Iv Heparin Research Articles

A Method to Improve Continuous Renal Replacement Therapy Circuit Survival Time in Critically Ill Coronavirus Disease 2019 Patients With Acute Kidney Injury.

Optimizing continuous renal replacement therapy circuit survival in coronavirus disease 2019 patients admitted to the ICU. Single-center prospective observational cohort study. Tertiary academic teaching ICU. Between March 19, 2020, and May 18, 2020, 11 out of 101 coronavirus disease 2019 patients were treated with continuous renal replacement therapy comprising 127 continuous renal replacement therapy days. A nonrandomized observational comparison of circuit anticoagulation modalities using standard regional citrate anticoagulation, continuous IV heparin anticoagulation, or the combination of regional citrate anticoagulation with either continuous IV heparin or therapeutic dose nadroparin. Circuit patency was shorter than 24 hours using standard regional citrate anticoagulation or continuous IV heparin anticoagulation. Median circuit survival increased with at least 165% when the combination of regional citrate anticoagulation with either continuous IV heparin or therapeutic dose nadroparin was applied. Continuous renal replacement therapy circuit patency is diminished in coronavirus disease 2019 ICU patients. Combining regional citrate anticoagulation with either continuous IV heparin or therapeutic dose nadroparin increases filter survival as compared with regional citrate anticoagulation alone in this nonrandomized observational study.

Intracardiac Fibrinolysis and Endothelium Activation Related to Atrial Fibrillation Ablation with Different Techniques.

Objective The effect of pulmonary vein isolation (PVI) on fibrinolytic and endothelial activation with currently applied periprocedural anticoagulation has not been explored. We measured markers of fibrinolysis and endothelium activation before and after PVI with the second-generation cryoballoon (Cryo), pulmonary vein ablation catheter (PVAC-Gold), and irrigated radiofrequency (IRF). Methods Markers of fibrinolysis and endothelium activation in left atrial (LA) blood samples were measured in 31 patients before and after PVI (Cryo:10, PVAC-Gold: 7, IRF: 14). Periprocedural anticoagulation included uninterrupted vitamin K antagonist and iv heparin (ACT≥300 sec) during LA dwelling. Results Levels of D-dimer (median; interquartile range, mgFEU/L) increased with all techniques (PVAC: 0.34; 0.24–0.50 versus 0.70; 0.61–1.31; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; PAP complex level (ng/ml) increased after Cryo (247.3, 199.9–331.6 versus 270.9, 227.9–346.7; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; PAI-1 activity (%) decreased with the PVAC (1.931; 0.508–3.859 versus 0.735, 0.240–2.707; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; VWF antigen levels and FVIII activity increased after PVI with all the 3 techniques. The levels of soluble VCAM-1 (ng/ml) did not change after PVAC procedures, but increased after Cryo (542, 6; 428.5–753.1 versus 619.2; 499.8–799.0; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; p=0.0313, Cryo: 0.33; 0.28–0.49 versus 0.79; 0.65–0.93; Conclusion PVI with contemporary ablation techniques and periprocedural antithrombotic treatment induces coagulation and endothelium activation of similar magnitude with different ablation methods.

P1701 Biatrial thrombus detection in a patient with atrial paroxysmal fibrillation and asymptomatic massive pulmonary embolism

