Predictors Of Thromboembolism Research Articles

Thrombogenesis-associated genetic determinants as predictors of thromboembolism and prognosis in cervical cancer

Venous thromboembolism (VTE) is a leading cause of death among cancer patients. Khorana score (KS) is the most studied tool to predict cancer-related VTE, however, it exerts poor sensitivity. Several single-nucleotide polymorphisms (SNPs) have been associated with VTE risk in the general population, but whether they are predictors of cancer-related VTE is a matter of discussion. Compared to other solid tumours, little is known about VTE in the setting of cervical cancer (CC) and whether thrombogenesis-related polymorphisms could be valuable biomarkers in patients with this neoplasia. This study aims to analyse the effect of VTE occurrence on the prognosis of CC patients, explore the predictive capability of KS and the impact of thrombogenesis-related polymorphisms on CC-related VTE incidence and patients’ prognosis regardless of VTE. A profile of eight SNPs was evaluated. A retrospective hospital-based cohort study was conducted with 400 CC patients under chemoradiotherapy. SNP genotyping was carried on by using TaqMan® Allelic Discrimination methodology. Time to VTE occurrence and overall survival were the two measures of clinical outcome evaluated. The results indicated that VTE occurrence (8.5%) had a significant impact on the patient’s survival (log-rank test, P < 0.001). KS showed poor performance (KS ≥ 3, χ2, P = 0.191). PROCR rs10747514 and RGS7 rs2502448 were significantly associated with the risk of CC-related VTE development (P = 0.021 and P = 0.006, respectively) and represented valuable prognostic biomarkers regardless of VTE (P = 0.004 and P = 0.010, respectively). Thus, thrombogenesis-related genetic polymorphisms may constitute valuable biomarkers among CC patients allowing a more personalized clinical intervention.

Impact of COVID-19 Pandemic and Lockdown on the Management of Upper Gastrointestinal Relationship between Mitral Annular Velocities and Left Atrial Appendage Emptying Velocity

Background: Mitral stenosis (MS) is a prevalent kind of valvular heart disease. Thromboembolism is one of the most severe complications, particularly when it is accompanied with atrial fibrillation (AF). When associated with Left atrial appendage (LAA) dysfunction, patients with sinus rhythm (SR) are also at risk for this condition. In mitral stenosis, LAA dysfunction is an independent predictor of thromboembolism. The aim of the study was to see if there is an association between mitral annular velocities measured with Doppler tissue imaging (DTI) and LAA function measured with transesophageal echocardiography (TEE), and to see if annular velocities can predict the presence of an inactive LAA in MS. Methods: This was an observational study carried out by the department of cardiology of the National Institute of Cardiovascular Diseases (NICVD). From January 2006 to December 2007, 60 MS patients were evaluated using transthoracic echocardiography and transesophageal echocardiography. The systolic (S-wave) and diastolic (Em- and Am-waves) annular velocities were measured. Inactive LAA was defined as a velocity of &lt;25 cm/sec for LAA emptying. Patients were divided into three groups. Group A (I) (n = 18): Sinus rhythm (SR) and LAA emptying velocity ≥25 cm/sec, group A (II) (n =22): SR and LAA emptying velocity &lt;25cm/sec and group B (n = 20): atrial fibrillation. Results: Thrombus was found in 14 patients, and spontaneous echo contrast (SEC) was found in 43. From group A to group B, S-wave and peak LAA emptying velocities decreased while SEC frequency and density increased. There was a positive correlation between LAA emptying versus S-wave &amp; Am wave velocity (p&lt;0.001, r= 0.708 and p&lt;0.001, r=0.495, respectively). Only S-wave was found to be an independent predictor of inactive LAA in multivariate regression analysis (p = 0.001, odds ratio = 0.133, 95%ci =0.032-0.556). The cutoff value of S-wave in patients with SR for predicting the presence of inactive LAA was.........

