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Abstract Background Sepsis and thrombo-embolic disease are well known complications of thalassemia major. Intracardiac thrombi are however rare and can lead to diagnostic dilemmas. Case presentation We report the case of a 20-year-old female splenectomised thalassaemia major patient with severe iron overload, who presented with life threatening sepsis associated with a liver abscess. Discovery of a large oscillating intra cardiac lesion on 2D echocardiogram confirmed by Contrast Enhanced Computed Tomography (CECT) chest in the right atrium extending from the left hepatic vein through the inferior vena cava complicated the clinical course. After a prolonged Intensive Care Unit (ICU) stay supported with antibiotics and anticoagulation, she recovered with evidence of resolution of the intra cardiac thrombus. Conclusions Early recognition and prompt aggressive treatment of sepsis in patients with thalassemia is essential to prevent complications. Intracardiac thrombosis is a potentially treatable cause for an intra cardiac mass in patients with thalassemia major, which should not be missed.

Background: Sepsis and thrombo-embolic disease are well known complications of thalassemia major. Intracardiac thrombi are however rare and can lead to diagnostic dilemmas. Case presentation: We report the case of a 20-year-old female splenectomised thalassaemia major patient with severe iron overload, who presented with life threatening sepsis associated with a liver abscess. Discovery of a large oscillating intra cardiac lesion on 2D echocardiogram confirmed by Contrast Enhanced Computed Tomography (CECT) chest in the right atrium extending from the left hepatic vein through the inferior vena cava complicated the clinical course. After a prolonged Intensive Care Unit (ICU) stay supported with antibiotics and anticoagulation, she recovered with evidence of resolution of the intra cardiac thrombus. Conclusions: Early recognition and prompt aggressive treatment of sepsis in patients with thalassemia is essential to prevent complications. Intracardiac thrombosis is a potentially treatable cause for an intra cardiac mass in patients with thalassemia major, which should not be missed. [ABSTRACT FROM AUTHOR]

Background: SARS-COV-2 is primarily a respiratory illness. However, beyond respiratory illness and associated acute and long-term medical complications, it manifests as stroke, including acute ischemic stroke and hemorrhagic stroke. Clinical evidence reported the occurrence of both venous and arterial thromboembolic complications in SARS-COV-2 positive patients due to hypercoagulable state, hyperinflammatory response, cardiomyopathy, and endothelial inflammation. Materials and Methods: This is a retrospective, single-center cohort study, which includes confirmed SARS-COV-2-positive patients hospitalized between March 2021 and February 2022. Clinical and biochemical data were analyzed. Noncontrast computed tomography of the brain was performed to assess the area and type of stroke. Results: Among all the included 703 patients with SARS-COV-2, 42 patients developed stroke. SARS-COV-2 patients who developed stroke were older and had multiple comorbidities. Patients had higher quick sequential organ failure assessment (qSOFA) score on hospitalization (P < 0.05), higher in-hospital mortality, and had poor clinical outcomes (P < 0.0001). In multivariate regression analysis, there were higher odds of in-hospital mortality linked with higher qSOFA scores (odds ratio 4.47, 95% confidence interval 1.21–16.5; P = 0.025). SARS-COV-2 patients developing stroke had high total leukocyte counts, high neutrophil counts, low platelet counts, low lymphocyte counts, raised C-reactive protein, raised ferritin levels, raised interleukin-6, raised fibrinogen, and D-dimer as compared to those without stroke. Conclusion: Patients with SARS-COV-2 who developed stroke had more severe clinical symptoms, poor clinical outcomes, and higher in-hospital mortality rates compared to those without stroke.

• We conducted a systematic review and meta-analysis on studies that compared standard dose with high dose IV TXA, defined as ≥2 g or ≥30 mg/kg as a single bolus, in adults (≥ 16 years of age) with hemorrhage. • When compared to standard dose, high dose IV TXA probably reduces transfusion requirements (OR, 0.86; 95% CI, 0.76–0.97; p = 0.01) with an uncertain effect on thromboembolic events and mortality. • Despite an uncertain effect on mortality, high dose TXA may be able to play an integral role in survival, particularly when the risk of exsanguination is high. Standard dose (≤ 1 g) tranexamic acid (TXA) has established mortality benefit in trauma patients. The role of high dose IV TXA (≥2 g or ≥30 mg/kg as a single bolus) has been evaluated in the surgical setting, however, it has not been studied in trauma. We reviewed the available evidence of high dose IV TXA in any setting with the goal of informing its use in the adult trauma population. We searched MEDLINE, EMBASE and unpublished sources from inception until July 27, 2022 for studies that compared standard dose with high dose IV TXA in adults (≥ 16 years of age) with hemorrhage. Screening and data abstraction was done independently and in duplicate. We pooled trial data using a random effects model and considered randomized controlled trials (RCTs) and observational cohort studies separately. We assessed the individual study risk of bias using the Cochrane Risk of Bias for RCTs and the Newcastle-Ottawa Scale for observational cohort studies. The overall certainty of evidence was assessed using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). We included 20 studies with a combined total of 12,523 patients. Based on pooled RCT data, and as compared to standard dose TXA, high dose IV TXA probably decreases transfusion requirements (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76 to 0.97, moderate certainty) but with possibly no effect on blood loss (mean difference [MD] 43.31 ml less, 95% CI 135.53 to 48.90 ml less, low certainty), and an uncertain effect on thromboembolic events (OR 1.33, 95% CI 0.86 to 2.04, very low certainty) and mortality (OR 0.70, 95% CI 0.37 to 1.32, very low certainty). When compared to standard dose, high dose IV TXA probably reduces transfusion requirements with an uncertain effect on thromboembolic events and mortality. Systematic review and meta-analysis, level IV. [ABSTRACT FROM AUTHOR]