Abstract Introduction Computed tomography (CT) is a noninvasive test for detection of LA and LAA thrombus.Although the transesophageal echocardiogram is the gold standart method, it can have rare but potential life threatening complications.Case report:A 62 y.o woman presented to the ER complaining of palpitations started less then 12h ago with no chest pain or dispnea.She was diagnosed with high rate paroxysmal atrial fibrillation (HR∼120/min).The ECG showed AF with no specific changes,the troponin I (TPI) level was negative and a TTE revealed a dilated left atria.The other lab results were within normal range(TBC and blood chemistry).Her past medical history included hypertension and diabetes type 2 for 10 years and 6 months respectively both on regular treatment and obesity.Also 2 months ago she was diagnosed with Hashimoto thyroiditis and close monitoring of TSH was recommended but no treatment.Subsequently,LMWH (enoxaparin) and amiodarone loading dose for cardioversion were started.After 24h the pt was still in AF,with a controlled heart rate and no complains.However ECG changes were noticed (evolutive T negative waves in leads D1,D2,aVL,V3-V6).A D-Dimer was requested and came back negative,O2 saturation was 97%.The asymptomatic pt was transferred to the Cardiology ward for further evaluation.TPI remained negative.Due to the cardiac risk factors and the ECG changes it was decided to perfom a coronary angiography which resulted normal.An electrical cardioversion was considered.Both TEE and pulmonary angio CT were requested prior.Because of the ECG changes the CT was performed first and showed central and peripheric bilateral pulmonary artery clots present also in both the left and right atrial auricles.Due to the massive thromboembolism(PE) unfractioned heparin was immediately started (aPTT 50-70s).A new TTE showed a PAP of 50 mmHg.Approximately 10h after the heparin infusion,the pt became hypotensive and started complaining of dyspnea,tachypnea,cough,pleuritic pain and fever(high temperature 39.5-40ᵒC).Considering the deteriorating conditions she was consulted by a cardiac surgery team and it was decided to perform an emergency surgical pulmonary embolectomy despite the high risk.Within 24h,the pt underwent a surgical embolectomy of the right and left pulmonary branches after incision of the pulmonary artery, as well as a clot embolectomy of the right and left atria auricles (confirmed by intraoperatory TEE).She was put on an iv heparin regimen and recovered well.She was discharged 2 weeks later in good condition,with a PAP of 40 mmHg,on acenocoumarol with persistent AF.1.5 years later she is in NYHA class I,in sinus rhythm taking rivaroxaban 20 mg/d.Discussion: Biatrial thrombus detection in both atrial auricles is rare as well as in this case a massive PE without a stroke.CT can be used as an alternative modality for detecting thrombus in selected high risk patients because it shows a good diagnostic accuracy with high sensitivity and specificity. Abstract P1701 Figure. Biatrial clots on CT and removed ones

Role of Postoperative Anticoagulation in Predicting Digit Replantation and Revascularization Failure: A Propensity-matched Cohort Study.

The use of intravenous heparin after digit replantation or revascularization (DRR) varies greatly. The insufficient evidence presents a lack of clinical equipoise needed for a randomized trial; as such, a matched propensity score analysis was performed to evaluate the role of postoperative anticoagulation after DRR. The purpose of this study was to determine if the use of postoperative therapeutic anticoagulation reduced the risk of digit failure. A retrospective cohort of patients who underwent DRR from 2005 to 2016 was identified. A propensity score was calculated based on age, smoking, injury mechanism, procedure type, vein graft, and number of digits injured. Patients were matched 1:2 by propensity score to create 2 groups with similar risks of receiving anticoagulation postoperatively. Generalized estimating equation logistic model was used to determine differences in digit failure between groups. Digit replantation or revascularization was performed on 282 patients (92% male; median age, 43 years). Postoperative anticoagulation was administered in 69 (24%) patients, with continuous IV heparin in 34 patients and intravenous heparin with dextran in 35 patients. Digit failure occurred in 88 patients overall, representing 38% of patients receiving anticoagulation and 29% of those not. Major complications were higher among the anticoagulated patients (13% vs 3.3%). After propensity score matching, use of anticoagulation was not associated with digit failure (odds ratio, 0.79; 95% confidence interval, 0.47-1.32). Among DRR patients with similar predisposing characteristics for postoperative therapeutic heparin or dextran, the use of therapeutic anticoagulation does not have a protective effect against digit failure. Studies are needed to define the role of postoperative IV anticoagulation in DRR and to justify the risk of its administration.