A meta-analysis of clinical risk factors for stroke in anticoagulant-naïve patients with atrial fibrillation

The aim of this study is to summarize data from prospective cohort studies on clinical predictors of stroke and systemic embolism in anticoagulant-naïve atrial fibrillation (AF) patients. EMBASE, MEDLINE, Global Index Medicus, and Web of Science were searched to identify all studies published by 28 November 2019. Forty-seven studies reporting data from 1 756 984 participants in 15 countries were included. The pooled incidence of stroke in anticoagulant-naïve AF patients was 23.8 per 1000 person-years (95% CI 19.7-28.2). Older age was associated with incident stroke or systemic embolism, with a pooled hazard ratio (HR) of 2.14 (95% CI 1.85-2.47), 2.83 (95% CI 2.27-3.51), and 6.87 (95% CI 6.33-7.44) for age 65-75, ≥75, and ≥85 years, respectively. Other predictors of stroke or systemic embolism included history of stroke or TIA (HR 2.84, 95% CI 2.19-3.67), hypertension (HR 1.60, 95% CI 1.37-1.86), diabetes (HR 1.28, 95% CI 1.20-1.37), heart failure (HR 1.25, 95% CI 1.11-1.40), peripheral artery disease (pooled HR 1.35, 95% CI 1.04-1.75), vascular disease (pooled HR 1.21, 95% CI 1.06-1.39), and prior myocardial infarction (pooled HR 1.08, 95% CI 1.03-1.14). Female sex was a predictor of thromboembolism in studies outside Asia (HR 1.35, 95% CI 1.15-1.59), but not in those done in Asia (HR 0.95, 95% CI 0.81-1.10). This study confirms age and prior stroke as the strongest predictors of stroke or systemic embolism in anticoagulant-naive AF patients. Other predictors include hypertension, diabetes, heart failure, and vascular disease. Female sex seems not to be universally associated with stroke or systemic embolism.

Value of Serum Galectin-3 Levels as A Predictor of Thromboembolism in Nonvalvular AF

Value of Serum Galectin-3 Levels as A Predictor of Thromboembolism in Nonvalvular AF

Thromboembolic risks associated with paroxysmal and persistent atrial fibrillation in Asian patients: a report from the Chinese atrial fibrillation registry

BackgroundSeveral studies have reported on atrial fibrillation (AF) outcomes, including thromboembolism in patients with paroxysmal and non-paroxysmal AF; however the findings still remain controversial on whether risks differ between these clinical subtypes and limited data are available in Asian cohorts.MethodsWe compared the risk of thromboembolism between paroxysmal and persistent AF patients, in a large contemporary Chinese cohort study. A total of 8529 non-valvular atrial fibrillation (NVAF) patients from the Chinese Atrial Fibrillation Registry (CAFR) study were enrolled. The study subjects were divided into two groups: paroxysmal AF (PaAF, defined as AF lasting within 7 days, n = 4642) and persistent AF (PeAF, lasting over 7 days, n = 3887) groups.ResultsIn non-anticoagulated patients, PeAF group demonstrated a higher risk of stroke, all-cause death, cardiac/ non-cardiac death and composition of stroke/ transient ischemic attack (TIA)/peripheral thromboembolism (PT)/all-cause death, compared to the PaAF group. No significant difference was found in anticoagulated subjects. On multivariate analysis in non-anticoagulated patients, age ≥ 75 years (P = 0.046) and prior stroke/TIA/PT (P = 0.018) but not AF type (P = 0.63) were significantly associated with the risk of stroke/TIA/PT events.ConclusionsStroke, all-cause death and cardiac/non-cardiac death in Chinese NVAF population was increased in non-anticoagulated PeAF patients compared with PaAF group, but same between anticoagulated PeAF and PaAF patients. After adjustment, AF type was not an independent predictor of thromboembolism in NVAF patients.Clinical trial registrationChinese Clinical Trial Registry ChiCTR-OCH-13003729. Registered 22 October 2013.

