + VKA group (3.2%) and 3 in the DAPT + DOAC group (12.5%). Stroke occurred in 2 patients: 1 patient in the DAPT group (0.5%) and 1 patient in the DAPT + DOAC group, 4.1% None of these findings were statistically significant. One-year occurrence of bleeding events was also evaluated: 23 patients presented a bleeding event, 14 in the DAPT group (8%), 7 in the DAPT + VKA group (22.5%) and 2 in the DAPT + DOAC group (8.3%); p=0.010. Conclusion(s) Our findings suggest that there is no statistically significant difference in the incidence of thrombotic complications, when comparing the treatment options. Patients using the combination of DAPT+VKA have a higher incidence of bleeding. Funding Acknowledgement Type of funding sources: None.

S2907 Portal Vein Thrombosis in the COVID-19 Era: A Rare Presentation

Introduction: An increased incidence of venous thromboembolism (VTE) has been reported with SARS-COV2 (severe acute respiratory syndrome coronavirus 2) infections. VTE in unusual sites like the portal vein is limited to case reports. This report adds to the growing body of literature about thrombotic complications with SARS-COV2 infections. Case Description/Methods: A female aged 39 with a medical history of diabetes, hypertension and cholecystectomy presented with three days of right upper quadrant (RUQ) pain. She denied substance use, cirrhosis, autoimmune disease or previous VTE. On presentation, vitals were stable. She had RUQ tenderness. Blood work revealed elevated alkaline phosphatase and transaminases. White cell count, bilirubin and coagulation were normal. Imaging revealed occlusive thrombus of the right portal vein proximal to the bifurcation with peripheral extension (images 1 and 2). Extensive hypercoagulable and infectious workup was negative. She was immediately started on enoxaparin. A chest x ray was suggestive of SARS-COV2 infection and confirmatory testing was positive. Her symptoms improved and lab abnormalities resolved. She was discharged home with oral anticoagulants and instructions to self-isolate. Discussion: Most reported cases of Portal vein thrombosis (PVT) with SARS-COV2 are incidental. Our patient presented with RUQ abdominal pain, highlighting an unusual presentation. PVT is rare and occurs with cirrhosis, connective tissue disease, malignancies, pancreatitis and thrombophilia. These were absent in our patient and other causes of hypercoagulability such as antiphospholipid syndrome, proteins C, S and antithrombin deficiencies, Factor V mutations were ruled out. SARS-COV2 infected patients experience a hypercoagulable state with the incidence of thrombotic complications as high as 31%. Some have suggested that systemic inflammation leads to endothelial dysfunction, causing Von-Willebrand Factor and toll-like receptor activation, leading to platelet aggregation and coagulation cascade initiation. Others have speculated that inflammatory cytokines bind to endothelial surface angiotensin converting enzyme receptor leading to lymphocytic endotheliitis and prothrombotic gene overexpression. Anticoagulation should be used in PVT to reduce complications of intestinal infarction and portal hypertension. Recanalization occurs in 60% of cases with anticoagulation in the first week. We used therapeutic enoxaparin and switched to an oral anticoagulant for a 6-month course.Figure 1.: Image 1 a and b: CT scan showing right portal vein thrombosis, just at its bifurcation (blue arrows) c: chest x ray showing bilateral patchy opacities.