P11 Intraoperative management of paravalvular leak of the melody valve in mitral position

Introduction A male infant was diagnosed and treated for Group B Streptococcus meningitis from day 10 of life after uncomplicated pregnancy and delivery. During this intravenous antibiotic treatment he presented with symptoms of heart failure. The diagnosis of infective endocarditis of the mitral valve with mixed pathology and impaired LV function was established on day 26 of life. His weight was 4kg at that time. On day 34 of life attempt of valve repair failed and 17mm mechanical prosthesis was implanted into mitral position. 2 subsequent bypass surgeries followed this initial operation on day 79 and 82 due to partially blocked prosthesis including re-do mitral valve replacement. Despite otherwise good clinical progression conversion from iv Heparin to Warfarin remained unsuccessful requiring several courses of thrombolysis due to repeated blockage of one leaflet of the prosthesis. Treatment and Complication: The mechanical prosthesis was replaced with Melody valve 6 months after the initial and 4 months after the last surgery at a body weight of 7.4kg. The Melody valve was implanted by dilating it to 14mm under direct vision. Post bypass transoesophageal echocardiography showed a 4mm significant paravalvular leak (figure 1). Result No significant leak after repeat balloon dilatation of the valve was detected (figure 2).

HAEMOSTASIS CHANGES AND ENDOTHELIUM ACTIVATION DURING PERCUTANEOUS TRANSCATHETER ISOLATION OF THE PULMONARY VEINS IN PATIENTS WITH ATRIAL FIBRILLATION

HAEMOSTASIS CHANGES AND ENDOTHELIUM ACTIVATION DURING PERCUTANEOUS TRANSCATHETER ISOLATION OF THE PULMONARY VEINS IN PATIENTS WITH ATRIAL FIBRILLATION

Effects of conjugated linoleic acid supplementation and exercise on post-heparin lipoprotein lipase, butyrylcholinesterase, blood lipid profile and glucose metabolism in young men

This study was designed to investigate the effects of conjugated linoleic acid (CLA) supplementation and endurance exercise training-induced changes on post-heparin lipoprotein lipase (PH-LPL) and butyrylcholinesterase (BChE) activities along with leptin, insulin and lipid levels in plasma by a randomized double blind experiment. Eighteen sedentary male volunteers were randomly divided into CLA and Placebo (PLC) supplementation groups. Both groups underwent daily supplementation of either 3g CLA or 3g placebo for 30days, respectively, and performed exercise on a bicycle ergometer 3 times per week for 30–40min at 50% VO2 peak workload. For plasma glucose, insulin and leptin levels and BChE activity fasting blood was used. For PH-LPL measurements, blood was collected 15min after 50IU/kg iv heparin injection. In all groups, there is a statistically significant decrease in BChE (p=0.03, p=0.02) and leptin (p=0.002), insulin and HOMA-IR levels (p=0.02). Exercise with or without CLA supplementation decreased insulin levels and increased insulin sensitivity. PH-LPL activity was increased significantly in both groups, displaying increased fatty acid mobilization. We conclude that though CLA supplementation and exercise can affect these parameters, CLA is not more effective than exercise alone. Hence, a prolonged supplementation regime may be more effective. Taken together in our small study group, our findings display that BChE is a potential marker for synthetic function of liver, fat metabolism, an obesity marker, a function long overlooked.

Intravenous Lipid and Heparin Infusion-Induced Elevation in Free Fatty Acids and Triglycerides Modifies Circulating Androgen Levels in Women: A Randomized, Controlled Trial

The polycystic ovarian syndrome (PCOS) is characterized by hyperandrogenism and associated with obesity and impaired glucose metabolism. Despite the high prevalence of PCOS and the considerable clinical impact, the precise interplay between metabolism and hyperandrogenemia is not entirely clear. The objective of the study was to analyze the effects of iv lipid and heparin infusion on circulating androgen levels in healthy women. This was a randomized, controlled, crossover trial. The study was conducted at an endocrinology center. Patients included 12 healthy young women during the early follicular phase of two subsequent cycles. After an overnight fast, a 20% lipid/heparin or a saline/heparin infusion was administered in random order for 330 min. A detailed characterization of androgen metabolism was performed. Elevations in free fatty acids and triglycerides, induced by lipid/heparin infusion, elevates the levels of androstenedione, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), testosterone, 5alpha-dihydrotestosterone, estrone, and 17beta-estradiol. Urinary excretion of DHEA, DHEAS, 5-androstene-3beta,17beta-diol, and the sum of urinary excreted DHEA and its 16-hydroxylated downstream metabolites, 16alpha-hydroxy-DHEA and 5-androstene-3beta,16alpha,17beta-triol, were reduced. The mechanism of iv lipid and heparin infusion-induced elevation of circulating androgens described here might contribute to the development of hyperandrogenism in women with PCOS and suggests that lowering of hyperlipidemia might be a potential therapeutic target in patients with PCOS to treat hyperandrogenemia.

