Thromboembolic Episodes Research Articles

Antithrombotic therapy and bleeding events after aortic valve replacement with a novel bioprosthesis

ObjectiveSeveral recent-generation surgical tissue valves have been found to have bleeding rates exceeding rates recommended by regulatory bodies. We explored bleeding events using data from the Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial for the Avalus valve (Medtronic, Minneapolis, Minn) to examine whether this end point remains relevant for the evaluation of bioprostheses. MethodsPatients (n = 1115) underwent aortic valve replacement. Bleeding and thromboembolic event episodes in patients within 3 years postimplant were analyzed for frequency, timing, and severity, focusing on patients taking antiplatelet/anticoagulant medications at the time of the event. Clinical and hemodynamic outcomes are also reported. ResultsAt 3 years, the Kaplan-Meier cumulative probability estimate of all-cause death was 7.2% (cardiac, 3.6%; valve-related, 1.1%). The Kaplan-Meier cumulative probability estimates of all and major hemorrhage were 8.7% and 5.2%, respectively. Ninety-nine bleeding events occurred in 86 patients: most occurred >30 days postsurgery. Among the 51 late major bleeds, in 5 cases the patients were taking anticoagulant/antiplatelet medication for prophylaxis after surgical aortic valve replacement at the time of the event, whereas the remaining patients were taking medications for other reasons. Age (hazard ratio, 1.035; 95% confidence interval, 1.004-1.068), peripheral vascular disease (hazard ratio, 2.135; 95% confidence interval, 1.106-4.122), renal dysfunction (hazard ratio, 1.920; 95% confidence interval, 1.055-3.494), and antithrombotic medication use at the time of the event (hazard ratio, 1.417; 95% confidence interval, 1.048-1.915) were associated with late bleeds (major and minor). ConclusionsOverall clinical outcomes demonstrated low mortality and few complications except for major bleeding. Most bleeding events occurred >30 days after surgery and in patients taking antiplatelet and/or anticoagulation for indications other than postimplant prophylaxis.

ANMCO statement: Arterial and venous thromboembolism: what implications for clinical practice?

Acute myocardial infarction, stroke, peripheral arterial disease and pulmonary embolism share thrombosis as a common mechanism. Some well-known risk factors for arterial thromboembolism are recognized as "weak risk factors" of venous one, too. Arterial and venous thrombosis share also some pathophysiological mechanisms, including inflammation, endothelial damage, and hypercoagulability. It is likely, thus, that any disease related to arterial and venous thrombosis belong to the same "pan-vascular syndrome", that constitutes itself a chronic, recurrent inflammatory disease. According to the available data, there are elements for implementing an omni-comprehensive cardiovascular evaluation after an episode of venous thromboembolism, requiring the investigations, in addition to the known unrecognized prothrombotic conditions, also of indirect signs and risk factors for a possible arterial thromboembolic event. Large, prospective studies are needed to establish the more appropriate therapeutic strategies in this context.The aim of the present statement is to make aware all the physicians involved in the management of arterial and venous diseases and to provide some tools for evaluating the implications of related major risk factors. Thus, it could be possible to lay the foundation for a reduction of total cardiovascular risk, in terms of primary and secondary prevention of arterial and venous thromboembolism.

PCV57 STUDY ON THE ATTRIBUTABLE COSTS OF VENOUS THROMBOEMBOLISM AND BLEEDINGS IN DENMARK. COMPARISON OF THE DIFFERENCE-IN-DIFFERENCE AND THE DIFFERENCE-IN-ACTUAL-COSTS METHODS

