Rate Of Thrombotic Complications Research Articles

Perioperative Coagulation Changes in Total Pancreatectomy and Islet Autotransplantation.

Thrombotic complications after total pancreatectomy with islet autotransplantation (TPIAT) are common. However, the systemic changes to coagulation in the perioperative period have not been well studied. Our objective was to evaluate the derangements in coagulation in the perioperative period for this procedure. This was a prospective observational study of patients undergoing elective TPIAT for chronic pancreatitis. Multiple methods of evaluating coagulation, including 2 viscoelastic assays and standard laboratory assays were obtained at defined intraoperative and postoperative intervals. Fifteen patients were enrolled. Laboratory values demonstrated initial intraoperative hypercoagulability before significant systemic anticoagulation after islet infusion with heparin. Hypercoagulability is again seen at postoperative days 3 and 7. Subgroup analysis did not identify any major coagulation parameters associated with portal vein thrombosis formation. Apart from the immediate period after islet cell and heparin infusion, patients undergoing TPIAT are generally hypercoagulable leading to a high rate of thrombotic complications. Portal vein thrombosis development had minimal association with systemic derangements in coagulation as it is likely driven by localized inflammation at the time of islet cell infusion. This study may provide the groundwork for future studies to identify improvements in thrombotic complications.

ESTIMATION OF SERUM CRP,FERRITIN,D-DIMER,LACTATE DEHYDROGENASE IN COVID 19 PATIENTS

Background: Severe COVID-19 illness is associated with intense inflammation, leading to high rates of thrombotic complications that increase morbidity and mortality . New laboratory tests capable of differentiating between severe and non-severe cases and appropriate management of COVID-19. Aims and Objective: Aim to investigate the association between several biomarkers, including serum C-reactive protein (CRP), Lactate Dehydrogenase, D-dimer, and serum ferritin, and COVID-19 severity. Methodology: The study was conducted during September 2020-Dec-2021 among Covid patients confirmed by RT-PCR and admitted to Government general hospital.LDH was estimated in semi-auto analyzer by UVkinetic method and serum Ferritin, CRP, D-dimer was estimated by Immunoturbidometric method. Results: Amongst 1200 SARS-CoV-2 patients, Elevated CRP levels were seen in 88 percent of patients, D-Dimer in 94 percent of patients, Ferritin in 83 percent of patients, LDH in 93 percentof patients. Discussion: Elevated serum CRP, D-dimer, and serum ferritin levels were associated withan increased poor outcome that comprises mortality, severe COVID-19, ARDS, and the need for ICU care in patients with COVID-19.

Mid-term Surgery Outcomes in Patients With COVID-19: Results From a Nationwide Analysis.

Determine mid-term postoperative outcomes among coronavirus disease 2019 (COVID-19)-positive (+) patients compared with those who never tested positive before surgery. COVID-19 is thought to be associated with prohibitively high rates of postoperative complications. However, prior studies have only evaluated 30-day outcomes, and most did not adjust for demographic, clinical, or procedural characteristics. We analyzed data from surgeries performed at all Veterans Affairs hospitals between March 2020 and 2021. Kaplan-Meier curves compared trends in mortality and Cox proportional hazards models estimated rates of mortality and pulmonary, thrombotic, and septic postoperative complications between patients with a positive preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test [COVID (+)] and propensity score-matched COVID-negative (-) patients. Of 153,741 surgical patients, 4778 COVID (+) were matched to 14,101 COVID (-). COVID (+) status was associated with higher postoperative mortality ( P <0.0001) with a 6-month survival of 94.2% (95% confidence interval: 93.2-95.2) versus 96.0% (95% confidence interval: 95.7.0-96.4) in COVID (-). The highest mortality was in the first 30 postoperative days. Hazards for mortality and postoperative complications in COVID (+) decreased with increasing time between testing COVID (+) and date of surgery. COVID (+) patients undergoing elective surgery had similar rates of mortality, thrombotic and septic complications, but higher rates of pulmonary complications than COVID (-) patients. This is the first report of mid-term outcomes among COVID-19 patients undergoing surgery. COVID-19 is associated with decreased overall and complication-free survival primarily in the early postoperative period, delaying surgery by 5 weeks or more reduces risk of complications. Case urgency has a multiplicative effect on short-term and long-term risk of postoperative mortality and complications.