Elevated Free Fatty Acids Attenuate the Insulin-Induced Suppression of PDK4 Gene Expression in Human Skeletal Muscle: Potential Role of Intramuscular Long-Chain Acyl-Coenzyme A

We investigated the effect of elevated plasma free fatty acid and insulin concentrations on PDK4 mRNA transcript and protein content and long-chain acyl-coenzyme A accumulation in human skeletal muscle. On two occasions, 10 healthy men underwent hyperinsulinemic-euglycemic clamps for 6 h with (LIPID) and without (CON) iv Intralipid (20% at 90 ml/h) plus heparin (200 U prime + 600 U/h) infusion. Glucose disposal was approximately 50% lower at the end of the clamp in the LIPID compared with the CON trial (37.8 +/- 4.4 and 79.6 +/- 4.0 micromol/kg lean mass.min, respectively; P < 0.01). In the LIPID trial, muscle long-chain acyl-coenzyme A concentration increased after 6 h, but not 3 h of lipid infusion (P < 0.01). Muscle PDK4 mRNA, but not protein, was down-regulated by 2-fold within 3 h in both clamps and decreased further (6-fold; P < 0.01) at 6 h in the CON but not the LIPID clamp. The lipid-induced attenuation in the suppression of PDK4 gene expression was not dependent on the activation of the Akt/FOXO3 pathway. Accumulation of im lipids plays a more important role than impaired activation of Akt-mediated pathways in the regulation of muscle PDK4 gene expression in lipid-induced acute insulin-resistant states.

Case report: Cerebral vein thrombosis after subarachnoid analgesia for labour

We report a case of sagittal sinus thrombosis occurring after spinal analgesia for labour to highlight the difficulty of such diagnosis in the presence of postpartum atypical headache following regional anesthesia/analgesia. A previously healthy 21-yr-old, primiparous, preeclamptic parturient was admitted to the hospital at 37 weeks gestation for uterine contractions. Before pregnancy she was taking no medication other than oral contraceptives and was a non-smoker. Spinal analgesia was established on the first attempt at 8 cm of cervical dilation, in the setting of rapid progression of labour. Following an uneventful delivery, on the third day postpartum, the patient experienced gradual onset of an atypical headache with unclear postural character, followed by focal neurological signs five days later. Emergency neuroimaging revealed direct evidence of thrombosis in the posterior sagittal venous sinus. Anticoagulation was initiated with iv heparin (500 UI x kg(-1) x day(-1)). The patient's headache decreased progressively and full motor recovery was noted by day 14 postpartum. After 24 days, the patient was discharged without any neurological disability. Common inherited thrombophilic dispositions were absent, with the exception of a decrease in protein S level. Central venous thrombosis, while rare, is a recognized cause of puerperium stroke. The present case highlights the importance of considering the diagnosis in the presence of postpartum atypical headache following spinal anesthesia/analgesia. Early intervention with systemic heparinization is critical when the diagnosis is confirmed.

Catastrophic Antiphospholipid Syndrome

The catastrophic antiphospholipid syndrome is a potentially life-threatening condition with a high mortality, which requires a high degree of clinical awareness on the part of attending physicians. Patients with this syndrome have in common: a) clinical evidence of multiple organ involvement developed over a very short time period; b) histopathological evidence of multiple small vessel occlusions, and c) laboratory confirmation of the presence of antiphospholipid antibodies, usually in high titre. The combination of high doses of intravenous (iv) heparin, iv steroids, iv gamma globulins and/or repeated plasma exchanges is the basic treatment of choice for all patients with this severe condition.