210Predictors of thromboembolism in patients with atrial fibrillation and valvular heart disease according to the EHRA classification: beyond mitral stenosis and mechanical prosthetic heart valves

Abstract Background Atrial fibrillation (AF) and valvular heart disease (VHD) often coexist. They are independent causes of mortality and morbidity, and both have been associated with risk of thromboembolic events. Historically, the definition of VHD in AF patients has been inconsistent, which led to the proposal of a new classification of AF patients with VHD: the “Evaluated Heartvalves, Rheumatic or Artificial” (EHRA) valve classification, categorizing patients into: EHRA Type 1 VHD and EHRA Type 2 VHD. EHRA Type 1 VHD comprises AF patients with mitral stenosis (moderate-severe, of rheumatic origin) or a mechanical prosthetic valve replacement. EHRA Type 2 VHD includes AF patients with any other heart valve disease or a bioprosthetic valve replacement. The thromboembolic risk in this latter heterogeneous group is uncertain and, thus, identifying clinically relevant predictors of thromboembolism will facilitate more individualized risk stratification and identify high-risk subgroups, thereby, optimize prevention strategies. Purpose In a large nationwide cohort study, we aimed to identify clinically relevant predictors of thromboembolism in AF patients with EHRA Type 2 VHD. Methods We conducted a cohort study of AF patients with co-existing EHRA Type 2 VHD, identified by ICD-10 codes using record linkage between nationwide registries in Denmark from 2000 through 2018. Time-to-event analysis was applied to describe the association between EHRA Type 2 VHD and risk of thromboembolism. We used a multivariable Cox proportional hazards regression model with time since incident AF diagnosis as the underlying time axis to estimate predictors of the outcome at 5-years of follow-up. Parameters included were clinically relevant risk factors, statin therapy, antithrombotic therapy, and time since VHD diagnosis. Results A total of 27,254 patients with EHRA Type 2 VHD was identified. After 5 years of follow-up, the rate of thromboembolism was 3.27 per 100 person-years. History of thromboembolism (HR: 4.85, 95% CI: 4.43–5.31) and age ≥75 (HR: 1.97, 95% CI: 1.70–2.28) were the strongest predictors of thromboembolism, but age 65–74, female sex, vascular disease, diabetes mellitus, hyperlipidemia/hypercholesterolemia, history of bleeding, and increasing CHA2DS2-VASc score were also independent predictors [Figure]. Predictors of thromboembolism Conclusion Among AF patients with VHD beyond mitral stenosis and mechanical prosthetic heart valves, the rate of thromboembolism is high after 5 years of follow-up. The strongest clinically relevant predictors of thromboembolism are history of thromboembolism and age ≥75. Future studies examining the optimal antithrombotic prevention strategy for EHRA Type 2 VHD are encouraged. Acknowledgement/Funding The study was supported by “The BMS/Pfizer European Thrombosis Investigator Initiated Research Program 2018 (ERISTA)” and the Obel Family Foundation.

Performance and validation of R-CHA2DS2VASc score for thromboembolism in patients with hypertrophic cardiomyopathy

ObjectiveTo validate the modified R-CHA2DS2VASc score as a predictor of thromboembolism in HCM patients. MethodsA total of 446 HCM patients were enrolled in our study, thirty-one (6.95%) patients experienced thromboembolic events during the follow-up time of 1786.7 person-years. The association between R-CHA2DS2VASc score and risk of thromboembolism was assessed by Cox’s proportional hazard analysis. The discriminatory power of R-CHA2DS2VASc score for thromboembolism prediction was assessed by Harrell’s C-statistic and validated internally by bootstrapping methods. Calibration plot was plotted by observed versus expected probabilities of thromboembolism. ResultsThe R-CHA2DS2VASc score was well calibrated with 0.84 thromboembolic events per 100 person-years in the predefined low risk (R-CHA2DS2VASc score ≤2) group, 1.84 in the low to moderate risk (R-CHA2DS2VASc score 3-4) group, 4.67 in the moderate to high risk (R-CHA2DS2VASc score 5-7) group, and 17.54 in the high risk (R-CHA2DS2VASc score ≥8) group. Hazard ratios for thromboembolism were 2.88 (95%CI: 1.06-7.82, P=0.038) for low to moderate versus low risk group, 5.30 (95%CI: 2.14-13.12, P=0.0003) for moderate to high versus low risk group, and 16.57 5.30 (95%CI: 4.96-55.33, P<0.0001) for high versus low risk group after adjusting left atria size. The Harrell’s C statistic was 0.7737 (95% CI: 0.65-0.89) for R-CHA2DS2VASc score. ConclusionThe R-CHA2DS2VASc score has shown good calibration and discriminative power in the prediction of thromboembolism for HCM patients. It should be considered as a potential decision support tool for HCM patients during clinical practice.