P1720: HOW TO IMPROVE THE TIME IN THERAPEUTIC RANGE (TTR) OF ANTICOAGULATED CHILDREN DURING THE COVID-19 PANDEMIC: TELECONTROL VERSUS TRADITIONAL HOSPITAL CONTROL

Background: The Covid-19 pandemic generated added difficulty in carrying out oral anticoagulation controls in children, due to limited travel to health centers for the mobility restrictions. Children there is greater difficulty in maintaining adequate coagulation times, measured in times in therapeutic range (TTR) due to the significant individual variability in anticoagulant medication that can cause thrombotic or hemorrhagic complications. We proposed carrying out controls at home telematically as an alternative to traditional hospital controls, avoiding travel during the pandemic and evaluating the safety of the results and the quality of life (QoL) Aims: To assess the efficacy of remote control in children with chronic oral anticoagulation compared to patients with hospital control based on the analysis of TTR during covid-19 pandemic as well as QoL Methods: Observational and longitudinal study comparing 2 cohorts: remote control group and hospital control group. During 2020, the patients were included in the remote control group in accordance with the usual clinical practice, keeping in hospital control those children who had to follow specific treatments in the hospital (cancer treatments). Classified the patients according INR ranges and age: 3 groups INR ranges established (1.8-2.2; 2.2-2.5 and 2.5-3) according to medical criteria and 3 age groups (0-6 yrs, 7-12 yrs, and 13-16 yrs). In January 2021, TTR data defined in both groups were collected according to Rosendaal’s methodology. Given the complexity of the TTR due to the pharmacokinetic variability of the antivitamin K drugs, which means that the specific determination in one day does not correspond to the INR values ​​that the patient will present on the days between the controls, we calculated the TTR of each patient by the fraction (number of INR in therapeutic range/total number of INR). We distributed patients into 4 groups: Group A: patients with less than 25% TTR. Group B: patients who have been between 25%-50% of TTR. Group C: patients who have been between 50%-75% of TTR. Group D:patients who have more 75% of TTR Results: 44 patients were included: 23 remotely controlled (mean age 8.4 yrs) vs. 21 hospitalized (mean age 9.1). Reasons for anticoagulation: surgery, catheters, cancer, heart disease and vasculitis. Controls outside the therapeutic range were on average higher in the hospital group (15.1 vs 3.3), maintaining these differences for all ages and INR ranges. 91% children in remote control spend more than 75% in TTR compared to 13% of the hospital group, being significant in children older than 7 years, with INR 2.2-2.5 and with catheters or heart disease. 5 children in the remote-control group with 100% of their determinations in TTR. 16 bleeding events were documented, 12 in hospital group(4 major bleedings)and 4 bleedings (all minor) in remote control. 15 thrombotic events (14 hospital control vs 1 in remote control). 81 doses of low molecular weight heparin (LMWH) and 31 doses of vitamin K (VK) were administered to hospital control children vs. 15 doses of LMWH and 6 vials VK to remote control children Summary/Conclusion: Remote control of anticoagulation in children is an effective and safe alternative to traditional hospital control, with very high TTR results. Using this type of control to avoid travel during mobility restrictions due to the covid-19 pandemic led to improved results, with fewer emergency visits related to anticoagulation, with a lower rate of bleeding or thrombotic complications, and less need for LMWH support. or VK compared with children with hospital control

Low-molecular-weight heparin compared with unfractionated heparin in critically ill COVID-19 patients

BackgroundThrombosis in COVID-19 worsens mortality. In our study, we sought to investigate how the dose and type of anticoagulation (AC) can influence patient outcomes. MethodsThis is a single-center retrospective analysis of critically ill intubated patients with COVID-19, comparing low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) at therapeutic and prophylactic doses. Of 218 patients, 135 received LMWH (70 prophylactic, 65 therapeutic) and 83 UFH (11 prophylactic, 72 therapeutic). The primary outcome was mortality. Secondary outcomes were thromboembolic complications confirmed on imaging and major bleeding complications. Cox proportional-hazards regression models were used to determine whether the type and dose of AC were independent predictors of survival. We performed Kaplan-Meier survival analysis to compare the cumulative survivals. ResultsOverall, therapeutic AC, with either LMWH (65% vs 79%, P = .09) or UFH (32% vs 46%, P = .73), conveyed no survival benefit over prophylactic AC. UFH was associated with a higher mortality rate than LMWH (66% vs 28%, P = .001), which was also evident in the multivariable analysis (LMWH vs UFH mortality, hazard ratio: 0.47, P = .001) and in the Kaplan-Meier survival analysis. Thrombotic and bleeding complications did not depend on the AC type (prophylactic LMWH vs UFH: thrombosis P = .49, bleeding P = .075; therapeutic LMWH vs UFH: thrombosis P = .5, bleeding P = .17). When comparing prophylactic with therapeutic AC, the rate of both thrombotic and bleeding complications was higher with the use of LMWH compared with UFH. In addition, transfusion requirements were significantly higher with both therapeutic LMWH and UFH. ConclusionsAmong intubated critically ill COVID-19 intensive care unit patients, therapeutic AC, with either LMWH or UFH, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with UFH.

COVID-19-related thrombotic complications experience before and during delta wave.

ObjectiveHypercoagulability and thrombotic complications seen in SARS-CoV-2 patients, as well as the associated pathophysiology, have been reported extensively. However, there is limited information regarding the factors related to this phenomenon and its association with the COVID-19 delta variant.MethodsA retrospective review including patients admitted to a tertiary center with a COVID-19 positive test and at least one acute thrombotic event confirmed by imaging between June 2020 and August 2021 was performed. We compared the rates of thrombotic events in patients with COVID-19 before and during the Delta peak. We also analyzed the association of the thrombotic complications with demographic characteristics, comorbidities, anticoagulation strategies, and prothrombotic markers while describing other complications secondary to COVID-19 infection.ResultsOut of 964 patients admitted with COVID-19 diagnosis, 26.5% (n=256) had a thrombotic event evidenced by ultrasound (US) or computerized tomography (CT) scan. Venous thromboembolism was found in 60% (n=153), arterial thrombosis in 23% (n=60), and both venous and arterial thromboses in 17% (n=17) of the study cohort. Of all patients, 94% were not vaccinated. Delta variant wave patients (DW) had thrombotic episodes in 34.7% (n=50/144) of cases compared to 25% (n=206/820) of non-Delta wave (NDW) patients, posing an estimated risk 1.36 times higher in patients infected with COVID-19 during the DW than NDW. Overall, DW subjects were significantly younger (p<0.001) with lower BMI (p=0.021) compared to NDW patients. Statistical analyses showed African American patients were more likely to have arterial thrombosis compared to the other groups when testing positive for COVID-19 (OR: 1.78 [CI: 1.04 – 3.05], p=0.035), whereas immunosuppressed patients had less risk of arterial thrombosis (OR: 0.38 [CI: 0.15 – 0.96], p=0.042). Female gender (OR: 2.15 [CI: 1.20 – 3.85]. p=0.009) and patients with active malignancy (OR: 5.99 [CI: 2.14 – 16.78]. p=0.001) had an increased risk of having multiple thrombotic events at different locations secondary to COVID-19.ConclusionCOVID-19 infection is associated with elevated rates of thrombotic complications and an especially higher risk in patients infected during the Delta variant peak. We highlight the importance of vaccination and the development of new anticoagulation strategies for COVID-19 patients with additional hypercoagulable risk factors to prevent thrombotic complications caused by this disease.

The significance of D-dimer investigation in Iraqi children with COVID-19

Background: The proportion of children affected with COVID-19 accounted for approximately 1 to 2 % of all infected cases and the disease often follows a mild to moderate disease. Increased coagulation and events that are thrombotic were repeatedly recorded in adult patients with COVID-19. Nevertheless, till now, there is no consensus about thrombotic events in children in published articles. Aim of the study: to make evaluation of d-dimer level in children with COVID-19 and the rate of thrombotic complications. Patients and methods: The present research that is of cross sectional type was carried out in Children and Maternity Teaching Hospital in Al-Diwaniyah Province, Iraq. The study included 168 children with COVDI-19 proved by positive RT-PCR results following nasopharyngeal swabs. The age ranged from one month up to 15 years and the study included 77 girls and 91 boys. Results: The current study included 168 children affected by COVID-9. The median level of d-dimer in those enrolled children was 0.3 µg/ml with a range of 0.05 to 11 µg/ml. According to a cutoff value of &gt; 0.05 µg/ml, children were categorized into 73 (43.5 %) cases as having high d-dimer level and 95 (56.5 %) as having normal d-dimer level.

Venous and arterial thromboembolism in patients with cancer treated with targeted anti-cancer therapies

Patients with cancer have an increased risk of venous- and arterial thromboembolism (VTE/ATE). Anti-cancer treatments including surgery, radiotherapy, and certain chemotherapies contribute to the increased risk of VTE and/or ATE. Over the past years, the therapeutic landscape in medical oncology has changed dramatically with the introduction of targeted anti-cancer therapies and cancer immunotherapy. These novel treatment approaches have revolutionized patient care with significant improvements in response rates and survival times of patients. These agents specifically target refined pathophysiological pathways engaged in tumour development and progression involving, among others, angiogenesis, growth factor receptor signalling and anti-tumoral immune regulation. Therefore, distinct off-target effects lead to characteristic adverse event profiles for certain treatments. For several targeted and immunotherapeutic anticancer agents, increased rates of VTE and/or ATE have been reported. For example, a prothrombotic effect has been reported for antiangiogenic agents, EGFR-targeted treatments, CDK4/6-inhibitors, and 2nd generation BCR-ABL-inhibitors. Further, very recently, data emerged on substantial rates of thrombotic complications in patients treated with immune checkpoint inhibitors. In this review, we comprehensively summarize currently available evidence on risk profiles and potential mechanisms of thrombosis in patients with cancer treated with targeted anti-cancer therapies, and discuss current limitations in available data and potential future perspectives.

Chronic Subdural Hematoma.

Chronic subdural hematoma (cSDH) is typically a disease that affects the elderly. Neurosurgical evacuation is generally indicated for hematomas that are wider than the thickness of the skull. The available guidelines do not address the common clinical issue of the proper management of antithrombotic drugs that the patient has been taking up to the time of diagnosis of the cSDH. Whether antithrombotic treatment should be stopped or continued depends on whether the concern about spontaneous or postoperative intracranial bleeding, and a presumably higher rate of progression or recurrence, with continued medication outweighs the concern about a possibly higher rate of thrombotic complications if it is stopped. In this article, we review publications from January 2015 to October 2020 addressing the issue of the management of antithrombotics in patients with cSDH that were retrieved by a selective search in the Pubmed and EMBASE databases, and we present the findings of a cohort study of 395 patients who underwent surgery for cSDH consecutively between October 2014 and December 2019. The findings published in the literature are difficult to summarize concisely because of the heterogeneity of study designs. Among the seven studies in which a group of patients on antithrombotics was compared with a control group, four revealed significant differences with respect to the risk of thromboembolic complications depending on previous antithrombotic use and the duration of discontinuation, while three others did not. In our own cohort, discontinuation of antithrombotics (including both plasmatic and antiplatelet drugs) was associated with thrombotic complications in 9.1% of patients. These findings imply that the management of antithrombotics should be dealt with critically on an individual basis. In patients with cSDH who are at elevated risk, an early restart of antithrombotic treatment or even an operation under continued antithrombotic therapy should be considered.

Comparison of Solitaire and Neuroform Stenting for Coiling of Intracranial Bifurcation Aneurysms.

To compare the technical performance and outcomes of Solitaire and Neuroform stents for treatment of intracranial bifurcation aneurysms (IBAs). IBAs treated by stent-assisted coiling using a Solitaire or Neuroform stent between October 2010 and December 2019 were retrospectively evaluated. Patient demographics, aneurysm information, treatment technique, periprocedural and device-related complications, parent artery angle change, along with initial and follow-up angiographic results were analyzed. One hundred twenty-one patients with 121 IBAs treated with Solitaire (n = 101) or Neuroform (n = 20) stent-assisted coiling were included. Aneurysm size, thrombotic and hemorrhagic complication rate, initial occlusion rate and in-stent stenosis between the two cohorts were not significantly different. Aneurysm location was significantly different between the two groups (p = 0.032). Jailing technique rate for coiling was significantly higher in the Solitaire than the Neuroform group (70.3% vs. 35.0%, p < 0.01). Follow-up DSA demonstrated a significantly lower recurrence rate for the Solitaire cohort (2.9% vs. 22.2%, p = 0.016). Parent artery angle changes, immediately post-operative and on follow-up were significantly greater in the Solitaire stent group (p < 0.05). For intracranial bifurcation aneurysms, Solitaire stent-assisted coiling achieved a significantly lower recurrence rate and induced more favorable parent artery angular remodeling than Neuroform stenting.

Use of Systemic Anticoagulation in COVID-19: Delving Beyond Theoretical Hypothesis.

BackgroundStudies suggest that COVID-19 infection may induce increased hypercoagulability, leading to thrombotic complications. The high rates of thrombotic complications among patients receiving standard-dose deep venous thrombosis (DVT) prophylaxis have prompted some clinicians to support the empiric increase of anticoagulation (AC) doses used for prophylaxis in patients with COVID-19. At present, the optimal anticoagulant agents, dosages, and duration have not been designated. We conducted a retrospective study to assess for outcomes in patients who received treatment for COVID-19 based on various dosings of AC.MethodsThis was a single-institution, retrospective cross-sectional study including patients with a positive COVID-19 test who were admitted within the St. Joseph’s Health Network from September to November of 2020. The inclusion criteria were men and women aged 18 years or older who had confirmed COVID-19 by polymerase chain reaction (PCR). Medical charts of patients who met the inclusion criteria were audited to obtain information. The patients were separated into three cohorts: those who received DVT prophylactic dose of AC, those who received an intermediate dose of AC, and those who received therapeutic AC.ResultsA total of 440 patients were included in the study, of whom 236 were Hispanic (50.3%), 131 were Caucasian (27.1%), 47 were African American (10.7%), and 26 were Asian (5.9%). The most common comorbidities were hypertension (273/440 [62.2%]), diabetes 189/440 [43.1%]), and coronary artery disease (60/440 [13.7%]). In the DVT prophylactic dose of AC cohort, there were 215 patients, and the average length of stay was 10.3 days. Eleven patients experienced bleeding events, five patients experienced thrombotic events, 16 patients required mechanical ventilation, and 20 patients died. In the intermediate dose of AC cohort, there were 63 patients, and the average length of stay was 10.3 days. Three patients experienced bleeding events, two patients experienced thrombotic events, seven patients required mechanical invasive ventilation, and 11 patients died. In the therapeutic dose of AC cohort, there were 162 patients, and the average length of stay was 14 days. In this cohort, 19 patients experienced bleeding events, 12 patients experienced thrombotic events, 26 patients required invasive mechanical ventilation, and 29 patients died. Patients who received intermediate dosing of AC also had the lowest risk of thrombotic events (0.05). Patients who received intermediate dosing of AC had the lowest rates of requiring both high-flow nasal cannula (p = 0.0001) and invasive mechanical ventilation (p = 0.031). Patients who received intermediate dosing of AC had a lower rate of bleeding compared to those who received the DVT prophylaxis dose and systemic AC dose (p = 0.037). The DVT prophylactic and intermediate dosing of AC groups had a shorter length of stay in comparison to the systemic AC group (p = 0.0002).ConclusionIn comparison to the venous thromboembolism prophylaxis dose and systemic AC dose groups, intermediate dosing of AC had the lowest rates of hemorrhage, mortality, length of stay, and requirement of high-flow nasal cannula or mechanical invasive ventilation. In the systemic dose AC group, there were worse clinical outcomes in terms of length of stay, incidence of bleeding events, requirement of mechanical ventilator use, and rate of mortality.

RBC Transfusion in Venovenous Extracorporeal Membrane Oxygenation: A Multicenter Cohort Study.

In the general critical care patient population, restrictive transfusion regimen of RBCs has been shown to be safe and is yet implemented worldwide. However, in patients on venovenous extracorporeal membrane oxygenation, guidelines suggest liberal thresholds, and a clear overview of RBC transfusion practice is lacking. This study aims to create an overview of RBC transfusion in venovenous extracorporeal membrane oxygenation. Mixed method approach combining multicenter retrospective study and survey. Sixteen ICUs worldwide. Patients receiving venovenous extracorporeal membrane oxygenation between January 2018 and July 2019. None. The primary outcome was the proportion receiving RBC, the amount of RBC units given daily and in total. Furthermore, the course of hemoglobin over time during extracorporeal membrane oxygenation was assessed. Demographics, extracorporeal membrane oxygenation characteristics, and patient outcome were collected. Two-hundred eight patients received venovenous extracorporeal membrane oxygenation, 63% male, with an age of 55 years (45-62 yr), mainly for acute respiratory distress syndrome. Extracorporeal membrane oxygenation duration was 9 days (5-14 d). Prior to extracorporeal membrane oxygenation, hemoglobin was 10.8 g/dL (8.9-13.0 g/dL), decreasing to 8.7 g/dL (7.7-9.8 g/dL) during extracorporeal membrane oxygenation. Nadir hemoglobin was lower on days when a transfusion was administered (8.1 g/dL [7.4-9.3 g/dL]). A vast majority of 88% patients received greater than or equal to 1 RBC transfusion, consisting of 1.6 U (1.3-2.3 U) on transfusion days. This high transfusion occurrence rate was also found in nonbleeding patients (81%). Patients with a liberal transfusion threshold (hemoglobin > 9 g/dL) received more RBC in total per transfusion day and extracorporeal membrane oxygenation day. No differences in survival, hemorrhagic and thrombotic complication rates were found between different transfusion thresholds. Also, 28-day mortality was equal in transfused and nontransfused patients. Transfusion of RBC has a high occurrence rate in patients on venovenous extracorporeal membrane oxygenation, even in nonbleeding patients. There is a need for future studies to find optimal transfusion thresholds and triggers in patients on extracorporeal membrane oxygenation.

Stroke epidemiology and outcomes in the modern era of left ventricular assist devices.

The care for the patients with end-stage heart failure has been revolutionized by the introduction of durable left ventricular assist devices, providing a substantial improvement in patient survival and quality of life and an alternative to heart transplantation. The newest devices have lower instances of mechanical dysfunction and associated pump thrombosis. Despite these improvements in complications, the use of continuous flow assist devices is still associated with high rates of thrombotic and hemorrhagic complications, most notably stroke in approximately 10% of continuous flow assist devices patients per year. With the newest HeartMate 3 devices, there have been lower observed rates of stroke, which has in part been achieved by both improvements in pump technology and knowledge of the risk factors for stroke and neurological complications. The therapeutic options available to clinicians to reduce the risk of stroke, including management of hypertension and antithrombotics, will be reviewed in this manuscript.

Anticoagulants after Discharge in Patients with COVID-19: What we Know at the End of 2021

This review discusses reasons for prolonged use of anticoagulants after discharge of patients with COVID-19 without additional indication for anticoagulation. Data regarding rate of thrombotic and thromboembolic complications in patients with COVID-19 after discharge from the hospital are presented. Large randomized controlled trials EXCLAIM, ADOPT, MAGELLAN, APEX and MARINER with prolonged use of anticoagulants in patients hospitalized with acute nonsurgical diseases before pandemia of COVID-19 are discussed. The first prospective randomized controlled trial MICHELLE with direct oral anticoagulant rivaroxaban in a dose 10 mg once daily after discharge of patients with COVID-19 with high risk at least venous thromboembolism are analyzed. It seems that the most relevant approach for the determination of indications for prolonged use of anticoagulants in doses dedicated for primary prevention of venous thromboembolism after discharge of patients with COVID-19 without apparent indication for anticoagulation is a modified IMPROVE VTE risk score with the addition of elevated in-hospital D-dimer level. And the most well-studied approach for anticoagulation in these patients is a direct peroral anticoagulant rivaroxaban 10 mg once daily for 35 (and possibly up to 45) days after discharge.

Pre-operative and post-operative atrial fibrillation in patients undergoing SAVR/TAVR

Atrial fibrillation (AF) is a common preoperative comorbidity and post-operative complication associated with cardiac surgery and is recognized as a significant predictor of adverse clinical outcomes. This review aims to highlight the current literature regarding the incidence, risk factors, and outcomes of atrial fibrillation in patients undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) procedures. A literature search of relevant articles was conducted via PubMed, Medline, and EMBASE. Pre-existing AF is seen in 6.3%-35.2% of SAVR patients and 15.7%-48.9% of TAVR patients and is associated with increased risk of mortality (OR = 2.2) and stroke (OR = 5.9). Postoperative AF (POAF) is more common after SAVR and in patients with hemodynamic instability. The rates for POAF range from 11.1%-84% following SAVR and range from 3.0%-55.6% following TAVR. In-hospital mortality (7.8% vs. 3.4%; P &lt; 0.01) and stroke (4.7% vs. 2.0%; P &lt; 0.01) are higher in the POAF group. POAF can be prevented via prophylactic antiarrhythmic medications and atrial pacing. Therapeutic anticoagulation is recommended as it reduces the risk of thrombotic complications following SAVR and TAVR procedures in the setting of POAF. Compared to those not on anticoagulant therapies, patients on anticoagulation have decreased rates of stroke (1.7% vs. 5.5%) and fewer 30-day thrombotic complications (3% vs. 40%). These preventive measures are essential as POAF is associated with more thromboembolic events, longer hospital stays, and higher overall morbidity and mortality rates.

Перспективы применения цилостазола в комплексном лечение больных облитерирующим атеросклерозом артерий нижних конечностей

Despite intensive study of pathophysiology, of molecular and cell mechanisms of progression of atherosclerosis, development and introduction of a wide range of new conservative and surgical treatment methods, until now the diseases of lower limb arteries (DLLA) are one of the most urgent problems of the modern vascular surgery and medicine in general. Intensive development of roentgen-endovascular methods of treatment for the diseases of lower limb arteries has led to a considerable revision of the tactics of management of this category of patients in the recent years. Despite the achievements of roentgen-endovascular surgery, frequency of obstructions after surgical revascularization of limbs remains high, both in early and late postoperative periods. It should also be noted that despite the intensive development of methods of therapy of patients with DLLA, frequency of limbs amputation in this category of patients remains high. One of the urgent problems of management of patients with DLLA after endovascular treatment is the problem of restenosis. In the recent years, new efficient methods of pharmacotherapy of DLLA have been developed and introduced into clinical practice, which allows significant improvement of medical prognosis in this category of patients and improvement of the outcomes. It should be noted that standard approaches to antithrombotic therapy in patients after endovascular surgeries based on use of antiaggregant drugs, can only decrease the rate of thrombotic complications, but not of restenosis, which, from the point of view of pathophysiology, is mainly hyperproliferative condition. Among promising approaches to treatment of restenosis, there is use of cilostazol, efficiency of which after endovascular surgeries on coronary and peripheral arteries has been proven in a number of studies.

Placement and management of Peripherally Inserted Central Catheters (PICC): Which complications? A retrospective 2-year single-centre experience

Introduction: Peripherally inserted central catheters (PICCs) are catheters placed in the central venous system, through a peripheral vein. PICCs’ are devices designed for intermediate to long-term use, which are usually implanted for long periods and may be subjected to mechanical and infectious complications as well as thrombosis and acute bleeding during insertion or maintenance procedures. The aim of this study is to investigate and describe the various types of complications resulting from placement and management of PICC catheters in patients admitted to the SS Antonio e Biagio e Cesare Arrigo Hospital wards. Methods: Data was collected from the medical records of patients undergoing PICC implantation from June 2018 to December 2019.Results: Data from 320 patients were included in the study. 55% of patients did not develop complications. 34% of all patients with complications had minor complications and 86% of devices were not removed before the end of treatment.Conclusions: PICCs’ appear to be safe devices for use, with acceptably low rates of infectious or thrombotic complications. The most common complications have been minor causes, potentially avoidable with adequate prevention measures.

Outcomes after extracorporeal membrane oxygenation support in COVID-19 and non-COVID-19 patients.

BackgroundVeno‐venous extracorporeal membrane oxygenation (V‐V ECMO) support is increasingly used in the management of COVID‐19‐related acute respiratory distress syndrome (ARDS). However, the clinical decision‐making to initiate V‐V ECMO for severe COVID‐19 still remains unclear. In order to determine the optimal timing and patient selection, we investigated the outcomes of both COVID‐19 and non‐COVID‐19 patients undergoing V‐V ECMO support.MethodsOverall, 138 patients were included in this study. Patients were stratified into two cohorts: those with COVID‐19 and non‐COVID‐19 ARDS.ResultsThe survival in patients with COVID‐19 was statistically similar to non‐COVID‐19 patients (p = .16). However, the COVID‐19 group demonstrated higher rates of bleeding (p = .03) and thrombotic complications (p < .001). The duration of V‐V ECMO support was longer in COVID‐19 patients compared to non‐COVID‐19 patients (29.0 ± 27.5 vs 15.9 ± 19.6 days, p < .01). Most notably, in contrast to the non‐COVID‐19 group, we found that COVID‐19 patients who had been on a ventilator for longer than 7 days prior to ECMO had 100% mortality without a lung transplant.ConclusionsThese findings suggest that COVID‐19‐associated ARDS was not associated with a higher post‐ECMO mortality than non‐COVID‐19‐associated ARDS patients, despite longer duration of extracorporeal support. Early initiation of V‐V ECMO is important for improved ECMO outcomes in COVID‐19 ARDS patients. Since late initiation of ECMO was associated with extremely high mortality related to lack of pulmonary recovery, it should be used judiciously or as a bridge to lung transplantation.