PPS-PEG Surface Coating to Reduce Thrombogenicity of Small Diameter ePTFE Vascular Grafts

Patency failure of small vascular synthetic grafts is still a major problem for coronary and peripheral revascularization. Thus, three new surface coatings of small synthetic grafts were tested in an acute pig model to evaluate their thrombogenicity (extracorporeal arterio-venous shunt) and in a chronic rat model to evaluate the tissue reaction they induced (subcutaneous implantation). In five domestic pigs (25-30 kg) an extracorporeal femoro-femoral arterio-venous shunt model was used. The study protocol included first a non-heparinized perfusion sequence followed by graft perfusion after 10,000 UI iv heparin. Grafts were perfused for 3 and 9 minutes. The following coatings were tested on ePTFE grafts: poly-propylene sulphide (PPS)--poly-ethylene glycol (PEG) (wet and dry applications) as well as carbon. Two sets of control were used, one dry and one wet (vehicle only). After perfusion grafts were examined by scanning electron microscopy for semi-quantitative assessment (score 0-3) of cellular and microthrombi deposition. To assess tissue compatibility, pieces of each material were implanted subcutaneously in 16 Wistar rats. At 2, 4, 8, 12 weeks four animals each were sacrificed for semi-quantitative (score 0-3) histologic evaluation of tissue reaction. In the pig model, cellular deposition and microthrombi formation increased over time. In non- heparinized animals, the coatings did not improve the surface characteristics, since they did not prevent microthrombi formation and cellular deposition. In heparinized animals, thrombogenicity was lowest in coated grafts,especially in PPS -PEG dry (p<0.05), and highest in controls. Cell deposition was lowest in PPS-PEG dry, but this difference was not statistically significant vs.controls. In the rat model,no significant differences of the tissue reaction could be shown between materials. While all coatings failed to add any benefit for lowering tissue reaction, surface coating with PPS -PEG (dry application) reduced thrombogenicity significantly (in heparinized animals) and thus appears to be promising for improving graft patency of small synthetic vascular prostheses.

Unexpected hospital-acquired bacteraemia in patients at low risk of bloodstream infection: the role of a heparin drip

Following a cluster of cases of unexpected hospital-acquired bacteraemia suspected to be related to an intravenous (iv) heparin drip, all cases of hospital-acquired primary bloodstream infection (BSI) in patients at low risk of bacteraemia were analysed over a four-year period. Ninety-six bacteraemic patients (6%) from 1618 episodes of hospital-acquired bacteraemia had a peripheral iv line as the only risk factor. These patients were divided into two groups: 60 patients with phlebitis and 36 without local signs of inflammation. Baseline features of the two groups were comparable, but in univariate and multivariate analysis, a significant association was found between iv heparin use, predominance of Gram-negative organisms (especially Klebsiella, Serratia and Enterobacter species), and absence of phlebitis. In spite of clear statistical association, however, the means by which the heparin solution became contaminated with Gram-negative organisms remained unknown. Following implementation of infection control methods concerning heparin handling, no more cases occurred. Unexpected hospital-acquired Gram-negative bacteraemia in patients with peripheral iv lines should prompt investigation of potential infusate-related infection, especially in patients without phlebitis and those receiving iv heparin.

INCREASED RISK OF HAEMORRHAGIC COMPLICATIONS IN RENAL ALLOGRAFT RECIPIENTS RECEIVING SYSTEMIC HEPARIN EARLY POST TRANSPLANTATION.