Usefulness of the Addition of Renal Function to the CHA2DS2-VASc Score as a Predictor of Thromboembolism and Mortality in Patients Without Atrial Fibrillation

Research is conflicting whether kidney function should be incorporated in thromboembolism risk prediction. Our published data showed that the CHA2DS2-VASc score predicts thromboembolism and mortality in those without atrial fibrillation. We used the Rochester Epidemiology Project medical records system to retrospectively evaluate whether adding renal impairment (1 point) to the CHA2DS2-VASc score (-R) enhances the score's prediction of mortality, thromboembolism, and atrial fibrillation in patients without atrial fibrillation. We identified patients that had an implantable cardiac monitoring device placed from January 1, 2004 to December 31, 2013, which was defined as the start date. Follow-up was through March 7, 2016. An implantable device was required to discern the absence of atrial fibrillation. Renal impairment was defined as chronic kidney disease stage 3 or greater. The population (n = 1,606) had a mean age of 69.8 years and median follow-up of 4.8 years. Baseline renal impairment was predictive of mortality (hazard ratio [HR] 2.06, 95% confidence interval [CI] 1.64 to 2.60, p <0.001), thromboembolism (HR 1.34, 95% CI 0.96 to 1.87, p = 0.09), and atrial fibrillation (HR 1.31, 95% CI 0.98 to 1.74, p = 0.07). Lower glomerular filtration rate correlated significantly with mortality. Increasing CHA2DS2-VASc-R score correlated significantly with mortality, thromboembolism, and incident atrial fibrillation. The addition of renal impairment to the CHA2DS2-VASc score improved the C-statistics for thromboembolism and survival from 0.72 to 0.73 (p = 0.01) and 0.70 to 0.72 (p <0.001). Adding renal impairment to the CHA2DS2-VASc score improves the score's prediction of thromboembolism and mortality in a population without atrial fibrillation, although the incremental benefit appears mild.

Utility of CHA2DS2-VASc and HAS-BLED Scores as Predictor of Thromboembolism and Bleeding After Left Ventricular Assist Device Implantation.

Ischemic and hemorrhagic events are the common causes of morbidity and mortality after continuous-flow left ventricular assist device (CF-LVAD) implantation. CHA2DS2-VASc score predicts thromboembolic (TE) event risk and HAS-BLED score predicts bleeding risk in patients on anticoagulant with atrial fibrillation (AF). We aimed to evaluate whether these scoring systems would be predictive of TE and bleeding complications after CF-LVAD implantation. From December 2010 to December 2014, 145 patients who underwent CF-LVAD implantation at a single center were included. Mean age was 50.7 ± 11.2 years, and 85.5% were male. Baseline CHA2DS2-VASc and HAS-BLED scores were retrospectively determined for patients with CF-LVADs. After device implantation, all patients were on warfarin (target international normalized ratio 2-3) as well as 300 mg of aspirin daily. Median length of support was 316 days (range 31-1,060), with 22 TE events (15.2%) and 32 bleeding (22.1%) events. The mean CHA2DS2-VASc score was 2.3 ± 1.4 and 2.5 ± 1.2 (p = 0.2) in patients with and without TE event, respectively. The mean HAS-BLED score was 1.8 ± 0.8 and 1.42 ± 0.6 (p = 0.004) in patients with and without bleeding, respectively. Baseline high HAS-BLED score was predictive of bleeding events after CF-LVAD implantation, whereas baseline CHA2DS2-VASc score was not predictive of TE events.

