Intensive Anticoagulation Therapy Research Articles

Pulmonary Thrombotic Complication of Mycoplasma pneumoniae Pneumonia in Chinese Children: Clinical Feature and Risk Factor Analysis.

Thrombotic disease is a rare but severe complication of Mycoplasma pneumoniae pneumonia in children, with pulmonary thrombosis (PT) being the most frequent type. This study aims to describe the clinical features of pediatric severe Mycoplasma pneumoniae pneumonia (SMPP) patients with PT, and to identify risk factors predictive of PT development in this population. We retrospectively enrolled 60 children with SMPP complicated by PT who were admitted to Children's Hospital Affiliated to Zhengzhou University from January 2019 to October 2023. We reviewed their demographic data, laboratory tests and imaging examinations to describe their clinical features. We used multivariate logistic regression analysis to identify significant risk factors for PT in SMPP. The PT group exhibited higher incidences of chest pain, hemoptysis, inflammation and elevated D-dimer levels, as well as more severe pulmonary damage and transaminitis complication, compared to the non-PT group. The left pulmonary artery was the predominant location of PT in SMPP children. A multivariate analysis revealed that C-reactive protein (CRP) and D-dimer were significant predictors of PT in SMPP patients, with odds ratios of 1.10 and 3.37, respectively. The optimal cutoff values of CRP and D-dimer for predicting PT in SMPP were 76.73 mg/L and 3.98 µg/mL, respectively. In SMPP, CRP >76.73 mg/L and D-dimer >3.98 µg/mL are independent predictors of PT. These findings suggest that SMPP-induced excessive inflammation may contribute to PT pathogenesis. Early and intensive anticoagulant, anti-inflammatory and antimycoplasma therapy may improve the disease course and prognosis.

The effect of COVID-19 on the thromboembolic outcomes in atrial fibrillation patients in the long run

Background While there has been a wealth of reports concerning the acute effects of the coronavirus disease 2019 (COVID-19), further information is needed to see how things unfold in the long run. This research aimed to ascertain whether the COVID-19 pandemic has increased the probability of thromboembolic events in atrial fibrillation (AF) patients. Methods In this retrospective study, we scanned 952 AF patients and classified 643 eligible ones per their history of catching COVID-19. Two hundred thirty-nine of 643 patients had a history of COVID-19 (Group 1), and 404 did not (Group 2). We then compared two years of thromboembolic events between the groups. Results Composite thromboembolic outcomes were seen in 76 (11.8%) patients. Of those, 32 (13.4%) were in Group 1, and 44 (10.8%) were in Group 2 (p = .03). 10 of 32 patients (31%) in Group 1 and 11 of 44 (25%) in Group 2 died because of thromboembolic events (p = .02). Histories of diabetes mellitus, chronic obstructive pulmonary disease, and COVID-19 independently predicted thromboembolic events in AF patients. Conclusions Having caught COVID-19 is likely to be associated with increased long-term thromboembolic outcomes in AF patients. Albeit the study design does not permit us to infer causality, our results question the necessity of more intensive anticoagulant therapy and closer follow-up in AF patients with past COVID-19.

Multisystem inflammatory syndrome complicated by pulmonary embolism in a child

Purpose - to present a clinical case of a particular complication of post-COVID multisystem inflammatory syndrome (MIS) - pulmonary embolism (PE) which developed due to primary hereditary thrombophilia in a child for better understanding of the MIS evolution and prognosis in children (MIS-C). Case report. In an 11-year-old boy who previously had no hemorrhagic manifestations, the first symptoms of the disease occurred in the form of fever and a hemorrhagic rash on the lower extremities. Later, he developed signs of respiratory failure, his condition worsened, and bilateral community-acquired viral pneumonia caused by COVID-19 was diagnosed. The child presented with post-COVID MIS manifested as PE, which caused further genetic examinations for hereditary thrombophilia. Primary thrombophilia was detected (F2 gene - prothrombin (20210 G>A) D68.5). Concomitant hereditary pathology was probably the reason for a severe course of the infection and the development of a complication in the form of PE requiring intensive and long-term anticoagulant therapy. Conclusions. In case of PE detection, especially in young patients, examinations to confirm or rule out hereditary or acquired thrombophilia are required, that defines recurrent venous thromboembolism prevention programs. This clinical case report is a contribution to the study on the issues of MIS-C, defining links between pulmonary complications (transient or persistent) and serious sequelae in the future. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Гіпереозинофілія як фактор ризику тромбоемболії легеневої артерії при онкологічних захворюваннях у практиці лікаря-інтерніста

