Intravenous Heparin Research Articles

Hybrid revascularization of the heart and brain: which carotid endarterectomy is preferable?

The aim of this study was to analyse the inpatient and long-term results of hybrid surgery, incorporating percutaneous coronary intervention (PCI) and different types of carotid endarterectomy (CEA).
 Materials and methods. A prospective, open-label cohort comparison study was conducted in 20182020 and included 363 patients with atherosclerosis of both the internal carotid artery (ICA) and coronary artery, who underwent hybrid revascularization of the brain and myocardium. All patients were divided into four groups based on the revascularization strategy: group 1 (n = 107; 29.5%) PCI + eversion CEA; group 2 (n = 98; 27%) PCI + classic CEA with patch angioplasty; group 3 (n = 72; 19.8%) PCI + glomus-sparing CEA according to R.A. Vinogradov; and group 4 (n = 86; 23.7%) PCI + glomus-sparing CEA according to A.N. Kazantsev. The follow-up period was 20.8 8.0 months.
 The patient received a loading dose of clopidogrel (300 mg) before the PCI, and the procedure was then performed in an endovascular operating room. A radial artery catheter was inserted, and the patient received 10,000 IU of intravenous heparin before the procedure. After the PCI, the patient was taken to the vascular operating room, where they underwent the CEA. The patient received 5,000 IU of intravenous heparin before artery clamping. Glomus-sparing CEA according to A.N. Kazantsev was performed as follows: an arteriotomy was conducted along the internal edge of the external carotid artery (ECA), adjacent to the carotid sinus and 23 cm above the ostium, and extending to the common carotid artery (CCA) (also 23 cm below the ECA ostium), depending on the size of the atherosclerotic plaque. The ICA was transected in the area bound by the ECA and CCA walls. Eversion CEA of the ICA was performed, followed by open CEA of the ECA and CCA. The ICA was implanted in its previous position in the preserved area.
 Results. No mortality was recorded during the inpatient follow-up period. All cases of myocardial infarction occurred after eversion and classic CEA: 3 in group 1 (2.8%) and 1 in group 2 (1.02%); р = 0.2. No ischaemic stroke was recorded only in patients who underwent CAE according to A.N. Kazantsev (р = 0.66); however, ischaemic stroke occurred in two patients in group 1 (1.8%), in two patients in group 2 (2.04%) and in one patient in group 3 (1.38%). The highest number of cardiovascular events occurred in group 1, due to carotid glomus injury, which led to poorly controlled hypertension during the inpatient stay. This tendency influenced the composite endpoints (death + myocardial infarction + ischaemic stroke), which were highest in group 1 (5 or 4.6%) compared to 3 (3.06%), 1 (1.38%) and 0 in groups 24, respectively (р = 0.18). The groups were comparable in the frequency of long-term complications. However, the incidence of ICA restenosis was lowest and no ECA thrombosis/occlusion was observed after glomus-sparing CEA according to R.A. Vinogradov and A.N. Kazantsev.
 Conclusion. A hybrid PCI + CEA for brain revascularization should be glomus-sparing. CEA according to A.N. Kazantsev was characterized by lack of procedural arteriotomy complications. This procedure enables blood pressure monitoring in the postoperative period, thus minimizing the risk of cardiovascular complications.

Therapeutic dilemma: When to start anticoagulation for cardiac thrombi in acute ischemic stroke? Lessons from cases

Ischemic stroke has been one of the major reason for morbidity and mortality all over the world. Anticoagulation treatment in patients with cerebral ischemic events caused by cardiac emboli is no longer a matter of debate. The problem is when to start. Because of a recurrence rate of 15 to 20% in the first few weeks after the initial event, direct anticoagulation by means of intravenous heparin followed by oral anticoagulants seems to be indicated. We are presenting 2 cases of patients who suffered cardio-embolic stroke due to cardiac thrombosis and had a therapeutic dilemma on when to start the anticoagulation treatment. Early anticoagulation treatment was associated with good clinical and neurological outcome. Keywords: anticoagulation; stroke; cardiac thrombus; cardio-embolic stroke; hemorrhagic stroke; warfarin.

Median arcuate ligament syndrome: A case report of a rare disease.