Periprocedural Anticoagulation Management of Patients with Thrombophilia

BackgroundAppropriate periprocedural management of the chronically anticoagulated patient with an inherited or acquired thrombophilia is uncertain. The objective of this study was to test “thrombophilia” as a potential predictor of the 3-month cumulative incidence of thromboembolism and major bleeding among chronically anticoagulated patients undergoing an invasive procedure. MethodsIn a prospective cohort study, consecutive chronically anticoagulated patients referred to the Mayo Thrombophilia Center for standardized periprocedural anticoagulation management who had venous thromboembolism and complete thrombophilia testing were categorized as “severe,” “non-severe,” or “no identifiable” thrombophilia. The 3-month cumulative incidence rates of thromboembolism, bleeding, and death were estimated using the Kaplan-Meier product limit method. ResultsAmong 362 patients with complete thrombophilia testing, 165 (46%) had a defined thrombophilia; 76 patients had severe thrombophilia, mainly due to antiphospholipid syndrome (66%). Half of the patients in each of the 3 groups received pre- and postprocedure heparin. During follow-up, there were no thromboembolic events, rare major bleeding events (1% for each group), and 4 deaths. Due to the very low event rates for each of these outcomes, Cox proportional hazard modeling could not be performed. ConclusionsPeriprocedural event rates were low irrespective of thrombophilia status. Inherited or acquired thrombophilia was not a predictor of thromboembolism, major bleeding, or mortality after temporary interruption of chronic anticoagulation for an invasive procedure.

Stroke Event Rates and the Optimal Antithrombotic Choice of Patients With Paroxysmal Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

The risks of stroke or systemic embolism and major bleeding are considered similar between paroxysmal and sustained atrial fibrillation (AF), and warfarin has demonstrated superior efficacy to aspirin, irrespective of the AF type. However, with the advent of novel oral anticoagulants (NOACs) and antiplatelet agents, the optimal antithrombotic prophylaxis for paroxysmal AF remains unclear.We searched Medline, Embase, CENTRAL, and China Biology Medicine up to October week 1, 2015. Randomized controlled trials of AF patients assigned to NOACs, warfarin, or antiplatelets, with reports of outcomes stratified by the AF type, were included. A fixed-effects model was used if no statistically significant heterogeneity was indicated; otherwise, a random-effects model was used.Six studies of 69,990 nonvalvular AF patients with ≥1 risk factor for stroke were included. Postantithrombotic treatment, paroxysmal AF patients showed lower risks of stroke (risk ratio [RR], 0.72; 95% confidence interval [CI], 0.59-0.87), stroke or systemic embolism (RR, 0.74; 95% CI, 0.63-0.86), and all-cause mortality (RR, 0.75; 95% CI, 0.67-0.83), while the major bleeding risk was comparable (RR, 0.96; 95% CI, 0.85-1.08). We were unable to detect the superiority of anticoagulation over antiplatelets for paroxysmal AF (RR, 0.72; 95% CI, 0.43-1.23), while it was more effective than antiplatelets for sustained AF (RR, 0.42; 95% CI, 0.33-0.54). NOACs showed superior efficacy over warfarin and trended to show reduced major bleeding irrespective of the AF type.The AF type is a predictor for thromboembolism, and might be helpful in stroke risk stratification model in combination with other risk factors. With the appearance of novel anticoagulant and antiplatelet agents, the best antithrombotic choice for paroxysmal AF needs further exploration.

Left atrial appendage obliteration in atrial fibrillation patients undergoing bioprosthetic mitral valve replacement.