LEFT ATRIAL THROMBUS AND COVID-19-ASSOCIATED COAGULOPATHY

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 (Coronavirus Disease of 2019) is a global pandemic caused by the rapidly spreading SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2). Although COVID-19 primarily affects the respiratory system, evidence suggests a strong predisposition for pro-thrombotic states with COVID-19 infection, manifesting as both venous and arterial thromboembolism. COVID-19 associated coagulopathy and its varying complications contribute to a significant portion or morbidity and mortality in addition to respiratory failure. CASE PRESENTATION: A 75-year-old woman with stage IV colorectal carcinoma, rheumatic mitral valve stenosis status-post recent balloon valvulotomy, and atrial fibrillation on warfarin presented with fever, cough, anosmia, ageusia, dyspnea, generalized weakness, and anorexia. She was admitted for neutropenic fever, acute hypoxic respiratory failure, and sepsis in the context of COVID-19 pneumonia. Computed tomography angiogram (CTA) of the chest showed bilateral infiltrates consistent with COVID-19 pneumonia, as well as a more unusual finding of a large 7 x 4 x 7 cm left atrial mass (Figure 1), consistent in appearance with a thrombus. Comparison with CTA chest one month prior confirmed that the thrombus was acute. On admission, the patient also had a supratherapeutic INR of 4. Echocardiography confirmed the suspicion for thrombus and redemonstrated restricted mitral valve leaflets consistent with rheumatic valvular stenosis. The patient was treated with supplemental oxygen, remdesivir, vancomycin, cefepime and filgrastim. She responded well and had resolution of her neutropenia, sepsis, and hypoxia. Because she formed the thrombus while on warfarin, decision was made to discontinue warfarin and transition to enoxaparin for anticoagulation. She was subsequently discharged home on hospice. DISCUSSION: Although venous thromboembolism is commonly encountered with COVID-19 patients, to our knowledge this case represents the first report of COVID-19 associated left atrial thrombus. Rheumatic mitral valve disease is a known risk factor for left atrial thrombus formation and colorectal carcinoma may have also contributed to hypercoagulability. However, the patient in our vignette had a supratherapeutic INR at the time of thrombus formation. Furthermore, the absence of thrombus on imaging one month prior confirms a temporal association with COVID-19 infection. As such, evidence suggests that hypercoagulability secondary to COVID-19 contributed to the formation of her left atrial thrombus. CONCLUSIONS: This case adds to the growing body of literature surrounding the profound hypercoagulability provoked by SARS-CoV-2 infection and reiterates the role of anticoagulation in the management of COVID-19 patients during the ongoing pandemic. REFERENCE #1: Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun. 2020;109:102433. REFERENCE #2: Incidence of thrombotic complications in critically ill ICU patients with COVID-19. lok FA, Kruip MJHA, van der Meer NJM, et al. Thromb Res. 2020;191:145–147. REFERENCE #3: Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844–847. DISCLOSURES: No relevant relationships by Nikhila Janakiram, source=Web Response No relevant relationships by Eva Ma, source=Web Response No relevant relationships by Andreas Mauer, source=Web Response

INCIDENTAL AND ASYMPTOMATIC SPLENIC INFRACTION AND INFRARENAL THORMBUS IN A PATIENT WITH COVID-19

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: In the COVID-19 pandemic, pathogenesis and complications of COVID-19 were studied intently. Due to the associated cytokine storm, it is theorized that this triggers a hypercoagulable state for venous and arterial thromboembolism. Elevated D-dimer, fibrinogen, c-reactive protein (CRP), ferritin, and procalcitonin were seen in thrombotic complications. CASE PRESENTATION: A 66 year old male with dyslipidemia presented 11 days after diagnosis of COVID-19. He had worsening shortness of breath, myalgias, and loss of taste. He denied any diarrhea, nausea, or vomiting. On physical exam, he had crackles with diminished lung sounds using his accessory muscles. He was hypoxic with oxygen saturation of 81% on room air. Labs showed normal WBC count, d-dimer of 1.42 mg/L, ferritin of 961 ng/mL, lactate dehydrogenase of 621 U/L, and CRP of 2.1 mg/dL. Chest x-ray showed atypical pneumonitis with patchy abnormalities. He was started on vapotherm 40 L with FiO2 of 100% proning as tolerated. He received dexamethasone, prophylactic enoxaparin, 1 unit of plasma therapy, remdesevir, ceftriaxone, and azithromycin. On day 2, dexamethasone was increased to twice daily due to hypoxemia. Due to elevated d-dimer of 2.64 mg/L, enoxaparin was changed to twice daily. On day 5, he required continuous positive airway pressure (CPAP) with pressure support of 10 and FiO2 of 85% with dexamethasone every eight hours. His d-dimer increased from 1.65 to 3.51 mg/L. Computed tomography angiogram (CTA) of chest showed extensive ground glass opacities and 2.4 x 1.9 x 1.3 cm distal thoracic aortic intraluminal thrombus. He was started on a heparin drip, and enoxaparin was discontinued. CTA of aorta showed thrombus or hypoattenuation within splenic artery and areas of wedge-shaped extending from the hilum and possible infarction with a six mm thrombus in the infrarenal abdominal aorta. Vascular surgeon recommended no surgical intervention since he was asymptomatic. His d-dimer peaked to 6.92 mg/L but trended down. After two days of heparin drip, he was transition to enoxaparin 1 mg/kg twice daily. He remained asymptomatic with no flank pain. DISCUSSION: At least 17 cases thus far found splenic infarction as a rare thrombotic complication of COVID-19. Presentation is usually with left flank pain, which our patient did not have. Elevation of d-dimer were predictive of thrombosis complications in those hospitalized. Management includes therapeutic dose anticoagulation like subcutaneous low molecular weight heparin before being discharge home with oral anticoagulant. CONCLUSIONS: Although pulmonary embolism is the most common thromboembolism complication of COVID-19, arterial thrombosis are common especially in critically ill patients. Physicians need to consider arterial and venous thrombosis and investigate appropriately based on symptoms in order to manage. Prophylactic anticoagulation is recommended for hospitalized COVID-19. REFERENCE #1: Santos Leite Pessoa M, Franco Costa Lima C, Farias Pimentel AC, et. al. Multisystemic Infarctions in COVID-19: Focus on the Spleen. Eur J Case Rep Intern Med. 2020 Jun 3;7(7):001747. doi: 10.12890/2020_001747. REFERENCE #2: 2. Klok FA, Kruip MJHA, van der Meer NJM, et. al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020 Jul;191:145-147. doi: 10.1016/j.thromres.2020.04.013. REFERENCE #3: 3. Besutti G, Bonacini R, Iotti V, et. al. Abdominal Visceral Infarction in 3 Patients with COVID-19. Emerg Infect Dis. 2020 Aug;26(8):1926-1928. doi: 10.3201/eid2608.201161. DISCLOSURES: No relevant relationships by Jayaramakrishna Depa, source=Web Response No relevant relationships by Cassandra Do, source=Web Response No relevant relationships by shyam Ganti, source=Web Response No relevant relationships by Mythili Kanthi Gudipati, source=Web Response