P173 Aims: To document the risk of haemorrhagic complications in renal allograft (RA) recipients requiring systemic heparinisation within the first 2 weeks post transplantation, compared to RA recipients not requiring heparin. Methods: A retrospective review of the records of the 326 RA recipients from 1/1998-7/2003 was performed. Data obtained included recipient demographics, requirement for and dosing of systemic heparin, nature and management of haemorrhagic complications. Statistics were performed by SPIDA. A p value < 0.05 was considered significant. Results: 16/326(4.9%) of RA recipients were initiated on intravenous (iv) unfractionated heparin within the study period. Enoxaparin was subsequently used in 10/16(62.5%) of these recipients. There was no difference in age, sex or type of renal transplant between the RA recipients receiving IV Heparin versus non-heparinised RA recipients. Indications for heparin included- 9 pre-existing thrombotic disorder (6 clinical thrombotic episodes & documented thrombotic disorder, 3 clinical thrombotic episodes only), 4 mechanical heart valve, 2 intrarenal arterial branch thrombosis, 1 early pulmonary embolus. Intravenous heparin was instituted at a median 8(1-14) days post transplantation. Heparin was instituted at a dose of 500-1,000 IU per hour to maintain an APTT level within twice the normal range. Haemorrhagic complications occurred in 10/16(62.5%) of RA recipients on IV heparin versus 11/310(3.5%) of non-anticoagulated RA recipients [p=0.0001]. Haemorrhagic complications in the IV heparin group were 5-periallograft haemorrhage (2 episodes prior to initiation of iv heparin), 8 perigraft/retroperitoneal haematomas, and 1 gastrointestinal bleed. Haemorrhagic episodes in the non-heparinised RA recipients included 7-periallograft haemorrhage, 4 perigraft haematomas. Haemorrhage occurred at a mean 9.75(2-43) days into the course of IV Heparin. The median peak APTT 24 hours prior to haemorrhage in RA recipients on Heparin was 68.5(58-180) versus a median peak APTT of 70(50-140) in RA recipients on Heparin who did not sustain a haemorrhagic complication [p=0.30]. Major intervention (predominantly surgery) was required in 6/16(37%) of RA recipients on IV Heparin versus 7/310(2.2%) of non-heparinised RA recipients [p<0.0001]. Enoxaparin was instituted at a mean 22.5(4-55) days post transplantation. Delayed haemorrhage subsequently occurred in 4/10(40%) of RA recipients on Enoxaparin at a median 18.75(3-44) days into the course of Enoxaparin. Haemorrhagic complications on Enoxaparin included 2-periallograft haemorraghe (both requiring surgery), 1 retroperitoneal haematoma, and 1 deep thigh haematoma. Conclusions: Haemorrhagic complications of both a major and of a minor nature occur more commonly in RA recipients requiring early post transplantation IV Heparin. Haemorrhage occurred despite APTT monitoring with APTT levels tending to be similar in RA recipients with/without complications. Delayed haemorrhage was also seen with the subsequent use of Enoxaparin.

Effects of heparin in experimental models of acute pancreatitis and post-ERCP pancreatitis

Background Acute pancreatitis (AP) is a complication of diagnostic or therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In a recent clinical trial, a decreased rate of post-ERCP pancreatitis was shown after prophylactic heparin treatment. The aim of this study was to evaluate the effects of prophylactic heparin application in various experimental models of AP and pancreatic duct obstruction and to assess the underlying mechanisms. Methods In various experimental models, pancreatic injury of graded severity was induced in Wistar rats: (1) mild pancreatitis by IV cerulein infusion over 6 hours; (2) severe pancreatitis by infusion of glycodeoxycholic acid into the pancreatic duct plus IV cerulein application over 6 hours. The clinical ERCP situation was imitated in groups (3) obstruction of the pancreatic duct and (4) infusion of contrast medium into the pancreatic duct plus obstruction. In every group the animals received either no heparin (n = six per group) or continuous IV heparin (n = six per group) starting before pancreatic injury. Histologic changes, amylase, and lipase in plasma were evaluated 12 hours after induction of pancreatic injury. Additional animals were treated to investigate pancreatic microcirculation by intravital microscopy (n = six per group). Results In groups 1, 3, and 4 (mild AP/duct obstruction/duct obstruction plus contrast medium), IV heparin-treated animals showed reduced edema, inflammation, and peak amylase values compared with the corresponding non-heparin-treated animals (P<.05). Moreover, mean erythrocyte velocity was significantly higher and leukocyte-endothelium interaction was reduced in these groups after prophylactic administration of heparin. In contrast, group 2 (severe AP) did not show any difference between control animals and animals that received heparin as assessed by histology and intravital microscopy. Conclusions Prophylactic systemic application of heparin provides a protective effect in mild AP and in experimental post-ERCP pancreatitis. The mechanism of the protective effects of heparin seems to be the reduction of leukocyte-endothelium interaction and the normalization of pancreatic microcirculation.