Left atrial appendage (LAA) obliteration is a proven stroke-preventive measure for patients with nonvalvular atrial fibrillation (AF). However, the efficacy of LAA obliteration for patients with AF after bioprosthetic mitral valve replacement (MVR) remains unclear. This study aimed to estimate the efficacy of LAA obliteration in preventing embolism and to investigate the predictors of thromboembolism after bioprosthetic MVR. We retrospectively studied 173 AF subjects with bioprosthetic MVR; among them, 81 subjects underwent LAA obliteration using an endocardial running suture method. The main outcome measure was the occurrence of thrombosis events (TEs). The mean follow-up time was 40 ± 17months. AF rhythm was observed in 136 patients postoperatively. The incidence rate of TEs was 13.97 % for postoperative AF subjects; a dilated left atrium (LA; > 49.5mm) was identified as an independent risk factor of TEs (OR = 10.619, 95 % CI = 2.754-40.94, p = 0.001). For postoperative AF patients with or without LAA, the incidence rate of TEs was 15.8 % (9/57) and 12.7 % (10/79; p = 0.603), respectively. The incidence rate of TEs was 2.7 % (1/36) and 4.2 % (2/48) for the subgroup patients with a left atrial diameter of < 49.5mm, and 38.1 % (8/21) and 25.8 % (8/31) for those with a left atrial diameter of > 49.5mm (p = 0.346). Surgical LAA obliteration in patients with valvular AF undergoing bioprosthetic MVR did not reduce TEs, even when the CHA2DS2-VASc score (a score for estimating the risk of stroke in AF) was ≥ 2 points.

Duration of Diabetes Mellitus and Risk of Thromboembolism and Bleeding in Atrial Fibrillation: Nationwide Cohort Study.

Guidelines advocate anticoagulant treatment to all patients with atrial fibrillation and concomitant diabetes mellitus. The potential refinement to thromboembolic risk stratification that may spring from subdividing diabetes mellitus is unexplored. The purpose was to investigate duration of diabetes mellitus as a predictor of thromboembolism and anticoagulant-related bleeding in patients with atrial fibrillation. Using nationwide Danish registries, we identified all patients discharged from hospital with an incident diagnosis of atrial fibrillation from 2000 to 2011. Hazard ratios with 95% confidence intervals for thromboembolism and bleeding according to years of diabetes mellitus duration in categories (0-4, 5-9, 10-14, and ≥15) and as a continuous variable using cubic splines were calculated by Cox regression. The study population comprised 137 222 patients with atrial fibrillation, of which 12.4% had diabetes mellitus. Compared with patients without diabetes mellitus and after adjustment for anticoagulant treatment and CHA2DS2-VASc components (congestive heart failure, hypertension, age, previous stroke, vascular disease, and sex), the risk of thromboembolism was lowest in the 0 to 4 years duration category (hazard ratio, 1.11; 95% confidence interval, 1.03-1.20), and highest in the longest duration category of ≥15 years (hazard ratio, 1.48; 95% confidence interval, 1.29-1.70). When analyzed as a continuous variable, duration of diabetes mellitus was associated with risk of thromboembolism in a dose-response-dependent manner, but not with a higher risk of bleeding during anticoagulant treatment. In patients with atrial fibrillation, longer duration of diabetes mellitus was associated with a higher risk of thromboembolism, but not with a higher risk of anticoagulant-related bleeding. Considering the critical balance between preventing thromboembolism and avoiding bleeding, longer duration of diabetes mellitus may favor initiation of anticoagulant therapy.

Left atrial appendage flow velocity after successful ablation of persistent atrial fibrillation: Clinical perspective from transesophageal echocardiographic assessment during sinus rhythm