IntroductionMedian arcuate ligament syndrome (MALS) is a rare condition caused by the compression of the celiac trunk by the median arcuate ligament, which may trigger a typical symptom triad: postprandial abdominal pain, weight loss, nausea and vomiting.Clinical caseA 58-year-old male was admitted to the emergency department due to abdominal pain, vomiting, fever and diarrhea. On admission, the patient was tachycardic, had abdominal distension, no peritoneal irritation signs, and a serum lactate level of 5 mmol/L. The computed tomography (CT) scan showed gastric and intestinal pneumatosis associated with pneumoportia. Conservative treatment with intravenous fluids, antibiotics and low molecular weight heparin, was initiated. The reassessment CT scan showed resolution of the gastric and intestinal pneumatosis and a severe stenosis of the initial portion of the celiac trunk with associated angulation. After recovery from the acute episode, an abdominal duplex ultrasound and an aortoiliac arteriography in forced inspiration and expiration was performed, corroborating the diagnosis of MALS. A laparoscopic decompression of the celiac trunk was performed.DiscussionSymptoms of MALS closely mimic other abdominal disorders, and it should be considered in the differential diagnosis. Currently, there are no international guidelines on MALS diagnostic criteria. Treatment is focused on decompression of the median arcuate ligament constriction of the celiac artery, with or without celiac lymph node removal.ConclusionMALS diagnostic and therapeutic approach must be patient focused. Laparoscopic decompression is an effective treatment and can provide immediate symptomatic relief, associated with the benefits of the less invasive nature of the procedure.

All in the Family: A Curious Case of Aortopathy

A 28-year-old African American male with history of intermittent headaches presented to an outside hospital (OSH) with few days history of severe right lower extremity pain, swelling and dyspnea. Lower extremity venous ultrasound revealed a large occlusive deep vein thrombosis (DVT) extending from the right common femoral to the right popliteal vein. Chest Computed tomography angiogram (CT Angiogram) revealed a 5.9 cm mid ascending thoracic aortic aneurysm, a 3.2 cm pulmonary artery dilatation and no evidence of pulmonary embolus. He was started on anticoagulation with intravenous heparin and transferred to our institution for surgical management of the aortic aneurysm and evaluation for large vessel vasculitis.

324 Unilateral pulmonary artery agenesis with controlateral embolism: a double vascular trouble

Abstract Methods and results A 60-year-old male patient underwent coronary angiography (CA) for a non-ST segment elevation myocardial infarction (NSTEMI). CA revealed significant multivessel disease. Both internal mammary arteries (AMI) were patent, with right IMA markedly larger than the left IMA. The exam revealed also an abnormal branch arising from the proximal right coronary artery extending backwards, likely to the right lung. Pre-operative chest radiograph demonstrated asymmetry of the two hemithoraces with slight elevation of the right hemidiaphragm, small ipsilateral lung, and mediastinal shift towards the right. The patient underwent urgent CABG surgery. Myocardial revascularization was successfully performed using both AMI and one saphenous vein segment. The postoperative course was complicated by respiratory failure requiring prolonged mechanical ventilation. A chest computed tomography angiography was performed, revealing complete absence of the right pulmonary artery and a left lower lobe segmental pulmonary embolism. Furthermore, blood in the hypoplastic right lung was supplied by multiple collaterals arising from RCA and right IMA. Intravenous heparin was started with clinical improvement. Two weeks later, a lung scintigraphy was performed, ruling out perfusion defects. The patient was discharged home on oral anticoagulation with warfarin. Conclusions Unilateral pulmonary artery agenesis (UPAA) is an uncommon congenital anomaly of the great vessels. Despite the absence of the pulmonary artery, blood supply of ipsilateral lung is provided by systemic collaterals originating from bronchial, intercostal, internal mammary, and sub-diaphragmatic arteries. More rarely, these collaterals may arise from the coronary arteries with different implications, ranging from asymptomatic condition to myocardial ischaemia and infarction. In our case, the condition was previously asymptomatic. The occurrence of pulmonary embolism contributed to worsen the ventilation–perfusion mismatch, explaining the respiratory failure during the postoperative period.