Incidence of Thrombotic Complications in COVID-19: On Behalf of ICODE: The International COVID-19 Thrombosis Biomarkers Colloquium

High rates of both venous and arterial thromboembolic events were observed early during the global COVID-19 pandemic, with severity of illness and need for intensive care unit admission correlating with increased thrombotic risk.

Application of tranexamic acid in the treatment of intertrochanteric fracture of femur

To investigate the application of tranexamic acid in the treatment of intertrochanteric fracture. From January 2017 to October 2019, 100 patients with intertrochanteric fracture were randomly divided into observation group (48 cases) and control group(52 cases). All patients received the same surgical treatment. The control group was given tranexamic acid 20 minutes before operation, and 15 mg/kg diluted in 250 ml sodium chloride injection, intravenous drip;the observation group was given tranexamic acid 0.5 g dissolved in 20 ml normal saline injected into femoral bone marrow cavity for local treatment on the basis of the control group. The blood loss, operation time and postoperative hospital stay were compared between two groups. Hematocrit, hemoglobin, D-dimer and fibrinogen levels were analyzed before and after operation, and the incidence of thrombotic complications was observed. The total blood loss, dominant blood loss, hidden blood loss and postoperative drainage volume of the observation group were significantly lower than those of the control group (P<0.05), and the postoperative hospital stay was significantly shorter than that of the control group (P<0.05). The postoperative hemoglobin and hematocrit of two groups were significantly lower than those before operation (P<0.05), while the postoperative hemoglobin and hematocrit of the observation group were significantly higher than those of the control group (P<0.05). The incidence of thrombotic complications in the observation group was 10.42%, which was not significantly different from that in the control group (11.54%)(P>0.05). Tranexamic acid combined with systemic and local application has important clinical significance in reducing perioperative blood lossand blood cell loss in patients with intertrochanteric fracture, and has good safety.

Meglumine Sodium Succinate to Correct COVID-19-Associated Coagulopathy: the Feasibility Study

Aim of the study: to evaluate the effect of meglumine sodium succinate (MSS) on the efficacy of anticoagulant therapy in patients with severe COVID-19 infection complicated by bilateral community-acquired pneumonia.Materials and methods. Overall efficacy of treatment was analyzed in 12 patients hospitalized to ICU with the diagnosis of severe confirmed COVID-19 coronavirus infection (U07.1) complicated by bilateral multisegmental pneumonia. All patients received prophylactic anticoagulation with unfractionated heparin. The patients were divided into two groups: 7 of them received a multi-electrolyte solution containing MSS 5 ml/kg daily for the entire ICU stay (3-10 days) as a part of therapy; 5 patients received a similar volume of a conventional multi-electrolyte solution containing no metabolically active substrates and comprised a control group. Coagulation parameters were measured in arterial and venous blood of all patients at the following stages: 1) upon admission to the ICU; 2) 2-4 hours after the first dose of heparin; 3) 8-12 hours after the second dose of heparin; 4) 24 hours after the beginning of intensive therapy. On the 28th day of follow-up, mortality, duration of ICU stay, and incidence of thrombotic complications in the groups were evaluated. Nonparametric methods of statistical analysis were used to assess intragroup changes and intergroup differences.Results. The group of patients administered with MSS had significantly fewer thromboembolic events during 28 days of treatment and shorter ICU stay. These patients responded faster to anticoagulant therapy, which was suggested by more distinct changes in coagulation parameters, i.e. increased APTT, persisting viable thrombocyte population, reduced D-dimer and fibrinogen levels.Conclusion. The metabolic action of succinate possibly increases endothelial resistance to damaging factors and reduces its procoagulant activity. The hypothesis requires testing in a larger clinical study with a design including laboratory evaluation of the efficacy of varying doses of the studied drug as well as aiming at elucidation of the mechanisms of its effect on specific pro- and anticoagulation system components.

Possibilities of Hyperinflammation Correction in COVID-19

Objective. To evaluate the effect of sodium meglumine succinate on the severity of the systemic inflammatory response syndrome when used in complex therapy in patients with severe COVID-19.Material and Methods. The clinical and laboratory data of 12 patients with the diagnosis «Novel coronavirus infection COVID-19 complicated by community-acquired bilateral polysegmental interstitial pneumonia» were analyzed. All patients underwent intensive therapy with a limited volume of water load in the intensive care unit in accordance with the recommendations of the Ministry of Health of the Russian Federation. Seven patients (observation group) received a polyelectrolyte solution containing meglumine sodium succinate (Reamberin) as part of the therapy at a daily dose of 5 ml/kg during the entire period of stay in the ICU (3–10 days). The control group included 5 patients who received a similar volume of a conventional polyelectrolyte solution containing no metabolically active substrates. The study was pilot in nature due to the small number of patients. The laboratory parameters of arterial and venous blood were measured at the following stages: 1) upon admission to the ICU; 2) 2–4 hours after the completion of Reamberin infusion; 3) 8–12 hours after drug administration; 4) 24 hours after the start of intensive care. Mortality rate and the incidence of thrombotic complications in the groups were assessed on the 28th day of observation. The presence of the therapeutic intervention effect was established using multivariate analysis of variance (MANOVA).Results. A positive effect of the study drug on the severity of systemic inflammatory response syndrome (SIRS) against the background of ongoing etiotropic therapy was noted. Efficiency criteria were the correction of hyperfibrinogenemia, normalization of the platelet count, decrease in the level of C-reactive protein, ferritin, and leukocytosis. A significant decrease in the frequency of thromboembolic events was observed within 28 days of treatment, as well as a reduction in the length of time the patients spent in the ICU.Conclusion. Based on the results of the pilot study, it can be assumed that the antihypoxic and antiradical effects of the drug contribute to the reduction of pulmonary and systemic endotheliitis, which is characteristic of severe forms of the disease and, as a result, inhibits the development of the systemic inflammatory response syndrome. The data obtained can serve as a basis for further in-depth studies.

Intraoperative tranexamic acid use in patients undergoing excision of intracranial meningioma: Randomized, placebo-controlled trial.

Background: Intracranial meningioma resection is associated with substantial intraoperative bleeding. Intraoperative tranexamic acid (TXA) use can reduce bleeding in a variety of surgical procedures. The objective of this study was to evaluate the effects of TXA treatment on blood loss and transfusion requirements in patient undergoing resection of intracranial meningioma.Methods: We conducted a prospective, randomized double-blind clinical study. The patient scheduled to undergo excision of intracranial meningioma were randomly assigned to receive intraoperatively either intravenous TXA or placebo. Patients in the TXA group received intravenous bolus of 20 mg/kg over 20 min followed by an infusion of 1 mg/kg/h up to surgical wound closure. Efficacy was evaluated based on total blood loss and transfusion requirements. Postoperatively, thrombotic complications, convulsive seizure, and hematoma formation were noted.Results: Ninety-one patients were enrolled and randomized: 45 received TXA (TXA group) and 46 received placebo (group placebo). Total blood loss was significantly decreased in TXA group compared to placebo (283 ml vs. 576 ml; P < 0.001). Transfusion requirements were comparable in the two groups (P = 0.95). The incidence of thrombotic complications, convulsive seizure, and hematoma formation was similar in the two groups.Conclusion: TXA significantly reduces intraoperative blood loss, but did not significantly reduced transfusion requirements in adults undergoing resection of intracranial meningioma.