To estimate the event costs of venous thromboembolism (VTE) episodes in Denmark, and the event costs of VTE-patients having major bleedings (intracranial, gastrointestinal and other). Two approaches to estimate the attributable costs were compared: the difference-in-difference (DiD) method and the difference-in-actual-costs (DiAC) method. The study was designed as a retrospective study utilizing the Danish national registries. All Danish incident patients (2004-2016) with VTE (deep vein thrombosis; ICD-10: DI801-DI803 or pulmonary embolisms; ICD-10: DI26) were compared with four controls without VTE. Furthermore, VTE patients with a major bleeding event within three years after diagnosis were compared with four non-bleeding VTE controls (all controls were propensity matched). Event costs included primary care, outpatient, admission, prescription medicine, home care, and lost production. The DiD-method calculates attributable costs by adjusting patients’ level of costs before the incidence and the general level and development in costs by deducting the average total costs of the controls. The DiAC method only adjusts for the level and development in costs by deducting the average total costs of control. 74,137 VTE patients (average 63 years), of which 4,887 had major bleeding, were included. The societal event costs of VTE the first incident year were €12,915 using the DiD-method and €22,128 using the DiAC method. For major bleedings the first year event costs were €9,376 (DiD) and €24,423 (DiAC). Similar picture is seen in year 2 and 3, although at a lower level. Given the age of the VTE-patients lost production explained a major part of the annual event costs. Except for medicines, all costs were significantly higher for VTE-patients than for controls. Using both methods (DiD/DiAC) the attributable societal event costs of VTE and major bleedings were substantial, especially the first year. The DiD method will result in more conservative results than the DiAC method.

P4443Elevated levels of D-dimer are associated with inflammation and disease activity rather than risk of venous thromboembolism in patients with granulomatosis with polyangiitis

Abstract Background Granulomatosis with polyangiitis (GPA) is one of antineutrophil cytoplasmic autoantibody (ANCA) – associated vasculitis. The disease is characterized by necrotising inflammation of small vessels causing tissue ischemia in a variety of organs with a wide range of clinical presentations. It has been established that active GPA is associated with a very high risk of venous thromboembolic events (VTEs). Purpose The aim of the present study was an evaluation of inflammation, coagulation and fibrinolysis markers, and their association with various clinical and laboratory parameters in GPA patients. Methods The group of 100 consecutive patients with GPA was prospectively followed in the study. In all patients echocardiography and laboratory tests were performed. Results The patients were followed up for an average of 4.0±1.9 years. In this group, D-dimer was elevated in majority (56%) of patients. The circulating levels of D-dimer were significantly higher in GPA patients in active stage of disease compared with those in remission (652 vs. 405 ng/ml, p=0.0002). In 23 patients venous thromboembolism was diagnosed during observation. However, there was no difference in D-dimer concentration between patients with and without VTE either in active stage or in remission. Among the 100 GPA patients higher D-dimer levels were observed in patients with coronary artery disease (p=0.04), atherosclerosis (p=0.01), hypertension (p=0.0049), diabetes (p=0.0065) and hypercholesterolemia (p=0.03). Moreover, correlation analysis showed that the levels of D-dimer correlated with hs-CRP (r=0.42; p<0.0001) and creatinine (r=0.58; p<0.0001). In patients with VTE, D-dimer levels correlated positively with age (r=0.5, p=0.02), right ventricle diameter (r=0.63, p=0.0017), right ventricle systolic pressure (r=0.44, p=0.04), and negatively with pulmonary artery acceleration time (r=−0.43, p=0.05). D-dimer – normal D-dimer – elevated p Inclusion – active stage n=44 (44%) n=56 (56%) Elevated creatinine 1 (2.27%) 25 (44.6%) <0.0001 Elevated CRP 5 (11.3%) 22 (39.2%) 0.0015 Venous thromboembolism 7 (15.9%) 16 (28.6%) 0.0712 CRP: C-reactive proteine. Conclusion In patients with Granulomatosis with polyangiitis elevated levels of D-dimer are associated with disease activity and inflammation, rather than with risk of venous thromboembolism. D-dimer is not a useful marker of venous thromboembolism episodes in patients with small vessel vasculitis.

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.

Safety and effectiveness of physical training in inotrop-dependent patients with compensation for chronic heart failure at the level of the III-IV functional class