790 Pacemaker lead and atrial thrombosis, a rare event but of high clinical importance

Abstract Aims Trans-venous lead-related thrombosis is an undervalued issue. Since the lack of guidelines or evidences regarding the best therapeutic option, treatment of endocavitary clots on pacemaker wire is left to individual decision between surgical catheter extraction, thrombolysis, or anticoagulation therapy. In some patients, the labile equilibrium between hemorrhagic and thrombotic events may further complicate management. Methods and results We report the case of a 86-years-old man with heart failure (HF) severely reduced ejection fraction due to chronic ischaemic cardiomyopathy and several co-morbidities. He had a reacution of HF requiring hospitalization secondary to new-onset atrial flutter. During hospital stay, in light of episodes of severe bradycardia, he underwent single-lead PM implantation. Few days after discharge he developed deep vein thrombosis in situ of PM electro catheter insertion (poor compliance to anticoagulation therapy was reported) which improved after few days of regular therapy assumption. After few months anticoagulation therapy was dismitted due to etiology unknown-anemization requiring transfusion, but 20 days later he was once again admitted, this time because of pulmonary embolism. Trans thoracic echocardiography (TTE) enlightened a severely dysfunctioning right ventricle and a mass in right atrium hanging the wire. Trans oesophageal echocardiography was then performed showing hyper-reflective and highly mobile material with numerous ‘arborizations’. Intravenous heparin was started as pulmonary embolism therapy. Once infective etiology was excluded, total body computer tomography was performed to investigate a possible paraneoplastic origin. Presence of a meningioma was enlightened. Heart-team evaluation excluded catheter extraction in light of patient’s frailty, while thrombolysis was controindicated. Vitamin K antagonists was then started. At 1 month follow up no further embolic neither haemorrhagic events were reported. TTE showed a reduction in mass dimension and an improvement in right ventricle function. Conclusions In a guidelines-lacking field, VKA can be an effective option in cases of lead-related thrombosis when surgery or thrombolysis is not suitable. Further studies are needed to establish their real effectiveness in management of E-C-related endocavitary thrombi.

Frequency of retinal hemorrhage after thrombolysis with streptokinase in patients presenting with ST-elevation myocardial infarction: A single-center experience at a large tertiary care center in Lahore, Pakistan

Background: Thrombolytic therapy with streptokinase is the mainstay of pharmacological treatment in acute myocardial infarction in Pakistan. Retinal hemorrhage is a common complication of streptokinase-induced thrombolysis and is often overlooked which can lead to permanent vision loss. Therefore, this study was carried out to determine the frequency of retinal hemorrhage after thrombolysis with streptokinase in patients presenting with ST-elevation myocardial infarction (STEMI).
 Patients and methods: It was an observational, cross-sectional study conducted at the Emergency Department of Mayo Hospital Lahore from 11-08-2015 to 10-02-2016. The patients underwent injection of streptokinase (1.5 million U) intravenously over 60 min and intravenous heparin 5,000 U bolus followed by 1,000 U/hour. Then patients were followed up for 24 hours followed by the ophthalmoscopy to confirm the presence of retinal hemorrhage. The data were entered and analyzed using SPSS version 20.
 Results: A total of 130 patients were included in this study. The mean age of patients was 62±9.86 years. The male to female ratio was 1.6:1. The retinal hemorrhage was present in 17 (13.08%) patients. About 80 (61.5%) were diabetics and 96 (73.8%) were hypertensive. Stratified variables like age, gender, hypertension, and diabetes were not found associated with retinal hemorrhage (p-value ≥0.05). 
 Conclusion: Retinal hemorrhage was found in 13.08% after streptokinase injection in patients presenting with STEMI. Although the association was statistically insignificant but still the proportion of retinal hemorrhage was substantially high in these patients. This higher percentage demands vigilant monitoring with the drug for timely diagnosis of this ignored complication which latter can be proved hazardous to the vision.

Role of acquired von Willebrand syndrome in the development of bleeding complications in patients treated with Impella RP devices

Axial flow pumps are standard treatment in cases of cardiogenic shock and high-risk interventions in cardiology and cardiac surgery, although the optimal anticoagulation strategy remains unclear. We evaluated whether laboratory findings could predict bleeding complications and acquired von Willebrand syndrome (avWS) among patients who were treated using axial flow pumps. We retrospectively evaluated 60 consecutive patients who received Impella devices (Impella RP: n = 20, Impella CP/5.0: n = 40; Abiomed Inc., Danvers, USA) between January 2019 and December 2020. Thirty-two patients (53.3%) experienced major or fatal bleeding complications (Bleeding Academic Research Consortium score of > 3) despite intravenous heparin being used to maintain normal activated partial thromboplastin times (40–50 s). Extensive testing was performed for 28 patients with bleeding complications (87.5%). Relative to patients with left ventricular support, patients with right ventricular support were less likely to develop avWS (87.5% vs. 58.8%, p = 0.035). Bleeding was significantly associated with avWS (odds ratio [OR]: 20.8, 95% confidence interval [CI]: 3.3–128.5; p = 0.001) and treatment duration (OR: 1.3, 95% CI 1.09–1.55; p = 0.003). Patients with avWS had longer Impella treatment than patients without avWS (2 days [1–4.7 days] vs. 7.3 days [3.2–13.0 days]). Bleeding complications during Impella support were associated with avWS in our cohort, while aPTT monitoring was not sufficient to prevent bleeding complications. A more targeted anticoagulation monitoring might be needed for patients who receive Impella devices.