Abstract. Pulmonary embolism is an urgent problem today. Diseases of the cardiovascular system, hereditary factors of impaired hemostasis, childbirth and pregnancy, surgical interventions, injuries, immobilization, dehydration, etc., can be risk factors for increased blood clot formation. In addition, one of the factors that significantly increases the risk of thrombosis is malignant neoplasms. It should be noted that there are factors that are rarely mentioned in the scientific literature as a risk factor for thrombosis, for example, blood hypereosinophilia. An increase in the level of eosinophils in peripheral blood can occur against the background of allergic and autoimmune diseases, parasitic and fungal infections, some diseases of the gastrointestinal tract, bone marrow diseases. The article reveals the pathogenetic basis of the influence of hypereosinophilia on the risk of thrombosis. Hypereosinophilia syndrome is closely associated with thrombosis, which may recur despite adequate anticoagulation or warfarin therapy. Eosinophils accumulate and express tissue factor and after its activation can initiate coagulation. The article describes the clinical case of a patient with lung cancer, which was accompanied by a leukemic reaction in the form of hypereosinophilia, and was complicated by deep vein thrombosis of the lower extremities and pulmonary embolism. The example of a clinical case shows the complex mechanism of hemostasis disorders against the background of the presence of a malignant neoplasm, especially when combined with paraneoplastic hypereosinophilia, which is an additional risk factor for the development of treatment-resistant venous thrombosis of various locations and thromboembolism of the pulmonary artery and requires preventive anticoagulation therapy, as well as more intensive and long-term anticoagulant therapy when deep vein thrombosis and pulmonary embolism has already developed.

Maska brzuszna ostrego zespołu wieńcowego czy ... ? Celowość włączenia badania przesiewowego aorty brzusznej do rutynowego protokołu badania echokardiograficznego

An 86-year-old woman with a history of hypertension, paroxysmal atrial fibrillation, chronic kidney disease, type 2 diabetes and hypothyroidism, was admitted due to weakness and atypical chest pain accompanied by dyspnoea, abdominal pain, vomiting and lack of appetite. Also, a month ago the patient underwent left lower limb erysipelas and reported a 10 kg decrease in body weight over the past year. On admission, the patient was hemodynamically stable. Electrocardiography revealed sinus rhythm, first-degree atrioventricular block, and persistent ST-segment depression in the anterolateral loads. Biochemical tests revealed elevated high-sensitivity troponin level and high N-terminal pro-B-type natriuretic peptide concentration. Echocardiography showed normal left ventricle systolic function, ejection fraction of 50%, without evidence of significant valvular heart disease. Taking into consideration all of the above, the diagnosis of the acute coronary syndrome was proposed. Due to the standards applied in our echocardiography protocol (screening of abdominal aorta dimension in people over 65-years-old), a significant widening of the abdominal aorta was found. In computed tomography angiogram, abdominal 57 mm aortic aneurysm with a haemorrhagic thrombus and right iliac aneurysm with a large thrombus with deep ulceration were confirmed. The whole clinical picture suggests that the patien’s complaints resulted from the presence of large abdominal aortic and common iliac artery aneurysms, accompanied by pressure on the adjacent abdominal organs and with a high risk of sudden rupture. The described case confirms the validity of supplementing routine echocardiographic protocol with a screening assessment of the abdominal aorta, following European Society of Cardiology guidelines. Accurate diagnosis, in this case, protected the patient from acute coronary syndrome invasive treatment, which could result in intensive anticoagulant and antiplatelet therapy implementation and lead to life-threatening complications.