Aim. To assess the safety and effectiveness of physical training in inotrop-dependent patients with stabilization of the course of chronic heart failure (CHF) at the level of the III-IV functional class (FC). Materials and methods. The prospective randomized study included men of 18-65 years old who were committed to Almazov National medical research center "due to decompensated CHF III-IV FC, left ventricular ejection fraction of 30% or less due to coronary heart disease or dilated cardiomyopathy receiving dopamine or dobutamine for 2 weeks or more, stabilizing heart failure at level III-IV FC and arterial pressure 90/60 mm Hg and above against the background of ongoing inotropic therapy. Patients were randomized into 2 groups: 1st - those participating in the physical rehabilitation program (PRP), 2nd - receiving standard CHF therapy. Results. There was no increase in the number of fatal cases and the number of patients with episodes of decompensation of CHF in the 1st group compared with the 2nd group. The number of episodes of CHF decompensation before FC IV was higher in the 2nd group compared to the 1st: 13 (50%) in the 1st group and 20 (80%) in the 2nd (p=0.04). Episodes of CHF decompensation, requiring transfer to the anesthesiology and resuscitation departments, were 2 times less frequent in patients of the 1st group compared to the 2nd: 8 (31%) and 16 (64%), respectively (p=0.03). In patients with the 1st group, malignant ventricular arrhythmias were not registered during physical training and for 3 hours after their completion. There was a tendency (without achieving a statistically significant difference) to a decrease in pulmonary thromboembolism episodes in patients of the 1st group compared with the 2nd (p=0.05). In the 1st group, after 6 months, there was a decrease in the number of lower respiratory tract infections - bronchitis + pneumonia compared with the 2nd group (p=0.0006). Conclusion. Participation of inotropic-dependent patients in individually designed RPF does not increase their mortality and does not increase their number of life-threatening cardiac rhythm disturbances. In the group of inotropic-dependent patients participating in RPF, there was a significant decrease in the number of lower respiratory tract infections and a tendency to a decrease in the number of pulmonary embolism compared with patients not participating in RPF.

Ocena zgodności z wytycznymi leczenia stosowanego w ramach prewencji powikłań zakrzepowo-zatorowych u hospitalizowanych chorych z migotaniem przedsionków

Introduction. Atrial fibrillation (AF) is the most common supraventricular arrhythmia. It results in an increased frequency of thromboembolic complications and a higher death rate. The frequency of arrhythmia is steadily increasing, and a sustained growth in the number of patients with AF can be expected in the coming years. Thromboembolic episodes are the most serious complications of AF. Anticoagulant treatment, based on recommendations, is considered to be the priority action in patients with AF. The aim of this paper is to evaluate compliance with guidelines for the prevention of thrombosis, recommended on discharge, in patients with non-valvular AF, who were hospitalised in a cardiology ward. Methods and materials. 4,099 patients with non-valvular AF, who had been hospitalised and discharged from a cardiology ward between 2004 and 2012, were subject to a retrospective analysis. We assessed the risk of thromboembolic (via CHADS 2 score) and haemorrhagic (via HAS-BLED score) complications, as well as data on comorbid conditions and the recommended anticoagulant prevention. The compliance of the prevention of thromboembolic complications with the guidelines was assessed according to the applied anticoagulant and antiplatelet treatment in particular groups of thromboembolism risk. Results. The average age of the examined group was 70.6 (± 10.9) years. AF co-existed most frequently with the following diseases: hypertension (74.8%), ischaemic heart disease (56.7%), and heart failure (54.8%). A low risk of thromboembolic complications was reported in 7.2% of patients, whereas 25.4% were rated as moderate risk, and 67.4% as high thromboembolic risk. A high risk of bleeding was reported in 34.6% of patients. In the prevention of thromboembolic complications, an oral anticoagulant, in monotherapy or in combination with antiplatelet drugs, was recommended for 64% of patients on discharge. According to the guidelines, 66.9% of patients from the examined group qualified for the prevention of thromboembolic complications: 62.4% of those with a high risk of stroke, 86% of those with a moderate risk, and 41.1% of those without stroke risk factors. The highest percentage of patients treated pursuant to the guidelines in the chosen clinical situations was to be seen among patients after a thromboembolic episode (70.8%). We found that in 73.8% of patients aged 65–74, and in 55.2% of patients over the age of 80, anticoagulant prevention was applied in accordance with the guidelines. Conclusions. On discharge from hospital, nearly two-thirds of patients with AF were subjected to the prevention of thromboembolic complications in accordance with the guidelines. Most often they belonged to the group of moderate risk, and least often to the group without thromboembolic risk factors. A high percentage of patients treated in line with the guidelines was seen in the patients who recovered from a thromboembolic episode. The percentage of patients with AF who were subjected to anticoagulant treatment in accordance with the guidelines decreased with age.