Peripheral arterial embolization and limb ischemia complicating septic internal jugular vein thrombosis: a case report of Lemierre’s syndrome

Purpose: Septic thrombophlebitis of the internal jugular vein is a life-threatening complication of venous thrombosis. While heparin is frequently added to antimicrobial therapy, its usefulness in patients with Lemierre’s syndrome is controversial. In this case report, we demonstrate that delayed use of intravenous heparin may be associated with septic embolization of peripheral arteries. Limb ischemia has rarely been reported in patients with Lemierre’s syndrome.
 Case presentation: Lemierre’s syndrome is a complex and unusual clinical entity, characterized by septic thrombophlebitis of the internal jugular vein and accompanied by sepsis. We present an unusual case of a young female with Lemierre’s syndrome who developed peripheral arterial embolization and Streptococcus pyogenes sepsis, complicating septic internal jugular vein thrombosis. The patient was initially treated with antibiotics without therapeutic heparin. The patient developed digital gangrene in all four extremities, septic meningitis, and a severe fungal infection; she died 6 weeks after admission secondary to multisystem organ failure. We discuss the importance of rapid diagnosis of disease extent in directing heparin treatment in patients with Lemierre’s syndrome.
 Conclusion: It may be advisable to treat Lemierre’s syndrome with anticoagulation in the acute setting.

Anticoagulation in syncardia total artificial heart recipients: anti-factor Xa or activated partial thromboplastin time?

Although the activated partial thromboplastin time (aPTT) has historically been the method of choice for anticoagulation monitoring in patients undergoing mechanical circulatory support with intravenous unfractionated heparin, it is being progressively superseded by the anti-factor Xa (anti-Xa) method. A retrospective single-arm, single-centre analysis of 20 patients who underwent total artificial heart implantation entailed simultaneous determinations of aPTT and anti-Xa. Agreement between these parameters was assessed using the Bland–Altman method. Despite a positive correlation between aPTT and anti-Xa, normal target ranges were poorly aligned: from 5th to 30th postoperative day, for anti-Xa values of 0.2 and 0.4 U/ml corresponding aPTT values were 52.1 and 65.2 s, 7.9 and 14.8 lower than predicted values, respectively. This was not associated with thromboembolic sequalae. It was not possible to demonstrate a significant relationship between the predictor variables (postoperative day; white blood cell count; C-reactive protein concentration; alanine transaminase and alkaline phosphatase level; bilirubin; haemoglobin; albumin and total protein concentration) and the agreement between aPTT and anti-Xa levels. In summary, when anti-Xa levels were used to guide anticoagulation therapy, corresponding aPTT levels were low with respect to target range. Methodology applied in this study is generalizable to other forms of mechanical circulatory support.

Zanubrutinib, obinutuzumab, and venetoclax with minimal residual disease-driven discontinuation in previously untreated patients with chronic lymphocytic leukaemia or small lymphocytic lymphoma: a multicentre, single-arm, phase 2 trial

We hypothesised that combining zanubrutinib with obinutuzumab and venetoclax (BOVen) as an initial therapy for chronic lymphocytic leukaemia and small lymphocytic lymphoma would lead to high rates of undetectable minimal residual disease (MRD), and we explored MRD as a biomarker for directing treatment duration. This multicenter, investigator-initiated, single-arm, phase 2 trial took place at two two academic medical centres in the USA. Patients were eligible for the primary cohort if they had treatment-naive chronic lymphocytic leukaemia or small lymphocytic lymphoma, required therapy, and were at least 18 years of age with an Eastern Cooperative Oncology Group performance status up to 2. BOVen was administered in 28 day cycles (oral zanubrutinib at 160 mg twice per day starting in cycle 1 on day 1; intravenous obinutuzumab at 1000 mg on day 1 [split over day 1 with 100 mg and day 2 with 900 mg for an absolute lymphocyte count >25 000 cells per μL or lymph nodes >5 cm in diameter], day 8, and day 15 of cycle 1, and day 1 of cycles 2-8; and oral venetoclax ramp up to 400 mg per day starting in cycle 3 on day 1) and discontinued after 8-24 cycles when prespecified undetectable MRD criteria were met in the peripheral blood and bone marrow. The primary endpoint was the proportion of patients that reached undetectable MRD in both the peripheral blood and bone marrow (flow cytometry cutoff less than one chronic lymphocytic leukaemia cell per 10 000 leukocytes [<10-4]) assessed per protocol. This trial is registered at clinicaltrials.gov (NCT03824483). The primary cohort is closed to recruitment, and recruitment continues in the TP53-mutated mantle cell lymphoma cohort. Between March 14, 2019, and Oct 10, 2019, 47 patients were screened for eligibility, and 39 patients were enrolled and treated. Median age was 62 years (IQR 52-70) with 30 (77%) of 39 male participants and nine (23%) of 39 female participants. 28 (72%) of 39 patients had unmutated immunoglobulin heavy-chain variable-region and five (13%) of 39 had 17p deletion or TP53 mutation. After a median follow-up of 25·8 months (IQR 24·0-27·3), 33 (89%) of 37 patients (95% CI 75-97) had undetectable MRD in both blood and bone marrow, meeting the prespecified undetectable MRD criteria to stop therapy after a median of ten cycles (IQR 8-12), which includes two cycles of zanubrutinib and obinutuzumab before starting venetoclax. After median surveillance after treatment of 15·8 months (IQR 13·0-18·6), 31 (94%) of 33 patients had undetectable MRD. The most common adverse events were thrombocytopenia (23 [59%] of 39), fatigue (21 [54%]), neutropenia (20 [51%]), and bruising (20 [51%]), and the most common adverse event at grade 3 or worse was neutropenia (seven [18%]) in the intention-to-treat population. One death occurred in a patient with intracranial haemorrhage on day 1 of cycle 1 after initiating intravenous heparin for pulmonary emboli. BOVen was well tolerated and met its primary endpoint, with 33 (89%) of 37 previously untreated patients with chronic lymphocytic leukaemia or small lymphocytic lymphoma reaching undetectable MRD in both peripheral blood and bone marrow despite a median treatment duration of only 10 months, owing to our undetectable MRD-driven treatment discontinuation design. These data support further evaluation of the BOVen regimen in chronic lymphocytic leukaemia and small lymphocytic lymphoma with treatment duration guided by early MRD response kinetics. Beigene, Genentech (Roche), Grais-Cutler Fund, Lymphoma Research Fund, Lymphoma Research Foundation, American Cancer Society, Farmer Family Foundation, and the National Instititutes of Health and National Cancer Institute.

