Lifelong Oral Anticoagulation Research Articles

OP176 Integrating Real-world Compliance In The Assessment Of Left Atrial Appendage Closure Versus Anticoagulation Therapy In Non-valvular Atrial Fibrillation

IntroductionIn patients with non-valvular atrial fibrillation (NVAF), left atrial appendage closure (LAAC) has demonstrated non-inferior efficacy and safety relative to life-long oral anticoagulation therapy (OAT) in a four-year randomized controlled trial (RCT) (PRAGUE-17). Sub-optimal compliance to OAT in the real-world setting (Simmons 2016) has been associated with increased risk of stroke (Ozaki 2020) and may alter efficacy estimates derived from RCTs in which compliance is generally higher. The study aims to model disease outcomes in NVAF patients treated with LAAC versus lifelong OAT when applying trial versus real world compliance to OAT.MethodsReal-world compliance to OAT in the Australian setting was investigated in a 10 percent Pharmaceutical Benefits Schedule (PBS) sample scripts analysis which measured treatment adherence and persistence to new oral anticoagulants (NOACs) and warfarin. Design of the 10 percent PBS analysis was informed by the compliance to medicine working group report and included the longest follow-up of any OAT compliance study identified in the literature. A Markov cohort model was developed to estimate the expected numbers of strokes and major bleeding events in NVAF patients.ResultsRates of NOAC discontinuation in PRAGUE-17 was higher at 20 months median follow-up (6.5%) versus compliance in the Australian setting (35.4% and 30.0% according to 3 and 6 month ceasing rules at 20 months follow-up). Applying sub-optimal compliance to lifelong OAT demonstrated in the Australian setting resulted in higher numbers of strokes over a life time modelled time horizon compared with LAAC.ConclusionsReal world compliance to medicines should be a consideration in economic analysis comparing lifelong medications to one-off surgical interventions.

Limitations in Contemporary Pharmacological Stroke Prevention Therapies in Atrial Fibrillation: A Descriptive Literature Review.

The most common arrhythmia, atrial fibrillation (AF), increases with age and is associated with a 5-fold increased risk of stroke. Although lifelong oral anticoagulation (OAC) is strongly recommended for stroke prevention in patients with AF and CHA2DS2-VASc ≥ 2 only 50-60% of patients in Western countries belonging to this group are treated with oral anticoagulants, and less than half of these adhere to therapy over time. Before 2010, the numerous limitations associated with vitamin K antagonists (VKAs) were considered to be the reason behind OAC underuse; however, the approval of direct oral anticoagulants (DOACs) that require once- or twice-daily intake, no regular blood tests and fewer drug-food interactions has resulted in only modest improvements in OAC use and adherence.

Anticoagulant Management of Mechanical Heart Valve Patients During Perioperative Surgery: A Case Report

Background: Patients with mechanical heart valves require lifelong oral anticoagulation. It will be a dilemma if a patient with a mechanical heart valve has surgery. This case report aims to discuss how to interrupt oral anticoagulants and bridging therapy in patients with mechanical heart valves who will be undergoing non-cardiac surgery. Case Report: A 26-year-old pregnant woman, G1P0A0, aterm with a mechanical mitral valve, will have elective Sectio Caesarian Transperitonealis (SCTP) surgery and Intra Uterine Device (IUD) insertion. The patient had a history of mitral valve replacement surgery (MVR) in 2014 and was routinely treated with 4 mg of warfarin at night. From the examination, blood pressure was 120/80 mmHg, heart rate was 90 beats per minute, and pulse rate was 90 beats per minute. The ECG examination found sinus rhythm with 1st-degree atrioventricular block, right axis deviation, 90 beats per minute, and left atrial enlargement. We decided to have oral anticoagulant interruption and bridging therapy by stopping warfarin three days before surgery. When the international normalized ratio (INR) falls <2, patients are given heparin injections (UFH) with an APTT target of 1.5-2.0 times from basic APTT. When the patient was about to be operated on, UFH was stopped 6 hours before surgery and resumed 12 hours after surgery. Warfarin was given one day postoperatively. Patients were adjusted to the dose of UFH according to the target. This patient had no thromboembolic events or bleeding before, during, or after surgery. The patient was allowed to be an outpatient and was given home therapy with Warfarin 5 mg at night. Results: We report a case of a 26-year-old female patient with a mechanical mitral valve who was going to undergo elective SCTP surgery and an IUD insertion. Patients at high risk of thrombo¬embolism due to surgery with a high risk of bleeding. Bridging therapy was performed using UFH. In the perioperative period, the patient did not experience thromboembolic events, and bleeding before, during, and after surgery could be well controlled. Conclusion: Perioperative management of patients with mechanical heart valves must be done carefully. Interruption of oral anticoagulants should be carefully considered considering the risk of thromboembolism and bleeding during the perioperative period. Guidelines recommend that in patients with mechanical heart valves, anticoagulation interruption for minor surgeries is avoided. Whereas in patients with major surgery, it is necessary to do bridging therapy with fast-acting anticoagulants such as UFH or LMWH. Keywords: mechanical heart valve, anticoagulant interruption, perioperative, bridging therapy Correspondence: Trisulo Wasyanto. Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University / Dr. Moewardi Hospital. Jl. Kol. Sutarto 132, Surakarta 57126, Central Java, Indonesia. Email: trisulo.wasyanto@staff.uns.ac.id. ORCID ID: 0000-0001-9900-0497. Mobile: +62811294225.