Feline arterial thromboembolism

Arterial thromboembolism is a common complication of feline cardiomyopathy. In many cats, underlying cardiac disease can be clinically silent. Risk factors for development of arterial thromboembolism include a previous episode of arterial thromboembolism; spontaneous echocardiographic contrast; severe left atrial enlargement; reduced left atrial and left ventricular function; and low left auricular appendage blood flow velocities. Diagnosis can be based on clinical signs, but echocardiography is necessary to confirm the presence of cardiomyopathy. Antithrombotic treatment is often empirical, as prospective studies are lacking. Clopidogrel has been shown to be superior to aspirin in prevention of subsequent arterial thromboembolism events, and future studies might show efficacy of other antithrombotic drugs. Cats that survive the initial thromboembolic event might have a fairly favourable prognosis, with a survival of over 12 months.

MLTI-11. IMPLANTABLE POLYMERIC BCNU AS AN ADJUNCT TO SURGERY FOR METASTATIC INTRACRANIAL DISEASE

SUMMARY: One hundred and thirty cases of craniotomy for tumor utilizing BCNU implantable chemotherapy were performed by the authors between including 23 cases for metastatic intracranial disease. The series included 12 woman and 11 men with an average age of 56.9 years. The diagnoses were as follows: non-small lung carcinoma (13), breast cancer (6), small-cell lung cancer (1), colon cancer (1), unknown primary (2). Patients undergoing resection plus implantable chemotherapy following whole brain radiotherapy (5 patients) or following stereotactic radiosurgery (5 patients) were the most common. Only patient developed possible local recurrence (3%). Complications included two cerebrospinal fluid leaks with associated complications requiring reoperations (11%) both following whole brain radiotherapy and 3 patients (17%) with thromboembolic episodes (3 deep venous thromboses, one with a pulmonary embolus and sudural hematoma). In this challenging population, local implantable chemotherapy appears relatively safe and a reasonable consideration as a surgical adjunct.

A less-intensive anticoagulation protocol of therapeutic unfractionated heparin administration for pregnant patients.

Heparin anticoagulant therapy for thromboembolic disorders during pregnancy is problematic due to unexpected adverse bleeding. To avoid bleeding, we have used a less-intensive anticoagulation protocol of unfractionated heparin (UFH). The protocol had a therapeutic activated partial thromboplastin time (APTT) ratio of 1.5-2.0 with the control value, a UFH dose of ≤ 30,000U/day, and an antithrombin (AT) activity target of ≥ 70%. In the present study, we evaluated this protocol using an anti-Xa assay. We collected UFH-treated plasma samples from ten consecutive pregnant Japanese patients with current or previous thromboembolic disorders. Seven patients remained in the therapeutic APTT ratio range (heparin-sensitive [HS] group). The other three patients had difficulty remaining within the therapeutic range (heparin-resistant [HR] group). In the HR group, two had AT deficiency and one had congenital absence of the inferior vena cava. Of the HS and HR samples, 73% and 31%, respectively, were within the therapeutic anti-Xa activity range 0.3-0.7U/mL, indicating difficulty for the HR group to remain within the therapeutic range. Neither major bleeding nor symptomatic thromboembolic episodes occurred in either group. These findings suggest that the less-intensive anticoagulation protocol is permissive and may be beneficial in the HS group.

D-dimer levels during and after anticoagulation withdrawal in patients with venous thromboembolism treated with non-vitamin K anticoagulants.

BackgroundD-dimer levels measured during and after vitamin K antagonist withdrawal may be used in clinical practice to assess the individual risk of recurrent venous thromboembolism. Currently, direct oral anticoagulants (DOACs) are frequently used in venous thromboembolism treatment; however, their pharmacokinetics and pharmacodynamics characteristics are completely different than vitamin K antagonists. The present study aimed at comparing the results of D-dimer levels during and after anticoagulation withdrawal in patients with venous thromboembolism treated with DOACs or warfarin.Material and methodsD-dimer levels were measured in 527 patients (“cases”) during DOACs treatment (T0) and after 15 (T15), 30 (T30), 60 (T60) and 90 (T90) days after their discontinuation and in 527 patients (“controls”) enrolled in the DULCIS study (all treated with warfarin), matched for sex, age (+/-3 y), type of D-dimer assay and site of venous thromboembolism. Both cases and controls received anticoagulant treatment after a first venous thromboembolism event that was unprovoked or associated with weak risk factors.ResultsThe rate of positive D-dimer results was significantly higher in cases than in controls at T0 (10.8% vs 5.1%, p = 0.002) and at T30 (18.8% vs 11.8%, p = 0.019), as well as at the other time-points, though not statistically significant.ConclusionD-dimer levels during and after stopping an anticoagulant treatment for a venous thromboembolism episode differ between patients treated with a DOAC than in those treated with warfarin. Specifically designed prospective studies are warranted to reassess the use of D-dimer as predictor of the risk of recurrent venous thromboembolism in patients treated with DOACs.