Postprocedural Radial Artery Compression Time In Chronic AnticoaguLated patients using StatSeal: The PRACTICAL-SEAL study

BackgroundPatients on uniterrupted chronic oral anticoagulation (OAC) therapy are at high-risk of bleeding during cardiac catheterization. We aimed to investigate the safety and efficacy of the StatSeal® disc for adjunct hemostasis in patients undergoing transradial coronary angiography under uninterrupted OAC therapy. MethodsPatients who underwent transradial cardiac catheterization without interrupted OAC therapy were included in this study. ResultsAmong 180 patients, 85 (47.2%) patients were on warfarin and 95 (52.8%) patients on novel oral anticoagulants (NOACs). Patients on NOACs were older (72.9 ± 9.6 versus 69.7 ± 10.8 years, P < 0.001) and had more atrial fibrillation/flutter (94.7% versus 62.4%, P < 0.001), whereas patients on Warfarin were more often women (43.5% versus 26.3%, P = 0.02) and had mechanical heart valves (27.1% versus 0%, P < 0.001). Intravenous unfractioned heparin (UFH) was administered in 96.5% of patients on warfarin (3799 ± 1342 units) and 93.7% patients on NOACs (4028 ± 1362 units), P = 0.27. There were no differences in terms of type and sheath size and the need for ad hoc coronary intervention. Time-to-first release of the hemostatic wristband was 56.2 ± 12.6 min and complete hemostasis was achieved in 71.1 ± 13.0 min, with shorter times among patients on NOACs (54.1 ± 11.7 and 58.5 ± 13.2 min, 68.9 ± 11.7 versus 73.6 ± 14.0 min, P = 0.02, for both). There were no significant differences in terms of bleeding. There was no radial artery occlusion among 112 participants who underwent color Doppler ultrasound. ConclusionThe present study shows that in patients undergoing transradial coronary angiogram under contemporary uninterrupted OAC therapy and periprocedural administration of UFH, the use of StatSeal® disc for adjunctive hemostasis was associated with short times to complete hemostasis.

Five recurrent episodes of Takotsubo syndrome provoked by various triggers over a period of 7 years: a case report

BackgroundTakotsubo syndrome (TTS), also known as stress cardiomyopathy or apical ballooning syndrome, presents as reversible regional left ventricular wall motion abnormalities in the absence of obstructive coronary artery disease. It is associated with a recurrence rate of approximately 4%. However, multiple recurrence episodes are rare in clinical settings, and the predictors of recurrence and preventive methods have yet to be fully elucidated.Case summaryA 69-year-old woman experienced two TTS episodes before complaining of sudden-onset epigastric pain without any particular trigger. No significant coronary lesion was observed on coronary angiography, while left ventriculography showed the typical findings of apical ballooning and a hyperkinetic wall motion at the basal level of the left ventricle. The patient was again diagnosed with recurrent TTS. On Day 5 of hospitalization, follow-up echocardiography showed mural thrombus formation in the left ventricular apex. Anticoagulant therapy with oral warfarin following intravenous heparin was effective in dissolving the thrombus. She was safely discharged on Day 16 of hospitalization. However, two additional recurrent TTS episodes provoked by emotional stress occurred afterwards. Since the final hospitalization, she has been prescribed perindopril 4 mg/day and β1-receptor-selective β-blocker bisoprolol 5 mg/day and has been able to avoid the 6th recurrence of TTS for more than 12 months at present.ConclusionMultiple recurrent TTS episodes are rare in the clinical setting. As such, the long-term follow-up of this case may provide clues on the pathophysiology of this disease and aid us in establishing effective preventive strategies.