Cerebral Venous and Sinus Thrombosis: Patients With a Fatal Outcome During Intravenous Dose-Adjusted Heparin Treatment

Although anticoagulation (AC) reduces the risk of a fatal outcome or severe disability in patients with cerebral venous and sinus thrombosis (CVST), prognosis of severe cases is still difficult to predict. The authors studied the clinical course of patients with CVST who died despite AC therapy to look for clinical features that might explain the lethal course of these patients. Retrospective analysis of a series of 79 consecutive patients with CVST who were treated with a standard regimen of dose-adjusted iv heparin. Case histories of patients with a fatal outcome are presented. The authors identified eight patients with a fatal outcome. All patients were stuporous or comatose at the start of AC, and four patients showed markedly delayed intracranial circulation times, indicating extensive venous thrombosis. Two patients improved, but deteriorated secondarily after reduction or discontinuation of AC. Sufficient activated partial thromboplastin time levels were reached only after a delay in three patients, and critical deterioration occurred in two of them during this time. Although inadequate AC may have contributed to the fatal outcome, some patients with extensive venous thrombosis who are stuporous or comatose at the start of AC may carry an increased risk of death, despite heparin therapy. More aggressive treatment approaches, such as endovascular thrombolysis, may be needed for this subgroup of patients with CVST.

Neurotrauma &amp; Deep Vein Thrombosis

Neurotrauma &amp; Deep Vein Thrombosis

Delayed Traumatic Hemothorax on Ticlopidine and Aspirin for Coronary Stent

A 64-year-old man presented with worsening dyspnea on exertion and hemothorax of the left chest 7 days after discharge from the hospital on ticlopidine and aspirin after coronary stent placement to his left circumflex artery. He had suffered traumatic rib fractures to the seventh, eighth, and ninth left ribs 28 days before this presentation and 21 days before starting the ticlopidine. Results of chest radiography at discharge 7 days earlier while on aspirin and after brief IV heparin had been negative except for minimal atelectasis and rib fractures barely visible on posteroanterior view. The delayed hemothorax had lowered the peripheral blood hematocrit to 23% and required tube thoracostomy drainage and blood transfusion. The delayed traumatic hemothorax in this case occurred on treatment with ticlopidine and did not recur with continuation of aspirin alone.

Atrial Fibrillation and Thromboembolism

Atrial Fibrillation and Thromboembolism

Saruplase in Myocardial Infarction.

Saruplase is an unglucosylated single-chain recombinant urokinase-type plasminogen activator. Dose finding studies in patients with acute myocardial infarction indicated that a dose of 80 mg of saruplase, given as a bolus of 20 mg and iv infusion of 60 mg in one hour, led to excellent patency figures.Saruplase is most effective when combined with a bolus of 5000 IU heparin followed by an iv heparin infusion for at least 24 hours.When saruplase is compared to other thrombolytic agents (streptokinase, alteplase, urokinase), it becomes apparent that its profile is excellent. Early patency rates are at least comparable to alteplase. Further reocclusion rates of saruplase after one day are lower than those of streptokinase and alteplase. Patency rates 24-72 hours after start of medication are comparable between saruplase and urokinase.The large database in over 6000 patients shows that saruplase, in comparison to the other thrombolytic agents, is safe. Its bleeding complication rate is significantly lower than streptokinase, and a trend to lower in-hospital mortality is observed when compared to urokinase.Summarizing, when comparing to the presently available thrombolytic agents, saruplase is a fast acting, effective and safe thrombolytic agent.