Rivaroxaban in the treatment of upper extremity deep vein thrombosis: A single-center experience and review of the literature

IntroductionDirect oral anticoagulants (DOACs) have become widely used to treat patients with venous thromboembolism (VTE), but evidence about their use in the treatment of upper extremity deep vein thrombosis (UEDVT) is lacking. ObjectivesTo assess rivaroxaban's efficacy and safety in the treatment of UEDVT. Patients/methodsThis was a single-center prospective observational study involving patients with their first UEDVT episode confirmed by duplex ultrasound scan. All patients initially received low-molecular-weight heparin for 1 to 2 days and then were switched to rivaroxaban for 3–6 months. The primary endpoint was any symptomatic episode of recurrent VTE. ResultsThirty patients were included in the study, and all patients were followed for 6 months. There were no episodes of recurrent symptomatic venous thromboembolism or asymptomatic UEDVT. No episode of major bleeding was observed. Clinically relevant non-major bleeding occurred in two patients (6.7%, 95% confidence interval [CI]: 1.9–21.4%) with uterine bleeding and large skin hemorrhage. Minor bleeding was observed in two patients (6.7%, 95% CI: 1.9–21.4%) presenting with nasal and gingival bleeding. Recanalization of the upper extremity deep veins was observed in all affected limbs at three months, and it persisted up to 6 months. The signs of upper limb post-thrombotic syndrome (PTS) were found in four patients (13.4%; 95% CI: 5.4–29.8%), and the mean modified Villalta score was 2.1 ± 1.9. ConclusionTreatment of UEDVT with rivaroxaban, preceded by one to two days of LMWH, seems to be safe and effective.

Single-center experience of extracorporeal membrane oxygenation mainly anticoagulated with nafamostat mesilate.

Bleeding remains the chief concern during extracorporeal membrane oxygenation (ECMO). Recently, several studies proposed nafamostat mesilate (NM) as an alternative anticoagulant to heparin due to reduced bleeding complications and comparable thromboembolic episodes. The aim of this study was to evaluate the clinical outcomes of ECMO anticoagulated mainly with NM. This was a retrospective observational case series of patients who were placed on ECMO between January 2011 and December 2017 at Chungnam National University Hospital. The main outcomes were bleeding and thromboembolic episodes. During the study period, a total of 91 ECMO runs on 87 patients were identified. There were 54 veno-venous runs and 37 veno-arterial runs. Among the 87 patients, 47 (54.0%) patients were successfully weaned and 29 (33.3%) survived to discharge. Most of the runs were anticoagulated with NM (n=68, 74.7%), followed by heparin (n=22, 24.2%) and argatroban (n=1, 1.1%). The mean duration of ECMO support was 11.3±11.1 days. The overall incidence of bleeding was 46.2% (n=42); 26 runs were anticoagulated with NM (26/68, 38.2%) and 16 with heparin (16/22, 72.7%) (P=0.005). The overall incidence of thromboembolic episodes was 12.1% (n=11). In the NM group, the incidence of hyperkalemia requiring any type of intervention was 17.6% (n=12). In this single center study, NM appears to be associated with fewer bleeding complications during ECMO without increasing the incidence of thromboembolic episodes.

Low-Dose Prasugrel vs Clopidogrel-Based Tailored Premedication for Endovascular Treatment of Cerebral Aneurysms.