Abstract 1122‐000170: Stent Retrievers Utilization in Endovascular Treatment of Cerebral Venous Sinus Thrombosis

Introduction : Patients with Cerebral Venous Sinus Thrombosis (CVT) are candidates for Endovascular Mechanical Thrombectomy (EMT) in cases of coma on presentation or clinical deterioration despite anticoagulation. We present two cases of CVT successfully treated with mechanical thrombectomy using Medtronic’s Solitaire Stent retriever. Methods : A retrospective review at a single center university hospital was performed for all cerebral venous sinus thrombosis case log from December 2018 to November 2020. Cases resistant to conventional medical therapy that underwent intrasinus stent retriever endovascular thrombectomy were noted. Results : Case 1: 26 year‐old male with a history of hypertension presented with 2 weeks of headaches, left sided numbness and blurriness of vision. Imaging revealed superior sagittal (SSS) and bilateral transverse sinus thrombosis. Patient was treated with heparin infusion and discharged home on oral apixaban. The following day he presented with new onset expressive aphasia. Imaging was unchanged. Due to worsening symptoms despite anticoagulation, Patient underwent mechanical thrombectomy using a stent retriever. Solitaire 6 × 40 mm stent was advanced and deployed through the microcatheter and retracted in the upper segment of posterior one third of SSS followed by alteplase infusion at 1 mg/hr (25 ml/hr) via Berenstein catheter for the next 36 hours. Intravenous heparin infusion was also started with aPTT goal 60–80. Cerebral angiogram was repeated two days later revealing successful recanalization of previously thrombosed SSS and bilateral transverse sinuses with significantly improved cerebral venous drainage. Patient was transitioned again to oral apixaban. Repeat CTA in 3 months showed significantly improved patency and recanalization. Case 2: A 42 year‐old male with history of ulcerative colitis presented with sudden onset right‐sided hemiparesis and hemisensory loss along with one month of headaches. Presenting NIHSS 14. Imaging revealed SSS thrombosis with thrombosis of the left transverse sinus complicated by left frontal intraparenchymal hemorrhage and subarachnoid hemorrhage. Patient underwent mechanical thrombectomy of SSS using Solitaire 6 × 40mm stent retriever with distal aspiration resulting in improved flow. Clinical course was complicated by seizures and acute respiratory distress syndrome requiring intubation followed by tracheostomy and G‐tube placement which were eventually removed during recovery. Patient was treated with high intensity heparin during his hospitalization and eventually transitioned to apixaban. Work up revealed protein S deficiency. Serial CT angiograms at 6 and 11 months revealed resolution of CVT. NIHSS improved to 1 with mRS of 2. Conclusions : These cases imply that intra‐cerebrovenous sinus mechanical thrombectomy with stent retrievers may be considered in patients with continuing worsening despite optimal medical management.

Heparin versus No Heparin before Endoscopic Vein Harvesting using Angioscopy

Background: Endoscopic vein harvesting (EVH) became a standard technique with several advantages over open vein harvesting (OVH). Thrombus formation inside the vein lumen is one of the main concerns after EVH. It is not known whether heparin use before EVH could prevent this complication. The study aimed to assess the safety of not giving intravenous heparin before starting the open system EVH procedure using the PeriVu™ Disposable Angioscopy (LeMaitre® VASCULAR- France) as a modality to assess the intraluminal vein clots.&#x0D; Methods: This research is a randomized study that compared two groups of patients undergoing CABG. One group had 2500 IU heparin before EVH using (Virtusaph plus, Terumo) (n=50) and the other group had EVH without giving heparin (n=50). Intraluminal clots in the vein segments were evaluated using PeriVu Disposable Angioscopy ( LeMaitre-VASCULAR).&#x0D; Results: Preoperative data were comparable between groups with no statistically significant difference. The mean duration of the procedure in the heparin group versus the non-heparin group was 30.6±5.8 and 28.7±5.9, respectively (P= 0.11). Intraluminal clots were detected in two segments out of 103 segments (1.94%) in the No heparin group, while none was detected in the heparin group (P= 0.24).&#x0D; Conclusion: There was no difference between heparin versus no heparin during endoscopic vein harvest regarding intraluminal thrombus formation. Further studies are recommended to confirm our findings.