Left atrial appendage flow velocity (LAAFV) is a predictor of thromboembolism in atrial fibrillation (AF) patients, as well as CHA2DS2-VASc score. However, little is known about LAAFV in sinus rhythm (SR) after catheter ablation. The aim of this study was to determine clinical predictors of low LAAFV in patients in whom stable SR had been maintained after catheter ablation for persistent AF. The study comprised 104 patients with persistent AF (median AF duration 24 months) in whom SR had been achieved and maintained for at least 6 months after the final ablation procedure. Transesophageal echocardiography was performed to assess LAAFV during SR after ablation. Lower LAAFV was defined as ≤40 cm/s. Mean LAAFV before ablation was 29 ± 11 cm/s (range 10-67 cm/s). In 23 (22%) patients, LAAFV remained low even after being in SR for at least 6 months. Multiple logistic regression analysis showed that CHA2DS2-VASc scores of ≥2 (odds ratio 2.18, 95% CI 1.19-3.99, P = .012) was an independent predictor of lower LAAFV after successful ablation. Seventeen (74%) of the 23 patients with low LAAFV during SR presented CHA2DS2-VASc scores of ≥2 complicated by spontaneous echo contrast during AF. Long-term maintenance of SR after catheter ablation for persistent AF does not guarantee LAAFV recovery. The CHA2DS2-VASc score appears to predict poor recovery of LAAFV. Further studies are necessary to confirm the usefulness of LAAFV during SR as a surrogate marker predicting thromboembolism in patients after AF ablation.

Real-world management, clinical outcome and predictors of thromboembolism during a one-year follow-up in patients with atrial fibrillation: The ATA-AF study

Real-world management, clinical outcome and predictors of thromboembolism during a one-year follow-up in patients with atrial fibrillation: The ATA-AF study

Incidence of thromboembolism, major bleeding and mortality in patients with mechanical heart valves

Background: Previous studies have reported rather low incidences regarding thromboembolism (TE) and bleeding in patients with mechanical heart valves (MHV), during oral anticoagulation treatment with warfarin, despite wide treatment ranges of international normalized ratio (INR) and poor time in therapeutic range (TTR). Methods: We conducted a complete study of all 546 patients which were followed in two centres who have undergone MHV replacement, for thromboembolism (TE), major bleeding and mortality during 2008-2011. Results: In total there were 398, 122 and 26 patients in the aortic, mitral and the combined aortic/mitral valve groups respectively. The mean (±SD) age were 68 (14), 69 (15) and 66 (17) respectively. A total of 56 TEs were documented in all patients, resulting in an incidence of 2.86 per 100 patient-year. The aortic valve patients had 37 TEs (2.56 per 100 patient-year), and mitral valve patients 17 TEs (4.01 per 100 patient-year). A total of 80 major bleedings were documented (4.09 per 100 patient-year). The aortic valve group had 60 (4.16 per 100 patient-year) and the mitral 19 (4.45 per 100 patient-year). TTR (INR 2-4) in centre 1 was 91.8% and 76.4% in centre 2 (INR 2-3). By multivariate analyses, significant predictors of TE were heart failure (Odds ratio [OR]: 2,17; 95% confidence interval [CI]: 1.17-4.02; p=0.01) and vascular disease (OR: 3.22; 95% CI: 1.05-9.85; p=0.04). Predictors of bleeding were previous hemorrhage (OR: 3.1; 95% CI: 1.64-5.89; p=0.001) and age > 75 (OR: 1.7; 95% CI: 1.01-2.8; p=0.047). 75 patients died during the follow up (3.83 per 100 patient-year), resulting in a standardized mortality ratio of 3.0 (CI: 2.4-3.8; p<0.001) compared to the general population of centre 1. Conclusion: The incidence of TE, major bleeding and total mortality in this study exceed previous reports despite high TTR and give additional risk estimates for clinical decision making.

Predictors of thromboembolism during coil embolization in patients with unruptured intracranial aneurysm