Antiplatelet premedication is widely accepted for interventional treatment of cerebral aneurysms to prevent thromboembolism. However, antiplatelet resistance sometimes limits the effectiveness of premedication. To compare 2 groups administered low-dose prasugrel (PSG group) or clopidogrel-based tailored antiplatelet (CPG group) in terms of platelet function and procedure-related complications. A total of 411 patients with 505 unruptured aneurysms who underwent endovascular treatment within the past 17 mo were retrospectively enrolled in this study. The PSG (225 patients with 277 aneurysms) and CPG groups (186 patients with 228 aneurysms) were administered the respective medication prior to endovascular treatment. We measure the response to the antiplatelet medication with a laboratory test. Episodes of periprocedural bleeding and thromboembolism were compared between the 2 groups. There were significant differences between the 2 groups in terms of the mean P2Y12 reaction unit values (125.7 in the PSG group vs 251.0 in the CPG group; P<.001) and percentage inhibition (57.8% vs 18.7%, respectively; P<.001). Drug resistance was 29.6% per patient in the CPG group and 2.7% per patient in the PSG group. The PSG group reported 1 thromboembolism and bleeding each; meanwhile, the CPG group reported 7 thromboembolism and 3 bleeding. Compared to clopidogrel administration, prasugrel administration significantly decreased the risk of thromboembolism (weighted hazard ratio, 0.17; 95% confidence interval, 0.03-0.99). However, the risk of bleeding was not significant. Prasugrel was found to be more effective in reducing periprocedural thromboembolism compared to clopidogrel.

Profilaxis farmacológica de la tromboembolia venosa en la prostatectomía radical

Background and aimPulmonary thromboembolism is one of the most common causes of non-surgical death in patients following urological abdominopelvic surgery. Since the beginning of prophylaxis for venous thromboembolic disease, episodes of deep vein thrombosis and pulmonary thromboembolism have decreased. Our objective is to analyse the prognosis factors of thromboembolic disease, the clinical variability in the use of pharmacological prophylaxis and the results of its application. Material and methodsRetrospective multicentric study of 610 patients undergoing radical prostatectomy between December 2013 and November 2014, in 7general hospitals in Spain, Italy and Portugal. Patients were classified according to their baseline characteristics into thrombotic risk groups and haemorrhagic risk groups. The venous thromboembolic events that occurred in the different groups were analysed. ResultsThe average age was 65.22years (48-78). The average body mass index was 26.7 and the average ASA risk 2.1. In all patients, early mobilization began in the first 24hours. In 4.1% intermittent pneumatic compression was used and 84.6% received pharmacological prophylaxis with low molecular weight heparins. Only 3.4% used the combination of mechanical prophylaxis with pharmacological prophylaxis. We observed a decrease in the incidence of thromboembolic events in the patients who received pharmacological prophylaxis, with an absolute risk reduction of 6.8%. There was no increase in the risk of haemorrhage in the patients who received pharmacological prophylaxis. ConclusionsIn this study on patients undergoing radical prostatectomy, there was no difference in haemorrhagic complications derived from the use of pharmacological prophylaxis for venous thromboembolic disease. Pharmacological prophylaxis reduces the risk of presenting a thromboembolic event in patients undergoing radical prostatectomy, although this risk is not associated with the approach technique.

Restoring pulsatility and peakVO2 in the era of continuous flow, fixed pump speed, left ventricular assist devices: 'A hypothesis of pump's or patient's speed?'

Despite significant improvement in survival and functional capacity after continuous flow left ventricular assist device implantation, the patient's quality of life may remain limited by complications such as aortic valve insufficiency, thromboembolic episodes and gastrointestinal bleeding attributed to high shear stress continuous flow with attenuated or absence of pulsatile flow and by a reduced peak oxygen consumption (peakVO2) primarily associated with a fixed pump speed operation. Revision of current evidence suggests that high technology pump speed algorithms, a 'hypothesis of decreasing pump's speed' to promote pulsatile flow and a 'hypothesis of increasing pump's speed' to increase peakVO2, may only partially reverse these barriers. A 'hypothesis of increasing patient's speed' is introduced, suggesting that exercise training may further contribute to the patient's recovery, enhancing peakVO2 and pulsatile flow by improving skeletal muscle oxidative capacity and strength, peripheral vasodilatory and ventilatory responses, favour changes in preload/afterload and facilitate native flow, formulating the rationale for further studies in the field.

Clinical trial on the effect of tranexamic acid on bleeding and fibrinolysis in primary hip and knee replacement