Management of acute pulmonary embolism after acute aortic dissection surgery

Acute aortic dissection (AAD) continues to be associated with high mortality and morbidity. Pulmonary embolism is also a life-threatening disease. The treatment of these life-threatening diseases remains controversial in case complications arise. Thrombolytic therapy and intensive treatment would be needed to manage these fatal diseases. A 49-year-old man with progressive back pain was admitted to our hospital. Computed tomography (CT) scan revealed type A AAD. Emergency operation for hemiarch replacement was performed. Two weeks postoperatively, the patient’s oxygenation worsened and his d-dimer levels elevated. CT scan revealed a massive thrombus in the bilateral pulmonary arteries. Intensive anticoagulation therapy was started immediately. On postoperative day 27, the patient was weaned from mechanical ventilation, but the false lumen with thrombus was recanalized again. The patient was discharged on postoperative day 75 without resulting in major complications for aortic dissection. The diagnosis of pulmonary embolism concomitant with AAD is difficult. The treatment of pulmonary embolism after AAD is controversial. Our strategy seems to be suitable for acute pulmonary embolism that occurs during the treatment of AAD.˂Learning objective: The diagnosis of pulmonary embolism concomitant with acute aortic dissection (AAD) is difficult. The treatment of pulmonary embolism after AAD is controversial. Investigating factor XIII levels might help in the early detection of pulmonary embolism.>

O18-5 - 2 Case Reports of Successful Treatment by Central ECMO with LV Venting for Severe Heart Failure Complicated with Alveolar Hemorrhage

Severe heart failure patients are sometimes complicated with alveolar hemorrhage due to pulmonary congestion. Patients with alveolar hemorrhage have high pulmonary vascular resistance, so LVAD attachment induces relative right heart failure which may require right heart system assist. In such cases, hemodynamic management becomes very difficult. With high pulmonary perfusion as well as intensive anti-coagulation therapy, alveolar hemorrhage might worsen. Furthermore, it is difficult to tell whether the cause of alveolar hemorrhage is pulmonary congestion or other diseases like organized pneumonia. Our present strategy for particularly severe heart failure is as follows: we adopt central ECMO support with RA drainage and ascending aorta perfusion to get adequate circulatory flow support. At the same time, LV venting from the apex is also used to release pulmonary congestion, which leads to recover pulmonary function, and reduce pulmonary vascular resistance. And as a next step, we aim to maintain hemodynamics by supporting left heart system only. Recently, we experienced 2 severe heart failure cases complicated with alveolar hemorrhage whose etiologies were hard to differentiate, which were successfully treated according to our strategy. Here, we are going to report these 2 cases with some discussions.

Hepatic arterial and portal venous complications after adult and pediatric living donor liver transplantation, risk factors, management and outcome (A retrospective cohort study).

ObjectivesHepatic arterial (HA) and portal venous (PV) complications of recipients after living donor liver transplantation(LDLT) result in patient loss. The aim of this study was to analyze these complications.MethodsWe retrospectively analyzed HA and/or PV complications in 213 of 222 recipients underwent LDLT in our centre. The overall male/female and adult/pediatric ratios were 183/30 and 186/27 respectively.ResultsThe overall incidence of HA and/or PV complications was 19.7% (n = 42), while adult and pediatric complications were 18.3% (n = 39) and 1.4% (n = 3) respectively. However early (<1month) and late (>1month) complications were 9.4% (n = 20) and 10.3% (n = 22) respectively. Individually HA problems (HA stenosis, HA thrombosis, injury and arterial steal syndrome) 15% (n = 32), PV problems (PV thrombosis and PV stenosis) 2.8% (n = 6) and simultaneous HA and PV problems 1.9% (n = 4). 40/42 of complications were managed by angiography (n = 18), surgery (n = 10) or medically (Anticoagulant and/or thrombolytic) (n = 12) where successful treatment occurred in 18 patients. 13/42 (31%) of patients died as a direct result of these complications. Preoperative PVT was significant predictor of these complications in univariate analysis. The 6-month, 1-, 3-, 5- 7- and 10-year survival rates in patients were 65.3%, 61.5%, 55.9%, 55.4%, 54.5% and 54.5% respectively.ConclusionHA and/or PV complications specially early ones lead to significant poor outcome after LDLT, so proper dealing with the risk factors like pre LT PVT (I.e. More intensive anticoagulation therapy) and the effective management of these complications are mandatory for improving outcome.