Identifying treatment heterogeneity in atrial fibrillation using a novel causal machine learning method

Lifelong oral anticoagulation is recommended in patients with atrial fibrillation (AF) to prevent stroke. Over the last decade, multiple new oral anticoagulants (OACs) have expanded the number of treatment options for these patients. While population-level effectiveness of OACs has been compared, it is unclear if there is variability in benefit and risk across patient subgroups. We analyzed claims and medical data for 34,569 patients who initiated a nonvitamin K antagonist oral anticoagulant (non-vitamin K antagonist oral anticoagulant (NOAC); apixaban, dabigatran, and rivaroxaban) or warfarin for nonvalvular AF between 08/01/2010 and 11/29/2017 from the OptumLabs Data Warehouse. A machine learning (ML) method was applied to match different OAC groups on several baseline variables including, age, sex, race, renal function, and CHA2DS2 -VASC score. A causal ML method was then used to discover patient subgroups characterizing the head-to-head treatment effects of the OACs on a primary composite outcome of ischemic stroke, intracranial hemorrhage, and all-cause mortality. The mean age, number of females and white race in the entire cohort of 34,569 patients were 71.2 (SD, 10.7) years, 14,916 (43.1%), and 25,051 (72.5%) respectively. During a mean follow-up of 8.3 (SD, 9.0) months, 2,110 (6.1%) of patients experienced the composite outcome, of whom 1,675 (4.8%) died. The causal ML method identified 5 subgroups with variables favoring apixaban over dabigatran; 2 subgroups favoring apixaban over rivaroxaban; 1 subgroup favoring dabigatran over rivaroxaban; and 1 subgroup favoring rivaroxaban over dabigatran in terms of risk reduction of the primary endpoint. No subgroup favored warfarin and most dabigatran vs warfarin users favored neither drug. The variables that most influenced favoring one subgroup over another included Age, history of ischemic stroke, thromboembolism, estimated glomerular filtration rate, Race, and myocardial infarction. Among patients with AF treated with a NOAC or warfarin, a causal ML method identified patient subgroups with differences in outcomes associated with OAC use. The findings suggest that the effects of OACs are heterogeneous across subgroups of AF patients, which could help personalize the choice of OAC. Future prospective studies are needed to better understand the clinical impact of the subgroups with respect to OAC selection.