P01 Catastrophic antiphospholipid syndrome presenting as diffuse peripheral and central thromboses

P01 Catastrophic antiphospholipid syndrome presenting as diffuse peripheral and central thromboses

COVID-19 in pregnant women with heart diseases. Adverse maternal and fetal outcomes. Case series from InCor registry of Pregnancy and Heart Disease

BackgroundHeart disease is the leading non-obstetric cause of maternal death during pregnancy. In this field, the emergence of pandemic COVID-19 has caused the worst-case scenario considering that pregnant women are more susceptible to viral infections, and preexisting cardiac disease is the most prevalent co-morbidity among COVID-19 deaths.PurposeTo assess the maternal and fetal outcomes of COVID-19 during pregnancy of women with heart diseases.MethodsDuring the year 2020, among 82 pregnant women with heart disease followed consecutively at the Instituto do Coração-InCor, seven of them with an average age of 33.2 years had COVID-19 during their pregnancies. The underlying heart diseases were rheumatic valve disease (5 pt), congenital heart disease (1 pt) and one case with acute myocarditis, without preexisting cardiopathy. The prescription (antibiotics, inotropes, corticosteroids and others) used was according to the clinical conditions required for each patient, however subcutaneous or intravenous heparin was used in all patients.ResultsOnly one case had an uneventful maternal-fetal course, the other six women required hospitalization / ICU for an average of 25.3 days, including the need for mechanical ventilation in two of them. Serious complications were related to respiratory failure (ADRS), recurrent atrial flutter with hemodynamic instability, acute pulmonary edema, and cardiogenic shock associated with sepsis which caused two maternal deaths. There were two emergency mitral valve interventional, percutaneous balloon valvuloplasty and valve bioprosthesis replacement, respectively. There were five premature births with an average gestational age of 34.2 weeks of gestation, which resulted in one stillbirth. Pathological findings of three placental and the six-months follow-up of the babies did not confirm vertical transmission of COVID-19.ConclusionsThe uncertain evolution given of the overlapping complications of three conditions – COVID-19, pregnancy, and heart disease – implies an increased risk for women with heart diseases of childbearing age, for whom pregnancy should be discouraged and planned after vaccinationFUNDunding AcknowledgementType of funding sources: None.

Cerebral Venous Sinus Thrombosis in Patients With SARS-CoV-2

Several neurological manifestations of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been reported, including cerebral venous sinus thrombosis (CVST). In this report, we discuss two cases of cerebral venous thrombosis in young patients with a recent SARS-CoV-2 infection and otherwise unrevealing workup. Case 1 was a 35-year-old man who was found unresponsive with urinary incontinence and vomitus on the floor. Computed tomography (CT) angiogram of the head revealed evidence of extensive venous thrombosis. Extensive workup for thrombotic disease was unrevealing and SARS-CoV-2 was detected via polymerase chain reaction. Anticoagulation was immediately initiated, and the patient made a good clinical recovery. Case 2 was a 31-year-old man who presented with severe decreased level of consciousness and was found to have extensive cerebral sinus thrombosis. Past medical history was significant for a recent SARS-CoV-2 infection diagnosed 12 days prior. The patient was treated with intravenous heparin and eventually oral anticoagulation with good clinical outcome. CVST is a potential cerebrovascular complication of SARS-CoV-2. We advise clinicians to consider this diagnosis in patients with a recent SARS-CoV-2 infection in the appropriate clinical setting. J Neurol Res. 2021;11(5):94-101 doi: https://doi.org/10.14740/jnr697