To identify the incidence of thromboembolic complications based on magnetic resonance imaging (MRI) and to explore the potential risk factors for thromboembolism (TE) during the periprocedural period of elective coil embolization for unruptured intracranial aneurysms. We retrospectively reviewed all aneurysm cases treated with coil insertion between January 2008 and March 2011. Two hundred eighty-two coiling procedures for unruptured aneurysms were included in this study. The patients' demographic characteristics were documented and records reviewed for abnormalities in diffusion-weighted imaging (DWI) seen on post-procedure MRI, intraoperative thrombus formation, and clinical signs of stroke. Overall, there were 87 (30.9 %) procedure-related complications in 282 aneurysms treated: 2 (0.7 %) procedural ruptures, 5 (1.8 %) symptomatic infarctions, and 80 (28.3 %) asymptomatic infarctions. Thromboembolic events during the procedure were observed more often in the the hyperlipidemia group (32/71 aneurysms, 45.1 %) than in the normal lipid profile group (39/196 aneurysms, 25.6 %; p = 0.002; chi-squre test). The coiling technique and size of the aneurysm were also associated with TE (p < 0.001 and p = 0.004). Hyperlipidemia seems to be associated with a significant increase in the rate of thromboembolic events. In preventive procedures, modifiable risk factors should be managed to reduce complications. Although permanent deficits are rare, the high rate of thromboembolic events suggests that improvements in the technique, such as the addition of antiplatelet agents and the development of new embolic materials, are necessary.

Procedure-Related Thromboembolism in Patients Underwent Atrial Fibrillation Ablation by Using an Open Irrigated Ablation Catheter

Purpose: Cerebral thromboembolism is a serious complication related to the catheter ablation of atrial fibrillation (AF). We investigated the procedural thromboembolism in patients with AF underwent catheter ablation. Methods: A total of consecutive 174 AF patients who underwent ablation by using an open irrigated ablation catheter was included in the present study. During all procedure, activated coagulation time was maintained 300–350 seconds. Brain diffusion-weighted magnetic imaging (DWI) was performed 2 day after the procedure in all subjects. Results: Cerebral thromboembolism was revealed by the DWI in 23.0% (40/174) of patients following the procedure. All patients with thromboembolism were asymptomatic. In univariate analysis, age was significantly higher (59.4±8.9 vs. 54.8±9.6 years, P=0.009), the left atrium was larger (41.6±5.7 vs. 38.7±5.5 mm, P=0.004) and history of AF was longer (8.4±6.8 vs. 5.3±4.3 years, P=0.0008) in patients with the thromboembolism than those without. In multivariate analysis, history of AF was the only independent predictor of procedure related thromboembolism in patients with AF ablation (odds ratio: 1.13, P=0.01). Conclusion: Procedure related silent thromboembolism was observed in a quarter of patients who underwent AF ablation with an open irrigated ablation catheter. The history of AF was an independent predictor of thromboembolism during catheter ablation of AF.

Incidence of Thromboembolism in Patients Who Discontinued Warfarin within 2 Months after Atrial Fibrillation Ablation

It is not yet determined when oral anticoagulation (OAC) can be discontinued after atrial fibrillation (AF) ablation. This study was to evaluate the incidence of thromboembolism (TE) in patients who discontinued warfarin within 2 months after catheter ablation (CA) of AF. Methods: The study population consisted of 179 patients who had undergone CA. Sixty four patients discontinued OAC within 2 months after CA (Off-OAC group) and 115 remained on OAC at least more than 2 months (On-OAC group). The primary endpoint was episode of TE. Results: Compared to Off-OAC group, On-OAC group had greater number of stroke history prior to CA (n=14, 12.2% vs. n=1, 1.6%, p<0.05). Other characteristics including CHADS2 score between two groups were similar. During mean 33 months of follow-up, none in Off-OAC group but 4 (3.5%) patients of On-OAC group had TE without significance (p=0.298). Univariate analysis revealed that age, sex, AF duration, follow-up duration, stroke history and CHADS2 score were related to development of TE. On multivariate analysis, AF duration (OR 1.021, CI: 1.002–1.041, p=0.032) was the only independent predictor of TE. Conclusion: OAC after AF ablation needs to be individualized with AF duration. The incidence of TE in patients who discontinued warfarin within 2 months was not different from those who continued warfarin for longer than 2 months.

Risk of Thromboembolism in Heart Failure: An Analysis From the Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT)

Risk of Thromboembolism in Heart Failure: An Analysis From the Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT)