Reversal Of Anticoagulation Therapy Research Articles

Reversal and Resumption of Anti-Thrombotic Therapy in VAD-Related Hemorrhage

PurposeStrict antiplatelet and anticoagulation management is essential for the acceptable long-term outcome after LVAD implantation. However, bleeding complications may often require an interruption of antithrombotic therapy. The ideal protocol of reversal and resumption of the therapy has not been established yet. The aim of this study was to assess the management of antithrombotic therapy for VAD-related hemorrhage in our institute.MethodsOf the 60 VAD patients from March 2011 to May 2020, 27 patients who have received the reversal and resumption of antithrombotic therapy for bleeding complications were enrolled in this study. The bleeding events leading to interrupt antithrombotic therapy were categorized into three groups: 1) intracranial hemorrhage requiring cranial surgery, 2) intracranial hemorrhage not requiring cranial surgery, 3) other hemorrhages. We retrospectively analyzed the process of reverse and resume antithrombotic therapy, changes in coagulation status, and interruption period.Results43 bleeding complications (25 intracranial hemorrhages, 9 gastrointestinal bleeding, 4 intrathoracic bleeding, 5 other bleedings) were recorded in this study. Reversal or interruption of antithrombotic therapy, PT-INR data before and after the event, and interruption period in each group were shown in the table. The level of PT-INR after the reversal of anticoagulation therapy was significantly different in the severity of bleeding. There were no thromboembolism events relating to reversal and interruption, as well as de novo bleeding after the resumption.ConclusionThis result suggested that proper evaluation and classification of hemorrhage events may contribute to the appropriate reversal or interruption of antithrombotic therapy for VAD-related hemorrhage. Strict antiplatelet and anticoagulation management is essential for the acceptable long-term outcome after LVAD implantation. However, bleeding complications may often require an interruption of antithrombotic therapy. The ideal protocol of reversal and resumption of the therapy has not been established yet. The aim of this study was to assess the management of antithrombotic therapy for VAD-related hemorrhage in our institute. Of the 60 VAD patients from March 2011 to May 2020, 27 patients who have received the reversal and resumption of antithrombotic therapy for bleeding complications were enrolled in this study. The bleeding events leading to interrupt antithrombotic therapy were categorized into three groups: 1) intracranial hemorrhage requiring cranial surgery, 2) intracranial hemorrhage not requiring cranial surgery, 3) other hemorrhages. We retrospectively analyzed the process of reverse and resume antithrombotic therapy, changes in coagulation status, and interruption period. 43 bleeding complications (25 intracranial hemorrhages, 9 gastrointestinal bleeding, 4 intrathoracic bleeding, 5 other bleedings) were recorded in this study. Reversal or interruption of antithrombotic therapy, PT-INR data before and after the event, and interruption period in each group were shown in the table. The level of PT-INR after the reversal of anticoagulation therapy was significantly different in the severity of bleeding. There were no thromboembolism events relating to reversal and interruption, as well as de novo bleeding after the resumption. This result suggested that proper evaluation and classification of hemorrhage events may contribute to the appropriate reversal or interruption of antithrombotic therapy for VAD-related hemorrhage.

Five-week use of a monopivot centrifugal blood pump as a right ventricular assist device in severe dilated cardiomyopathy

Right heart failure is a critical complication in patients requiring mechanical ventricular support. However, it is often difficult to provide adequate right ventricular support in the acute phase. A 41-year-old woman diagnosed with dilated cardiomyopathy with severe right heart failure underwent implantation of a paracorporeal pulsatile left ventricular assist device (LVAD, Nipro Corporation, Tokyo, Japan) and a MERA monopivot centrifugal pump (Senko Medical Instrument Manufacturing Co., Ltd., Tokyo, Japan) as a right ventricular assist device (RVAD). The patient developed ischemic enteritis 3 weeks after surgery, necessitating fasting and reversal of anticoagulation therapy. A target international normalized ratio of 1.5 was selected, and aspirin administration was discontinued. Following recovery without thromboembolic events, the patient failed the RVAD discontinuation test. Five weeks after surgery, the monopivot centrifugal pump was exchanged for a pulsatile pump. No thrombus was evident on the centrifugal pump. The patient was undergoing cardiac rehabilitation at the time of this writing and awaiting heart transplantation.

Massive sublingual hematoma secondary to anticoagulant therapy complicated by a traumatic denture: a case report

IntroductionSublingual hematoma secondary to excessive anticoagulation is a rare but potentially fatal condition, and few cases have been documented in the literature.Case presentationWe report the case of a 73-year-old Caucasian woman who attended our Accident and Emergency department with massive sublingual hematoma causing superior displacement of the tongue. The condition was found to be the result of an elevated international normalized ratio, further complicated by a traumatic mandibular denture.ConclusionsIn summary, we recommend the immediate reversal of anticoagulation therapy on admission of patients with severe sublingual hematoma. We further advise surgical decompression/drainage if required and to continue meticulous monitoring. In all cases of early recognition of sublingual hematoma, prompt medical treatment and continuous clinical monitoring is essential, and may prevent the need for a surgical airway procedure.

Rectus Sheath Haematoma: A Rare Cause of Abdominal Pain

Objective Rectus sheath haematoma (RSH) is a rare entity described as accumulation of blood within the rectus muscle. Patients can present with varying symptoms and signs, mimicking acute abdominal conditions. Failure to diagnose can result in unnecessary diagnostic procedures and surgical interventions. Methods We presented a series of 14 cases of RSH presenting to two emergency departments (ED) within a period of 3 years. Their demographic characteristics, medical history, presenting signs, symptoms and treatment were analyzed. Results Fourteen cases were diagnosed RSH. Seven cases were on warfarin treatment. Three RSH cases were diagnosed by ultrasonography (USG) only while the remainders had additional computed tomography (CT). Two cases had surgery due to haemoperitoneum, and the rest were treated conservatively with bed rest, analgesics and reversal of anticoagulation therapy. All patients were discharged from hospitals. Conclusions RSH is an important entity which must be considered in patients with known risk factors presenting to ED with abdominal pain. In elderly patients with a history of cough, anticoagulant use with palpable mass on abdominal wall, RSH must be considered as a possible diagnosis for unexplained abdominal pain. USG, together with CT in selected cases, should be performed to reveal this rare disease entity.

Les ruptures anévrismales intracrâniennes per-embolisation

The purpose of this study is to determinate the frequency, causes, management and outcome of aneurysmal rupture occurring during embolization. We present our experience with this severe and feared complication. We retrospectively reviewed 314 acute cerebral aneurysms that were treated with endovascular coiling. These patients were identified and the management and outcomes were recorded. The literature was reviewed. Six patients had an intraprocedural aneurysmal rupture. This complication occurred sporadically. Prevalence was 1.9%. Of these six, four were women and two were men. The mean age was 68 years (range: 43-74 years). Four aneurysms were located in the anterior circulation and two in the posterior circulation. Perforation occurred during microcatheterization of the aneurysm in one case and during coil deposition in five cases. In these five patients, aneurysmal rupture resulted from detachment of the first coil in three patients and detachment of the third and last coil in two patients. Hemodynamic changes were noted for one patient. The Glasgow Outcome Scale score at last follow-up examination was 1 in three patients and 3 in one patient (fair recovery). Mortality was 33% and morbidity was 16.7%. Aneurysmal perforation during embolization is a rare event (1.8 to 4.4%). When perforation is recognized, embolization can be completed immediately with further coil deposition and reversal of anticoagulation therapy.

Outcomes after aneurysm rupture during endovascular coil embolization.

Intracranial aneurysm rupture during placement of Guglielmi detachable coils has been reported, but the management and consequences of this event have not been extensively described. We present our experience with this feared complication and report possible neuroradiological and neurosurgical interventions to improve outcomes. We retrospectively reviewed the records for 701 patients with 734 intracranial aneurysms that were treated with endovascular coiling, during a 6-year period, in the metropolitan Minneapolis-St. Paul (Minnesota) area. This analysis revealed 10 cases of perforation during coiling. The management and outcomes were recorded, and the pertinent literature was reviewed. All 10 cases involved previously ruptured aneurysms. This complication occurred sporadically and was not observed in the first 100 cases. Perforation occurred during microcatheterization of the aneurysm in two cases and during coil deposition in eight cases. Seven of the perforated aneurysms were located in the anterior circulation and three in the posterior circulation. Six of the 10 patients made good or fair recoveries; all three patients with posterior circulation lesions died immediately after rehemorrhage. Elevated intracranial pressure (ICP) was noted for all five patients with intraventricular catheters in place. Bilateral pupil dilation and profound hemodynamic changes were noted for eight patients. Coiling was rapidly completed, and total or nearly total occlusion was achieved in all cases. Emergency ventriculostomy was performed to rapidly reduce increased ICP for two patients, both of whom made good recoveries. Hemodynamic and angiographic factors after perforation, such as prolonged systemic hypertension, persistent dye extravasation after deployment of the first Guglielmi detachable coil, and persistent prolongation of contrast dye transit time (suggesting ongoing ICP elevation), were correlated with poor outcomes. Previously ruptured aneurysms seem to be more susceptible to endovascular treatment-related perforation than are unruptured lesions. Worse prognoses are associated with iatrogenic rupture during coiling of posterior circulation lesions, compared with those in the anterior circulation. When perforation is recognized, the definitive treatment seems to be reversal of anticoagulation therapy and completion of Guglielmi detachable coil embolization. Immediate neurosurgical intervention is limited in these cases and focuses on decreasing ICP via emergency ventriculostomy. However, these measures may be life-saving, and neurosurgical assistance must be readily available during treatment of these cases.

The dilemma of discontinuation of anticoagulation therapy for patients with intracranial hemorrhage and mechanical heart valves.

Anticoagulant-related hemorrhage occurs with an incidence of approximately 1%/patient-year in mechanical heart valve recipients. Intracranial hemorrhage poses a difficult clinical choice; continuing anticoagulation therapy may enlarge the volume of the hemorrhage, early reinstitution of anticoagulation therapy may predispose patients to recurrence, and reversal of anticoagulation therapy may place patients at risk for systemic embolization involving the brain. The risk of embolization may also be greater for patients with atrial fibrillation, cage-ball valves in the mitral position, and reduced ventricular function. This dilemma exists because of a lack of data for a large series of patients. We reviewed the medical records and neuroimaging studies for a consecutive group of patients admitted with intracranial hemorrhage and mechanical heart valves. We reviewed neurological presenting data, cardiac risk factors for systemic embolization (atrial fibrillation, enlarged atrial chambers, reduced ventricular function, and the type and location of the metallic valve), and hospital management. We studied 39 patients with intracranial hemorrhage and mechanical heart valves (median age, 69 yr). Four patients had experienced previous transient ischemic attacks or minor strokes. The time from valve replacement to intracranial hemorrhage ranged from 2 months to 19 years (median, 6 yr). The type of intracranial hemorrhage was acute subdural hematoma (n = 20), lobar hematoma (n = 10), subarachnoid hemorrhage (n = 4), cerebellar hematoma (n = 3), or basal ganglionic hematoma (n = 2). Thirteen patients died within 2 days of admission. All 26 surviving patients received fresh frozen plasma and vitamin K. Fifteen patients underwent evacuation of acute subdural hematoma, and in one patient an anterior communicating aneurysm was clipped. The duration of discontinuation of anticoagulation therapy varied from 2 days to 3 months (median, 8 d). None of the patients developed transient ischemic attacks, ischemic strokes, valve thrombosis, or systemic embolization. No recurrence of intracranial hemorrhaging was observed during hospitalization and reinstitution of anticoagulation or antiplatelet agent administration. Temporary interruption of anticoagulation therapy seems safe for patients with intracranial hemorrhage and mechanical heart valves but without previous evidence of systemic embolization. For most patients, discontinuation for 1 to 2 weeks should be sufficient to observe the evolution of a parenchymal hematoma, to clip or coil a ruptured aneurysm, or to evacuate an acute subdural hematoma.