Abstract Background Tourniquet-induced ischaemia could increase fibrinolysis and enhance tranexamic acid (TXA) efficacy in total knee arthroplasty (TKA) compared to total hip arthroplasty (THA). The aims of this study are to compare the effect of TXA on bleeding and fibrinolysis in both types of surgery, and to record thromboembolic complications. Methods A prospective double-blind study was conducted on patients scheduled for TKA or THA who received TXA (2 bolus of 10 mg/kg) or placebo. Bleeding and fibrinolysis were evaluated. Doppler-ultrasound and computed tomography were performed in order to assess any thromboembolic complications. Results A total of 44 patients were included (11 THA and 11 TKA treated with TXA; 11 THA and 11 TKA as controls). Blood losses were significantly lower in the TXA group (mean 921 mL vs 1383 mL in THA and 969 mL vs 1223 mL in TKA), and no transfusions were needed with TXA, whereas 5 blood units were transfused in controls. TXA was equally effecting in reducing bleeding in both surgeries (33% in THA and 21% in TKA). The significant mean increase in d -dimers from baseline to 6 h after surgery (1004 μg/L to 10,284 μg/L in THA and 571 μg/L to 6480 μg/L in TKA) was attenuated by TXA (1077 μg/L to 2590 μg/L in THA and 655 μg/L to 2535 μg/L in TKA). There were no differences in thromboembolic episodes. Conclusions Prophylactic use of tranexamic acid is equally effective in reducing bleeding in TKA and THA. Both surgeries have a similar effect on fibrinolysis.

Safety profile of midline catheters in patients with active malignancy.

e18046 Background: Patients with malignancy often require a safe and reliable intravascular access for disease management along the spectrum of diagnosis to end-of-life care. Despite a growing interest on the use of midlines, there is a scarcity of data on their safety in cancer patients. Data from observational studies suggest a lower rate of thrombotic and infectious complications when compared to peripherally-inserted central catheters (PICCs). However, there are no formal recommendations tailored to oncologic patients on when to prefer one type of vascular access versus another. Methods: We retrospectively gathered data from all midline catheters inserted in patients with active cancer at our institution from January 2016 to June 2017, totaling 159 procedures. Our primary analysis sought to determine the incidence of venous thromboembolism (VTE), CRBSI and bleeding. Results: Out of a total of 159 procedures performed in patients with solid tumor and hematologic malignancies, chemotherapy infusion was the indication in 17 (10.69%), with difficult intravenous access being the indication in 97 patients (61%) and prolonged antibiotic therapy in 44 patients (27.6%). Only one patient got a midline for peripheral parenteral nutrition. The mean dwell time of midline catheters was 9.4 days. A total of 5 patients (3.14%) developed catheter-associated thromboembolic episodes. All of them had metastatic solid tumors. No events were reported in patients with hematologic malignancies. Of note, 2 of these 5 patients had a prior history of VTE. The number of days from device insertion to VTE ranged from 2-14 days, with an average of 9.5 days. Catheter-related infection occurred in 1 patient (0.62% or 0.66 per 1000 catheter-days). No bleeding complications were reported. Conclusions: Midline catheters appear to be a safe and cost-effective alternative for secure vascular access, especially in patients with non-metastatic solid tumors and hematologic malignancies. Caution and close monitoring for occurrence of VTE are advised for those with high metastatic burden and prior history of VTE. The rate of infectious complications are low, which is in concordance with previous literature.

ABCB1 2677G>T single nucleotide polymorphism influences warfarin dose requirement for warfarin maintenance therapy

Warfarin, a commonly prescribed anticoagulant, minimises development and recurrence of thromboembolic episodes in conditions such as deep vein thrombosis, pulmonary embolism, cardiac valve replacem...

Extraction in Patients on Oral Anticoagulant Therapy With and without Stopping the Drug: A Comparative Study.

The aim of this study was to compare postoperative hemorrhagic complications after dental extractions in two groups of patients receiving oral anticoagulants with one group receiving oral anticoagulant without interruption and another group stopping the drug 3days prior to extraction. A control group consisted of 30 patients who had stopped the oral anticoagulant 3days before undergoing dental extractions, resulting in a reduction in the average preoperative international normalized ratio (INR) from 2.8 to 1.6. The study group of 30 patients received the anticoagulant drug without any alteration before extractions and had an average preoperative INR of 2.7. All extractions were done under local anesthesia on an outpatient basis, and local measures consisting of gelfoam and sutures were used in all cases to control postoperative bleeding from extraction sockets. None of the patients had any immediate postoperative bleeding, and only one patient from the control group and two patients from the study group had mild delayed hemorrhage which was easily managed with local measures. There is no need to alter the dosage of oral anticoagulants prior to dental extractions provided the INR is within the therapeutic range of 2.0-4.0, extractions are done in least traumatic manner and local measures are used to control postoperative hemorrhage, thereby reducing the risk of thromboembolic episodes in these patients.