Association of prehospital antiplatelet therapy with survival in patients hospitalized with COVID‐19: A propensity score‐matched analysis

PurposeCoronavirus disease 2019 (COVID‐19) is associated with hypercoagulability and increased thrombotic risk. The impact of prehospital antiplatelet therapy on in‐hospital mortality is uncertain. MethodsThis was an observational cohort study of 34 675 patients ≥50 years old from 90 health systems in the United States. Patients were hospitalized with laboratory‐confirmed COVID‐19 between February 2020 and September 2020. For all patients, the propensity to receive prehospital antiplatelet therapy was calculated using demographics and comorbidities. Patients were matched based on propensity scores, and in‐hospital mortality was compared between the antiplatelet and non‐antiplatelet groups. ResultsThe propensity score‐matched cohort of 17 347 patients comprised of 6781 and 10 566 patients in the antiplatelet and non‐antiplatelet therapy groups, respectively. In‐hospital mortality was significantly lower in patients receiving prehospital antiplatelet therapy (18.9% vs. 21.5%, p < .001), resulting in a 2.6% absolute reduction in mortality (HR: 0.81, 95% CI: 0.76–0.87, p < .005). On average, 39 patients needed to be treated to prevent one in‐hospital death. In the antiplatelet therapy group, there was a significantly lower rate of pulmonary embolism (2.2% vs. 3.0%, p = .002) and higher rate of epistaxis (0.9% vs. 0.4%, p < .001). There was no difference in the rate of other hemorrhagic or thrombotic complications. ConclusionsIn the largest observational study to date of prehospital antiplatelet therapy in patients with COVID‐19, there was an association with significantly lower in‐hospital mortality. Randomized controlled trials in diverse patient populations with high rates of baseline comorbidities are needed to determine the ultimate utility of antiplatelet therapy in COVID‐19.

Therapeutic Plasma Exchange is Safe and Efficacious in Normalizing Increased Plasma Viscosity Associated with COVID-19

BackgroundCOVID-19 associated hyperviscosity is a potential driver for the increased rates of thrombotic complications and multi-organ failure associated with severe COVID-19. Limited experience suggests a promising role for Therapeutic Plasma Exchange (TPE) in COVID-19 management based on the hypothesis that clinical benefit is derived from reduction in plasma viscosity. However, systematic study evaluating the safety and efficacy of TPE in these patients has not been done.ObjectiveTo evaluate the safety and efficacy of TPE in a subset of critically ill patients with COVID-19 and elevated blood viscosity in a randomized controlled trial (RCT).Study Design and MethodsThis study was conducted in the intensive care units (ICUs) of 3 hospitals in our health system, with a limited initial enrollment target of 20 patients. Participants included adult COVID-19 patients with moderate elevation in plasma viscosity (2.3-3.5 centipoise) or significant hyperfibrinogenemia (>800 mg/dL) that were not improving despite standard supportive care. Patients with bacterial or fungal coinfection or moribund patients were specifically excluded. Upon enrollment, patients were randomized 1:1 to the treatment group (1 plasma volume TPE with frozen plasma (FP) replacement on 2 consecutive days) or control group (continued standard of care (SOC)). Primary measures included the safety/tolerability of TPE and change in plasma viscosity levels after TPE versus SOC. Secondary measures included evaluation of various clinical and laboratory parameters, including fibrinogen and other coagulation-related markers, mortality, bleeding and thromboembolic complications, ICU length of stay and time to discharge after enrollment.ResultsPreliminary analysis of collected data demonstrates that TPE is safe and well-tolerated in these patients, with adverse events limited to one mild occurrence of tachycardia that improved upon decreasing the flow rate. There was significant decrease in plasma viscosity in the TPE treatment group, compared to the SOC control group. Secondary measures of select laboratory parameters also show a significant decrease in fibrinogen, von Willebrand factor (vWF), Factor VIII, and erythrocyte sedimentation rate in the TPE treatment group. No significant differences were seen in levels of fibrin monomer, total IgG, total IgM, total protein, or total albumin between the two groups. Data collection and analysis for clinical parameters are ongoing. Conclusions and RelevanceHere we report preliminary results suggesting that TPE is safe and effective for normalizing plasma viscosity in critically ill COVID-19 patients. Concomitant removal of large plasma proteins (fibrinogen, vWF) hints at their role in driving the increased viscosity associated with severe disease, which may contribute to clotting and end-organ damage in COVID-19. Based on lack of change in total IgG/IgM levels, TPE is not anticipated to hinder the patient’s humoral immunity by removing existing anti-SARS-CoV-2 specific antibodies. These results warrant further studies on the utility of TPE to mitigate critical illness in COVID-19 patients.