P2Y12 Inhibitor Monotherapy: Considerations for Acute and Long-Term Secondary Prevention Post-PCI

Following percutaneous coronary intervention (PCI), an initial course of dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (P2Y12-i) is recommended to minimize the risk of thrombotic complications. After the initial period of DAPT, antiplatelet monotherapy, usually consisting of aspirin, is administered for long-term secondary prevention. However, over the last few years there has been accruing evidence on P2Y12-i monotherapy, both in the acute (i.e., post-PCI; after a brief period of DAPT, transitioning to monotherapy before six or 12 months in patients with chronic or acute coronary syndrome, respectively) and chronic (i.e., long-term secondary prevention; after completion of six or 12 months of DAPT, in patients with chronic or acute coronary syndrome, respectively) settings. In aggregate, most studies of short DAPT with transition to P2Y12-i monotherapy showed a reduced risk of bleeding complications, without any significant increase in ischemic events as compared to standard DAPT. On the other hand, the evidence on long-term P2Y12-i monotherapy is scarce, but results from a randomized trial showed that clopidogrel monotherapy outperformed aspirin monotherapy in terms of net benefit, ischemic events and bleeding. Antiplatelet therapy is also recommended for patients undergoing PCI and with an established indication for long-term oral anticoagulation (OAC). In this scenario, a brief period of triple therapy (i.e., aspirin, P2Y12-i and OAC) is followed by a course of dual antithrombotic therapy (usually with P2Y12-i and OAC) and ultimately by lifelong OAC alone. European and American guidelines have been recently updated to provide new recommendations on antithrombotic therapy, including the endorsement of P2Y12-i monotherapy in different settings. However, some areas of uncertainty still remain and further randomized investigations are ongoing to fulfil current gaps in knowledge. In this review, we assess the current knowledge and evidence on P2Y12-i monotherapy for the early and long-term secondary prevention in patients undergoing PCI, and explore upcoming research and future directions in the field.

Aortic valve neocuspidization using autologous versus bovine pericardium: Ozaki versus Batista.

The average living age of the population is constantly increasing and so is the incidence and prevalence of aortic valve disease. Surgical aortic valve replacement (SAVR) is the current gold standard treatment. Nevertheless, the use of prosthetic valves in SAVR is associated with issues that impact patients' quality of life. Aortic valve neocuspidization (AV Neo) offers a means to solve this dilemma by minimizing foreign valve tissue. AV Neo can either be performed using glutaraldehyde-treated autologous pericardium (Ozaki procedure) or bovine pericardium (Batista procedure). This commentary aims to discuss the recent study by Chan and colleagues which highlighted the surgical approach, clinical outcomes, and limitations of the Ozaki procedure, and compare this to the Batista procedure. A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Embase, and Scopus to collate the relevant research evidence. Although the Ozaki procedure can achieve favorable results whilst mainly avoiding the need for life-long oral anticoagulation with mechanical valves, it still has several limitations that may hinder results. AV Neo using glutaraldehyde-treated bovine pericardium, developed by pioneer cardiac surgeon Dr. Randas J. Vilela Batista, yields superior clinical outcomes to Ozaki's, including excellent survival, lower complications, and minimal need for reoperation as well as shorter operative times. AV Neo offers a means to perform SAVR whilst escaping the prosthetic valve issues. However, the Batista procedure has shown beyond doubt that it can be considered the superior approach for AV Neo over the Ozaki procedure.

The Use of Antiplatelet and Anticoagulation After TAVR: A Brief Review of Important Literature

Aortic stenosis is the most common valvular heart disease in the elderly patient population. Surgical aortic valve replacement (SAVR) has been the standard of practice for treating aortic stenosis for years. But recently in the past decade, the minimally invasive procedure Transcatheter aortic valve replacement/implantation (TAVR/TAVI) has been a revolutionary treatment modality for aortic stenosis patients, particularly those who are at high risk of surgery. The patients who undergo TAVR are at high risk for bleeding and thromboembolic events afterward. The use of antiplatelet and anticoagulation after TAVR is to decrease the risk of thromboembolic complications such as stroke, but it comes with the risk of bleeding associated with antiplatelet and antithrombotic. Current guidelines recommend the use of dual antiplatelet (DAPT) for 3 to 6-month after TAVR in the absence of an indication for oral anticoagulation followed by lifelong single antiplatelet therapy (SAPT). However, the use of dual antiplatelet is associated with an increased risk of bleeding without significant ischemic benefits. Lifelong oral anticoagulation is recommended for patients who have other indications for anticoagulation. These treatment guidelines are driven by expert opinion, given the lack of large randomized control trials (RCT). In this review, we aim to discuss the need for antithrombotic and antiplatelets after TAVR and review important literature about current practice and expert recommendations about antiplatelet and anticoagulation after TAVR.

Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement.

Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.

RENAL VEIN THROMBOSIS AT HIGH ALTITUDE

Though risk of venous thromboembolism in increased at high altitude, involvement of renal veins is rare. A 27-year-old soldier was evacuated from a height of 18000 feet after developing flank pain and haematuria. Ultrasound showed an enlarged left kidney and lack of flow in proximal renal vein. CT scan confirmed the presence of renal vein thrombus. Serum IgM Anti β-2 Glycoprotein I antibodies, IgG Anti β-2 Glycoprotein I antibodies and IgM anticardiolipin antibodies were detectable and the former two were present after three months also. Secondary causes of antiphospholipid syndrome were excluded. He was started on low molecular weight heparin and is now on lifelong oral anticoagulation with warfarin.

Left atrial appendage closure after cryoballoon ablation in patients with atrial fibrillation.

Cryoballoon ablation (CBA) is effective for patients with drug-refractory symptomatic atrial fibrillation (AF). For patients with ahigh risk of stroke (CHA2DS2-VASc score ≥2), life-long oral anticoagulation therapy should be continued even after successful catheter ablation. We investigated the safety and efficacy of concomitant use of asecond-generation CBA catheter for pulmonary vein isolation (PVI) and aleft atrial appendage closure (LAAC) device in patients with AF. We enrolled 27 patients (64.7 ± 6.3years, 74% male, 63% paroxysmal AF, 37% persistent AF, 4.8 ± 1.4 CHA2DS2-VASc score, and 3.6 ± 1.3 HAS-BLED score). In total, 85% of the patients had aprior stroke or TIA, and 30% of patients had aclinical history of bleeding. Patients received aCBA for PVI and underwent occlusion of the LAA with anLAAC device. The efficacy of CBA was defined as lack of arrhythmia recurrence (AF, atrial flutter, and/or atrial tachycardia lasting ≥30 s) after a90-day blanking period. The success of LAAC was determined by the rate of stroke, TIA, and/or bleeding events. The mean procedural time for CBA and LAAC was 80 ± 16 min and 44 ± 12 min, respectively. Acute PVI by CBA was achieved in 100% of the procedures, and 96% of patients obtained acute LAAC device placement during the procedure. Upon complete release of the LAAC device, only 62% patients (16/26) had no detectable leakage during intraprocedural transesophageal echocardiography. Three patients experienced an acute complication: apericardial effusion and two phrenic nerve palsy events. Mean follow-up was 18months (range 9-23months), and freedom from AF recurrence was 74% (20/27). The intraprocedural combination of CBA and LAAC is feasible in patients with non-valvular AF with ahigh risk of stroke, TIA, and/or bleeding. Larger long-term randomized studies are needed to judge the overall safety and efficacy of the combined procedure.

Incidence, Characteristics and Management of Persistent Peri-Device Flow after Percutaneous Left Atrial Appendage Occlusion

ABSTRACT Background : Severe peri-device leaks after left atrial appendage (LAA) occlusion requires continuation of life-long oral anticoagulation. However, the majority of patients referred for LAA occlusion are not suitable for anticoagulation. Data on the incidence, characteristics, and management of peri-device leak after LAA occlusion are scarce. Methods : We assessed the incidence of peri-device leak, its characteristics, and their management outcomes in 200 consecutive patients who underwent LAA occlusion between April 2016 and August 2018. Results : Severe persistent peri-device flow was present in 9/200 patients (4.5%) at 45 days. Baseline clinical characteristics were comparable between patients with or without severe leaks. However, patients with severe leaks had larger LAA diameter (24.5 ± 4.3 vs. 19.8 ± 3.7 mm, p < 0.001), and more sub-optimal deployments (100% vs. 26.7%, p < 0.001). Sub-optimal deployment parameters included: non-coaxial deployment, preferential single lobe deployment, incomplete coverage of a proximal side lobe, and shallow implantation. Among patients with severe leaks, 7 (78%) underwent percutaneous closure. Percutaneous closure with the Amplatzer Vascular Plug-II device had a 100% success rate and no short-term complications. Conclusions : Severe peri-device leak is present in ~5% of patients following LAA occlusion. Certain anatomical and procedural factors might contribute to the occurrence of peri-device leak. Severe leaks can be effectively closed with percutaneous techniques.

Percutaneous Pharmaco-Mechanical Thrombectomy of Acute Symptomatic Superior Mesenteric Vein Thrombosis

PurposeTo evaluate the safety and the efficacy of percutaneous pharmaco-mechanical thrombectomy (PPMT) of acute superior mesenteric vein (SMV) thrombosis.MethodsA database of patients treated between 2011 and 2018 with acute venous mesenteric ischemia (VMI) was reviewed. VMI was diagnosed in the presence of SMV thrombosis and CT evidence of jejunal thickening. All patients presented with mild to moderate peritonism, which allowed surgery to be postponed. Initial treatment consisted of heparinization. PPMT was indicated in case of worsening abdominal pain despite anticoagulation and was performed via a transjugular or transhepatic approach, using a rotational aspiration thrombectomy catheter, followed by transcatheter thrombolysis. Clinical success was defined as symptoms resolution. Technical success was defined as patency of > 50% of SMV at venography and resolution of jejunal thickening. Patients were discharged on lifelong oral anticoagulation (INR 2.5–3.5). Follow-ups were performed using CT and color Doppler ultrasound.ResultsPopulation consisted of eight males, aged 37–81 (mean 56.5 years). Causes for thrombosis were investigated. Urokinase infusion time ranged from 48 to 72 h (3,840,000–5,760,000 IU). Clinical and technical success was obtained in all cases. One patient experienced bleeding from the superior epigastric artery and was treated with embolization. One patient died of multi-organ failure after 35 days, despite resolution of SMV thrombosis. In no case was surgery required after PPMT; mean hospitalization was 14.1 days (9–24). Mean follow-up of remaining seven patients was 37.7 months (12–84 months).ConclusionPPMT of acute SMV thrombosis seems safe and effective, with an 87.5% long-term survival rate and a 12.5% major complication rate.

Bleeding Tolerance Among Patients With Atrial Fibrillation on Oral Anticoagulation

BackgroundOral anticoagulation increases the bleeding risk. We investigated how clinical factors and the level of atrial fibrillation (AF) knowledge affect the bleeding acceptance in patients with AF. MethodsIn 173 consecutive anticoagulated outpatients with AF (aged 68.7 ± 10.7 years, 39.3% male), the bleeding ratio was assessed based on the declared maximum number of major bleeds the people were willing to endure to avert 1 stroke. The Jessa AF Knowledge Questionnaire was used to assess the knowledge of AF. ResultsCompared with patients with the high bleeding ratio (≥ 4 accepted bleedings, n = 88, 50.9%), subjects with the low bleeding ratio (0-3 accepted bleedings, n = 85, 49.1%) were older, with longer duration of AF, suffered more commonly from heart failure, and were free of cerebrovascular events. Patients after major bleeding (n = 33, 19.1%) and those reporting minor bleeds on anticoagulation (n = 77, 44.5%) had lower bleeding ratio. The independent predictors of the low bleeding ratio were older age (odds ratio [OR], 2.50; 95% confidence interval [CI], 1.69-3.70), major bleeds on anticoagulation (OR, 3.33; 95% CI, 1.16-10.0), minor bleeds on anticoagulation (OR, 3.45; 95% CI, 1.67-7.14), and prior stroke/transient ischemic attack (OR, 0.47; 95% CI, 0.22-0.99). The level of knowledge of AF did not affect the bleeding ratio. ConclusionsThe key determinants of the bleeding ratio among anticoagulated patients with AF are age, and prior thromboembolic and bleeding episodes. The study could support identification of patients with AF who need additional effort to increase their acceptance of a life-long oral anticoagulation therapy.

Pathogenesis and Management of Thrombotic Disease in Myeloproliferative Neoplasms.

Chronic myeloproliferative neoplasms (MPN) are characterized by clonal expansion of an abnormal hematopoietic stem/progenitor cell and include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). Venous thrombosis, often at unusual sites, including splanchnic vein thrombosis and arterial thrombosis, as well as a hemorrhagic tendency and a propensity to transform into myelofibrosis or acute leukemia are common complications in patients with MPNs. The pathogenesis of thrombosis in MPN patients is complex and multifactorial. Disease related factors, such as an increase in blood cell counts (i.e., leukocytosis, erythrocytosis, and thrombocytosis), and more importantly presence of JAK2 mutation can interact with non-disease patient related factors such as age, previous history of thrombotic events, obesity, hypertension, hyperlipidemia, and presence of thrombophilic defects. The overall rate of recurrent thrombosis after venous thromboembolism (VTE) is 6.0 to 6.5 per 100 patient-years in patients with MPN compared to 2.7 to 3.7 per 100 patient-years in patients without MPN, and antithrombotic therapy with vitamin K antagonists (VKAs) is associated with a clear benefit, reducing the incidence of recurrence by 48 to 69%. Life-long oral anticoagulation with VKAs is the cornerstone of the antithrombotic treatment for splanchnic vein thrombosis (SVT). Patients with MPN-related cerebral venous thrombosis (CVT) should also be treated with long-term anticoagulation with VKAs. The role of direct acting oral anticoagulants in patients with thrombosis and MPN is not established and the use of these anticoagulants should be considered on an individual basis according to the risk of recurrent of VTE and bleeding.

Multicenter prospective observational long-term follow-up study of endocardial cardiac resynchronization therapy using the Jurdham procedure

Endocardial cardiac resynchronization therapy (eCRT) avoids the limitations and failures of coronary sinus (CS) resynchronization. However, data regarding long-term outcomes are lacking. The purpose of this study was to report the long-term outcome of eCRT performed using the Jurdham procedure in a real-world setting. eCRT was performed in patients who failed a CS implant or failed to respond to cardiac resynchronization therapy (CRT), or in selected patients requiring lifelong oral anticoagulation (OAC). Left ventricular ejection fraction (LVEF), New York Heart Association functional class (NYHA FC), and left ventricular stimulation parameters were assessed during long-term follow-up (FU). From August 2009 to March 2018, the Jurdham procedure was performed in 88 patients at 15 centers in 8 countries, with FU of 32.88 ± 61.52 months (range 0-88 months; 196 patient-years). NYHA FC improved from 2.9 preimplant to 1.3 during FU. LVEF increased <10 percentage points from baseline in 7% of patients, between 10 and 20 percentage points in 11% of patients, and >20 percentage points in 82% of patients. All-cause mortality at 60 months was 30.5%. Three transient ischemic attacks (1.53 per 100 patient-years) and 6 strokes (3.06 per 100 patient-years) occurred. Of the 6 patients with stroke, 4 (66%) had almost complete recovery. eCRT using the Jurdham procedure is an effective and safe technique in anticoagulated patients. This approach may be an attractive option for patients with failed CS implants or nonresponders to CS CRT. In addition, it might be a reasonable approach as a first option for treatment of patients requiring lifelong OAC.

Review on Future Targets and Current Trends in Transcatheter Left Atrial Appendage Closure

Atrial fibrillation is cause for a growing burden of thromboembolic stroke. Transcatheter left atrial appendage closure is an alternative to lifelong oral anticoagulation for many patients with nonvalvular atrial fibrillation. Reviewed here are three commonly used devices (Watchman, Amplatzer Cardiac Plug/Amulet, and Lariat) and their key clinical trials, special candidate patient populations, and recent investigations of the impact of post-procedure antithrombotic strategies. Transcatheter left atrial appendage closure devices provide noninferior thromboembolic stroke risk reduction and superior bleeding risk reduction compared with oral anticoagulation in nonvalvular atrial fibrillation. Very recent studies of post-procedure antithrombotic regimens describe a variety of anticoagulant and antiplatelet pharmacotherapies without clear impact on device-associated thrombus or post-procedure embolic stroke though more study is needed. Transcatheter left atrial appendage closure is a viable alternative to lifelong oral anticoagulation to decrease thromboembolism and bleeding in patients with nonvalvular atrial fibrillation who are at increased risk of adverse event with anticoagulants. Patient populations at risk of bleeding on anticoagulants have been demonstrated to benefit from this technology, but there are several additional benefits of left atrial appendage closure unrelated to bleeding risks for specific patient populations. Data on the optimal short-term (weeks to months) post-procedure antithrombotic regimens is emerging and will play a significant role in how to best treat patients and which patients will benefit most from left atrial appendage closure.

PO221 Gender Differences In Cardiovascular Risk Factors and Management at a Single Center Primary Preventive Cardiology Out-Patient Program: The Philippine Heart Center Experience

We present a case of acute myocardial infarction secondary to arterial thromboembolism in a 25-year-old man with systemic lupus erythematosus and antiphospholipid syndrome (APS). To our knowledge, based on the literature review, this patient is the youngest one with the acute coronary syndrome as a complication of APS. Acute myocardial infarction secondary to arterial thromboembolism is a rare presentation of APS. There are different recommended anticoagulation strategies in APS patients according to the presence of thrombosis of arterial or venous origin. Potential difficulties in the treatment may occur based on the clinical scenarios. A large number of APS patients require lifelong oral anticoagulation with vitamin K antagonists. Some non-vitamin K oral anticoagulants are being studied as drugs potentially useful in APS treatment. The recent studies suggest the role of aGAPSS score in assessing the risk of a recurrent thrombotic event as well as acute myocardial infarction in APS patients.

Totally Thoracoscopic Closure of the Left Atrial Appendage

The left atrial appendage (LAA) is a major site of clot formation in atrial fibrillation. Stand-alone thoracoscopic LAA complete closure can decrease stroke risk and may be an alternative to life-long oral anticoagulation. This report describes a technique for totally thoracoscopic LAA exclusion with an epicardial clip device. This approach provides a safe and likely more effective alternative to LAA management than other endocardial devices.

Splanchnic vein thrombosis in myeloproliferative neoplasms: treatment algorithm 2018

Myeloproliferative neoplasms (MPNs) are a leading cause of splanchnic vein thrombosis (SVT). SVT is observed in all MPNs and frequently affects young patients. Therapy should be addressed to three main goals: preventing thrombosis recurrence, managing the underlying MPN, and supporting liver dysfunction. Life-long oral anticoagulation with vitamin K antagonists is the cornerstone of the antithrombotic treatment. However, recurrences of SVT or other thrombosis may occur in 15–20% of patients. Direct oral anticoagulants can represent an alternative and preliminary data encourage comparative studies. Survival of patients with SVT in MPN is primarily influenced by the natural history of the underlying neoplasms, rather than the SVT event. An aggressive management is recommended and a treatment algorithm based on the different MPN subtypes is proposed. Hydroxyurea is the cytoreductive drug of choice in polycythemia vera and essential thrombocythemia, whereas ruxolitinib is indicated in intermediate and high-risk patients with myelofibrosis and in PV patients resistant or intolerant to hydroxyurea. The management of SVT in MPNs requires a multidisciplinary approach that may include a hematologist, a gastroenterologist, an interventional radiologist, and a surgeon. In the case of clinical deterioration despite pharmacological therapy, patients with SVT should be considered for invasive procedures or liver transplantation.

Surgical Treatment of Valvular Heart Disease: Overview of Mechanical and Tissue Prostheses, Advantages, Disadvantages, and Implications for Clinical Use

Valvular heart disease (VHD) affects a large number of patients annually. From a surgical standpoint, there are two primary options for valve replacement: mechanical or bioprosthetic. While there are clear advantages and disadvantages to either option, and recent literature does challenge some of the prior dictums of valve choice, a handful of absolutes remain true. Mechanical valves provide superior durability and freedom from re-operation when compared to their bioprosthetic counterparts, at the expense of bleeding or thrombotic complications associated with the need for lifelong oral anticoagulation. Unless a clear contraindication to oral anticoagulation exists, we recommend implanting mechanical valves for patients less than 60years old and those who are older than 65 but maintained on anticoagulation for reasons other than their valvular disease. Bioprosthetic valves should be placed in patients who are greater than 65years old or those patients who have a postoperative life expectancy of less than 10years. Valve choice in patients between the ages of 60 to 70 is not dictated by guidelines and is less clear, with patient preference playing a larger role than their age range.