THE INFLUENCE OF ANTIPLATELET MEDICATIONS ON INTRAOPERATIVE PATIENT BLOOD MANAGEMENT DURING ADULT CARDIAC SURGERY

Introduction Cardiac surgery is inherently associated with increased bleeding and transfusion requirements. The increased risk of bleeding is due to multiple factors; pharmacological (Intravenous heparin and Dual Antiplatelet Therapy-DAPT), patient (advanced age, preoperative anaemia, and female gender) and surgical (Emergency and redo surgery)1. This study aimed to determine if preoperative antiplatelet medication influenced intraoperative blood and blood products requirements during elective adult Isolated Coronary Artery Bypass Graft (CABG) and valve surgery. Methods Methodology: A Prospective observational study carried out between September to November 2020, MMUH Ethical committee approval ref: CA20-064 on 12/10/2020. Perioperative data were collected from fifty patients. This included demographic data, preoperative laboratories, pre-Cardiopulmonary Bypass (CPB) heparin dose, Activated Clotting Time (ACT) at baseline, post heparin and post protamine, blood products transfused and estimated blood loss (EBL). The inclusion criteria applied was isolated CABG, single valve surgery and elective operation. A one-paired Student t-test performed to detect a statistical difference between the two groups (Isolated CABG Vs Single valve Surgery) Results 31 patients met the inclusion criteria. 19 patients excluded because of the following reasons: emergency surgery n=3, redo surgery n=1, New Oral Anticoagulants (NOACS) medication n= 4, combined CABG & valve surgery/other n=12. 20 patients underwent an isolated CABG, and 11 patients underwent a single valve operation. DAPT was prescribed in 30% n=6/20 and 9% n=1/11 in the CABG and Valve group respectively. There was no statistical difference in the EBL at the end of the procedure between the two groups (CABG-624 ml Vs Valve-507 ml, p= 0.13). Intraoperative red cells transfusion between the two groups were similar, however Octaplasma, fibrinogen and platelets transfusion were higher in the valve group. Discussion DAPT were more frequently prescribed pre-operatively in patients undergoing elective CABG in comparison to single valve surgery. Pre & postoperative haemoglobin and EBL were similar between the two groups. Despite this, in the single valve surgery group (only 1 patient out of 9 received DAPT, n=1/9) received more blood products during the intraoperative period. This was statistically significant for the use of Octaplasma, Platelets and fibrinogen. Blood transfusion was not directed using ROTEM in any patients in either group. We, therefore, recommend the intraoperative use of ROTEM to guide blood transfusion for patients undergoing isolated single valve surgery.

THE "CLOT" THICKENS: HYPERKALEMIA DUE TO ACUTE LIMB ISCHEMIA IN COVID-19

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been implicated in a devastating inflammatory response resulting in thromboembolic events. Upwards of 40% of patients have been reported to have venous thromboembolism while the incidence of arterial thrombotic events, including acute limb ischemia (ALI), is estimated to be lower at 5%. This case highlights the importance of early recognition and treatment of ALI in COVID-19 to prevent significant morbidity and mortality. CASE PRESENTATION: A 59-year-old man with hypertension and pre-diabetes presented to our facility with tachypnea and hypoxia with oxygen saturation of 80%. He was placed on high flow nasal cannula but required intubation due to respiratory failure. Initial laboratory values revealed D-dimer 460 ng/mL, C-reactive protein 109 mg/L, ferritin 3,282 ng/mL, and creatine kinase 700 U/L. Right soleal vein thrombosis was identified on lower extremity ultrasound and he was started on intravenous heparin with therapeutic levels. On hospital day 4, he became acutely hypotensive and hyperkalemic to 7.9 mmol/L. Physical exam was notable for cold lower extremities with mottling while laboratory values showed lactate 4.1 mmol/L, D-dimer greater than 10,000 ng/mL, ferritin 23,712 ng/mL, and creatine kinase 21,078 U/L. Upon evaluation with lower extremity arterial duplex, there was no Doppler signal detected in the bilateral common femoral, superficial femoral, popliteal, posterior tibial, and anterior tibial arteries. A subsequent CT angiogram revealed extensive bilateral pulmonary emboli, acute total occlusion of the aorta beginning distal to the renal arteries, and extensive lower limb muscle stranding suggestive of ischemic injury. He was taken to the operating room and underwent emergent thrombolysis and thrombectomy. Unfortunately, he suffered severe reperfusion injury and expired shortly after the procedure. DISCUSSION: ALI presents with the 6 Ps: pain, pallor, paralysis, paresthesia, poikilothermia, and pulselessness. In COVID-19, it is estimated that 71% of arterial thrombotic events involve the lower extremities. Patients at risk are noted to be males over the age of 60 with diabetes and hypertension. Diagnosis can be made with duplex ultrasound, CT angiography, or MR angiography. After initiating therapeutic anticoagulation, vascular surgery should be consulted for management options such as catheter-directed thrombolysis, mechanical thrombectomy, or open surgery. CONCLUSIONS: This case highlights the significance of arterial thrombotic events in COVID-19 and the importance of early recognition of ALI. Unexplained hyperkalemia should be thoroughly investigated as it can be a presentation of myonecrosis secondary to ALI. Prompt initiation of anticoagulation and vascular surgery consult are vital in limiting morbidity and mortality. REFERENCE #1: Helms J, Tacquard C, Severac F, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020;46(6):1089-1098. DISCLOSURES: No relevant relationships by Talha Demirci, source=Web Response No relevant relationships by Himanshu Deshwal, source=Web Response No relevant relationships by ron goldenberg, source=Web Response