AB0477 Comparative Analysis of the Faults, Complications, Follow up in Patients with Wide Spectrum for Rheumatic Diseases Attached to Total Hip Replacement

ObjectivesThe feasible of the total hip replacement (THR) in the wide spectrum rheumatic diseases with hip involvements, analysis of the faults, complications, preliminary follow up.MethodsThe are 1069 patients, 773 women...

Value of Serial Echo-Guided Ramp Studies in a Patient with Suspicion of Device Thrombosis after Left Ventricular Assist Device Implantation

Thrombus formation inside of the pump is a major cause for device malfunction following the left ventricular assist device (LVAD) implantation. We recently established a novel ramp test protocol facilitating continuous bedside echo monitoring to optimize LVAD function and diagnosing device malfunctions. We describe a case of 29-year-old woman undergoing HeartMate II LVAD implantation, in whom serial ramp studies were used to diagnose intra-device thrombus after device implantation. The 1st ramp study at postoperative day (POD) 26 revealed adequate reduction in ventricular size according to the increase in LVAD speed (left ventricular end-diastolic diameter [LVEDD] at minimum and maximum speeds, 68 and 37mm, respectively). The patient was discharged home and received routine anticoagulation maintenance therapy. However, a 2nd ramp test was performed on POD 56 due to increased lactase dehydrogenase and brain natriuretic peptide levels and showed marked increase in left ventricle (LV) chamber size without adequate response to the LVAD speed changes (LVEDD at minimum and maximum speeds, 88 and 76mm, respectively). Given the suspicion for partial pump thrombosis, the patient was immediately hospitalized and received intravenous heparin infusion. After the optimization of the intensive anticoagulation therapy, the patient underwent a 3rd ramp study, which showed a remarkable improvement of the adequate response to LVAD speed changes. The patients eventually underwent cardiac transplant successfully, and the partial clot was found inside of the pump. This case demonstrates the usefulness of serial ramp studies in patients who are suspected to have device thrombosis.

Differential Diagnosis of Lemierre's Syndrome in a Patient with Acute Paresis of the Abducens and Oculomotor Nerves

Lemierre's syndrome is characterized by anaerobic septicemia, internal jugular vein thrombosis, and septic emboli associated with infections of the head and neck. We describe an unusual and clinically confusing case of a young woman with an acute paresis of the abducens nerve and partial paresis of the right oculomotor nerve. After an extensive imaging diagnostic procedure, we also documented a peritonsillar abscess and various types of thromboses in intracranial and extracranial veins. Furthermore, we found brain and lung abscesses, which led us to establish the diagnosis of Lemierre's syndrome. Despite intensive anti-coagulation and antibiotic therapy, the patient developed a mycotic aneurysm in the right internal carotid artery directly adjacent to the previously thrombosed cavernous sinus. In summary, we were able to confirm that Lemierre's syndrome may occur in conjunction with uncharacteristic symptoms. Due to the sometimes confusing clinical symptoms as well as clinical and radiological specialties, we had to work on an interdisciplinary basis to minimize the delay prior to establishing the diagnosis and therapy.

Clinical investigation of transradial access for emergent percutaneous coronary intervention in patients with acute myocardial infarction

BackgroundUse of intensive anticoagulation and antiplatelet therapy in acute myocardial infarction (AMI) potentially increases the risk of bleeding complications during percutaneous coronary intervention via the transfemoral route. Recently, the transradial access has been intensively employed as an alternative means for diagnostic and interventional procedures. A low incidence of vascular access site bleeding complications suggests that the transradial access is a safe alternative to the transfemoral technique in patients with AMI. The safety and efficacy of transradial access for emergent percutaneous coronary intervention in patients with AMI has not been investigated in the People’s Republic of China.MethodsWe analyzed data from our single-center registry on 596 consecutive patients between October 2003 and October 2010. The patients were retrospectively divided into a transradial group (n = 296) and a transfemoral group (n = 300). A dedicated doctor was appointed to collect the following data: puncture time, coronary angiography time, percutaneous coronary intervention time, X-ray exposure time, duration of hospitalization, and complication rates associated with puncture, such as puncture site bleeding, hematoma, pseudoaneurysm, and major adverse cardiac events.ResultsThere were no significant differences in baseline characteristics and angiographic findings between the two groups. There were also no significant differences in coronary angiography time (8.2 ± 2.4 versus 7.6 ± 2.0 minutes), percutaneous coronary intervention time (30 ± 6.8 versus 29.6 ± 8.1 minutes), or X-ray exposure time (4.6 ± 1.4 versus 4.4 ± 1.3 minutes) between the groups. There were significant differences in puncture time (4.4 ± 1.6 versus 2.4 ± 0.8 minutes) and duration of hospitalization (3.2 ± 1.6 versus 5.4 ± 1.8 days) between the groups (P < 0.001). The complication rate using transradial access was 2.03% (6/296) versus 6.0% (18/300) using transfemoral access (P < 0.0001).ConclusionTransradial access for emergent percutaneous coronary intervention is safe and effective in patients with AMI, and it is suggested that this route could be used more widely in these patients.

Association of coronary lipid core plaque with intrastent thrombus formation

Optical coherence tomography (OCT) and near-infrared spectroscopy (NIRS) allow assessment of the anatomy (OCT) and composition (NIRS) of coronary lesions. We sought to examine the association between pre-stenting lipid core plaque (LCP), as assessed by NIRS and post-stenting thrombus formation, as assessed by OCT. We reviewed the angiograms of nine patients who underwent coronary stenting in association with NIRS and OCT imaging. A large LCP by NIRS was defined as at least three 2-mm yellow blocks on the NIRS block chemogram with >200° angular extent. Intracoronary thrombus was defined as a mass of medium reflectivity protruding into the vessel lumen, discontinuous from the surface of the vessel wall. Mean age was 67 ± 7 years, and all patients were men, presenting with stable angina (56%), unstable angina (11%), or acute myocardial infarction (33%). The mean vessel lipid core burden index (LCBI) was 120 ± 45, and the mean highest 6-mm LCBI was 386 ± 190. Three patients had a large LCP and two of them (66%) developed intrastent thrombus after stent implantation compared to none of six patients without large LCPs (0%, P = 0.02). The thrombus resolved after intracoronary glycoprotein IIb/IIIa administration and balloon postdilation. Postprocedural myocardial infarction occurred in 33% versus 17% of patients with and without large LCP, respectively (P = 0.57). Stenting of large LCPs may be associated with intrastent thrombus formation, suggesting that more intensive anticoagulant and/or antiplatelet therapy may be beneficial in such lesions. © 2012 Wiley Periodicals, Inc.

Relationship between the Occurrence of Thromboembolism and INR Measurement Interval in Low Intensity Anticoagulation after Aortic Mechanical Valve Replacement

BackgroundWe investigated changes in the International Normalized Ratio (INR) and its measurement interval in patients with thromboembolic events who were treated by low intensity anticoagulation therapy after isolated mechanical aortic valve replacement.Materials and MethodsSeventy-seven patients who underwent surgery from June 1990 to September 2006 were enrolled in the study and observed until August 2008. The patients were followed up at 4~8 week intervals and their warfarin (Coumadin)® dosage was adjusted aiming for a target range of INR 1.5~2.5. The rate of thromboembolic events was obtained. Changes in the mean INR and INR measurement interval were comparatively analyzed between the normal group (event free group, N=52) who had no anticoagulation-related complications and the thromboembolic group (N=10). Hospital records were reviewed retrospectively.ResultsThe observation period was 666.75 patient-years. Thromboembolic events occurred in 10 patients. The linearized occurrence rate of thromboembolism was 1.50%/patient-years. Actuarial thromboembolism-free rates were 97.10±2.02% at 5 years, 84.30±5.22% at 10 years, and 67.44±12.14% at 15 years. The percentages of INR within the target range and mean INR were not statistically significantly different for the normal and thromboembolic groups. However, the mean INR during the segmented period just before the events showed a significantly lower level in the thromboembolic group (during a 4 month period: normal group, 1.86±0.14 vs. thromboembolic group, 1.50±0.28, p<0.001). The mean intervals of INR measurement during the whole observation period showed no significant differences between groups, but in the segmented period just before the events, the interval was significantly longer in thromboembolic group (during a 6 month period: normal group, 49.04±9.47 days vs. thromboembolic group, 65.89±44.88 days, p<0.01).ConclusionTo prevent the occurrence of thromboembolic events in patients who receive isolated aortic valve replacement and low intensity anticoagulation therapy, we suggest that it would be safe to maintain an INR level above 1.8 and to measure the INR at least every 7~8 weeks.

Anticoagulation Strategies for Atrial Fibrillation Patients with Left Atrial Appendage Thrombus

Backgrounds: The anticoagulation therapy is recommended to prevent thromboembolism in the patients with atrial fibrillation (AF). However, thrombus sometimes form at the left atrial appendage (LAA) despite the adequate anticoagulation therapy. The aim of this study is to clarify the therapeutic strategy for AF patients with LAA thrombus. Methods and Results: Among 250 AF patients who were performed the transesophageal echocardiography in our institute from Mar 2008 to May 2011, LAA thrombi were observed in 19 patients (7.6%; 64±9.5 years, male 15, chronic 17). The average value of the prothrombin time-international normalized ratio (PT-INR) in these patients was 1.84±0.34 at that time. All the thrombi had disappeared by administering both heparin and high dose of warfarin for 15±14 days in 9 patients, and high dose of warfarin alone for 85±59 days in the remaining 10. The value of PT-INR has finally reached 2.99±0.52 at the time of thrombus disappearance. The major complications including the hemorrhage had not occurred during the follow-up periods. Conclusions: The intensive anticoagulation therapy targeting the PT-INR value of 3.0 might be considered for the patients with LAA thrombus under regular anticoagulation therapy. The additional use of heparin might shorten the time to thrombus disappearance.

An Old Story: Aggressive Antithrombotic Approach Reduced or Increased the Risk of Destabilization and Adverse Events: More Questions Than Answers.

Abstract 4185Aggressive antithrombotic therapy with ASA, thienopyridine, GPIIb/IIIa inhbitors, eparin, and Vit.K antagonist (VKA) is used for unstable angina (UA), myocardial infarction (NSTEMI), acute coronary syndrome (ACS), stent implantation, atrial fibrillation (AF),VTE. The main findings of combination of antithrombotic drugs are their association with serious bleeding not withstanding some respectable benefit, and a great effects against thrombosis. At present the preferred approach for the long term treatment is VKA the dose should be adjusted to maintain a target INR of 2.5 (range: 2.0 to 3.0), the controversy focused in a patients with a high risk of recurrence a high intensity VKA therapy (INR: 3.1 to 4.0) although did not confirm a superiority in terms of thrombotic protection, new opportunities have emerged in the treatment of arterial thrombosis with the combinations of antithrombotic drugs (ASA 325mg every days, plus thienopyridine: ticlopidine 250mg orally twice a day, or clopidogrel / GPIIb-IIIa antagonist/ anticoagulant: VKA, LMWH, fondaparinux) with a significant inhibition of thrombosis but always a remarkable and unacceptable bleeding risk, and a narrow safety window. Question: what are the very primary strong end points (death, PE or symptomatic VTE, Myocardial infarction or stroke, recurrence!), or are the inhibition of platelet functions, of signalling pathways, of atherosclerotic process monitoring. Several trials have evaluated the role of long term anticoagulation therapy, and a high intensity anticoagulation and combination therapy with a marvel issue (by 32% to 48% reduction of the risk of relapse) but a burdensome toll of side effects (bleeding by 4.8% to 8.2%). We have studied 118 patients with a tailored therapy and individual strategies selecting the disease and comorbility, the dose, the timing, the manner, the potential validity and the variance of individual responses with a significant reduction of side effects (bleeding by 0.8% to 2.4%), and a preserved therapeutic benefit (by 34% to 44% reduction of the risk of relapse). Answers: the optimal management of antithrombotic therapy is the reduction of side events, and the mainstay of treatment is to maintain patency of the vessels, but it's not so easy, certainly the main road is to have a drug made to be measured. Disclosures:No relevant conflicts of interest to declare.

Pulmonary Capillary Bleeding in a Patient with Severe Left Ventricular Failure after Acute Myocardial Infarction under Anti-thrombotic Therapy

A 52-year-old man who was admitted for cardiogenic shock after acute myocardial infarction developed severe left ventricular dysfunction despite reperfusion therapy with coronary stents. After the 40th hospital day, he started to have cough and pulmonary infiltrates. Antimicrobial therapies and subsequent prednisolone for bronchiolitis obliterans organizing pneumonia were ineffective. Bronchoscopic examination revealed diffuse pulmonary bleeding and exudation of hemosiderin-containing macrophages in bronchial lavage fluid. Pulmonary capillary bleeding has been reported in the terminal stage of patients with mitral stenosis in the pre-cardiac surgery era. This complication reemerges in patients with severe heart failure receiving intensive anti-coagulation therapy after implanting a sirolimus-eluting coronary stent.

Risk factors contributing to hepatic artery thrombosis following living-donor liver transplantation

This study was carried out to investigate the risk factors contributing to hepatic artery thrombosis in living-donor liver transplantation. Two hundred and twenty-two recipients (113 adults and 109 children) of living-donor liver transplantation were the subjects of this study. The diagnosis of hepatic artery thrombosis was made by color-Doppler ultrasonography and/or hepatic angiography. Parameters for this study were: (1) donor sex, age, and body weight; (2) recipient sex, age, body weight, liver disease, preoperative prothrombin time, and type of arterial reconstruction; and (3) previous liver transplantation. Hepatic artery thrombosis occurred in 12 patients (5.4%) at 3 to 15 days posttransplant. Recipient female sex and metabolic disorder as the original disease were found to be significantly associated with hepatic artery thrombosis. The 5-year patient survival rate in recipients with hepatic artery thrombosis (58.3%) was significantly lower than that in recipients without this complication (84.4%). Female sex and metabolic disease may be factors contributing to hepatic artery thrombosis after living-donor liver transplantation. More intensive anticoagulation therapy for this patient population might decrease the incidence of hepatic artery thrombosis and, thus, posttransplant recipient mortality.

A Fatal Case of Malignant Atrophic Papulosis (Degos

Malignant atrophic papulosis (Degos' disease) is a very rare condition characterized by atrophic papular skin lesions and variable association of systemic involvement. We describe a 33-year-old man who presented with a widespread skin eruption consistent with malignant atrophic papulosis. During the course of the disease he even developed penile ulcerations, a symptom that has been reported only a few times previously. He subsequently died of multiple perforations of the small bowel 2.5 years after onset of the disease. Laboratory investigations revealed a mutation of factor V Leiden and the presence of lupus anticoagulant, but no anti-cardiolipin antibodies. The patient was treated with narrow-band ultraviolet (UV)B, prednisolone and, later, aspirin, pentoxifyllin and warfarin. Despite this very intensive anticoagulant and anti-platelet therapy, the treatment had no effect on the skin lesions and could not prevent systemic involvement.

Catastrophic antiphospholipid antibody syndrome following initiation of hemodialysis

Antiphospholipid syndrome (APS) is associated with arterial and venous thrombosis, pregnancy morbidity, and thrombocytopenia. Some APS patients develop rapid and disseminated microthrombosis and are known as having catastrophic APS or CAPS. We document here a case of CAPS in a patient who presented with various clinical symptoms and serious abnormalities of blood coagulation following initiation of hemodialysis after bilateral nephrectomy due to renal cancer. The patient developed multiple organ symptoms, including melena, visual disturbances, skin eruptions, lymph node swelling, urinary tract bleeding, backache, arteriovenous fistula occlusion, and chest pain. Based on the clinical course and serological and histological examinations, a diagnosis of CAPS was established. The patient recovered by following intensive anticoagulation and steroid therapy. Although CAPS is rare, once symptoms develop the condition deteriorates rapidly. Because of the associated high mortality, early diagnosis and prompt treatment are necessary.