This case report highlights the diagnostic challenges posed by pulmonary embolism (PE) in a young, otherwise healthy 33-year-old African American male with no apparent risk factors. The patient presented with penile pain, swelling, hematuria, flank pain, and rash, and was admitted for balanoposthitis and acute urinary retention. Despite prophylactic heparin, he suffered two cardiac arrests secondary to PE on the fifth day of hospitalization. Prompt thrombolytic therapy and heparin infusion were initiated, but his course was complicated by anuric acute kidney injury requiring hemodialysis, shock liver, and gastrointestinal bleeding. Imaging revealed a substantial thrombus burden in the pulmonary arteries. Notably, a hypercoagulable workup was negative. The absence of typical risk factors, negative hypercoagulable workup, and occurrence of PE despite prophylaxis underscore the importance of vigilance in recognizing atypical presentations. This case emphasizes the need for a high index of suspicion and comprehensive evaluation to diagnose PE in young patients without clear predisposing factors., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mohyeldin et al.)

Background COVID-19 has spread worldwide and has caused significant morbidity and mortality. Myocardial injury and thrombo-embolism are known complications for those with severe forms of disease. The incidence and risk factors for these complications for those patients who are asymptomatic or with mild forms of COVID-19 is unknown. Case summary In this report we describe the case of a 35-year-old man with no past cardiac history who presented with chest pain and a high-sensitivity troponin level of 386 ng/L in the context of an unspecified mild viral illness 1 month previously. Diagnostic evaluation revealed a new cardiomyopathy, left ventricular thrombus, and mid right coronary artery thrombosis. The coronary thrombosis was treated with thrombectomy. SARS-CoV-2 antibodies returned positive. He initially did well post-procedure; however, prior to discharge, he developed a second arterial thrombo-embolism event, a middle cerebral artery stroke. He was treated with thrombectomy and remains hospitalized. Discussion Recognition that mild COVID-19 can be complicated by subsequent cardiac injury and/or coagulopathy is important. As more people recover from this viral illness and return to normal activity levels, discussion among cardiac experts has begun regarding screening for occult myocardial injury in those who plan to resume competitive athletic activity. This case highlights the need for investigation regarding (i) the duration of thrombophilia after recovery from illness; (ii) the population that should receive thromboprophylaxis; and (iii) the duration of thromboprophylaxis therapy for COVID-19. [ABSTRACT FROM AUTHOR]

To compare the percutaneous Rotarex and Angiojet thrombectomy devices with regard to effectiveness and in vitro safety. The Rotarex and Angiojet devices were evaluated in an established in vitro pulsatile flow model with a human femoropopliteal vessel phantom. First pass recanalisation and thrombus weight were assessed after thrombectomy, as well as micro- and macro-emboli. Further, histological evaluation of the vascular phantom was performed to analyse vascular injuries. Thrombus weight did not differ significantly prior to the thrombectomy between the groups, but the Rotarex showed slight advantages in thrombus removal vs. the Angiojet regarding first pass recanalisation. Micro- and macro-emboli occurred in most of the endovascular manoeuvres performed; however, significantly more macro-emboli (2.37 ± 1.51 vs. 0.87 ± 0.83; p =.048) were observed using the Rotarex than the Angiojet. Macroscopic dissections were detected in the Rotarex group (n = 3) but not in the Angiojet group. Microscopic vascular injuries were detected significantly more often in the Rotarex group (Rotarex: 531.61 μm ± 102.81 μm; Angiojet: 705.42 μm ± 61.68 μm p =.001]). Both devices showed a comparable performance, with a slight advantage for the Rotarex regarding first pass recanalisation. Significantly more thrombo-emboli, and vascular injuries were observed in the Rotarex group with the latter being obviously the more tissue preserving procedure but potentially with a lower rate of recanalisation. Based on the present results, clinical randomised trials, including long term follow up, are needed to optimise and improve the use of catheter based procedures, taking into account the thrombus entity, localisation, and clinical history. [ABSTRACT FROM AUTHOR]

Objectives Endovascular aortic repair (EVAR) is associated with an increased risk of pulmonary embolism, which is often clinically silent and therefore difficult to recognise. The aim was to investigate the incidence of pulmonary embolism after EVAR using routinely performed pre- and post-operative aortic computed tomography angiography (CTA), and the association between pulmonary embolism and mortality. Methods This single centre retrospective cohort study included adult patients who underwent EVAR in the University Medical Centre Utrecht between January 2010 and July 2015 and who had a total aortic, thoracic aortic, or pulmonary CTA within one month post-operatively. Baseline and mortality data were obtained by reviewing hospital and general practitioner records. The primary outcome was pulmonary embolism within one month after surgery. Secondary outcomes were 30 day and six month mortality. Results During the study period, 526 EVARs were performed. Seventy-four of these procedures were included in the analysis of which there were 40 thoracic and 34 abdominal EVARs. In nine patients (12%, 95% CI 7–22) pulmonary embolism was observed of which one was central, two were segmental, and six were subsegmental. Seven were clinically silent and two were present on the pre-operative CTA. Thirty day mortality was significantly higher in patients with pulmonary embolism (relative risk 14.4, 95% CI 1.4–143, p =.037) though none of the deaths seemed directly attributable to it. Conclusions This study, although preliminary, suggests that silent pulmonary embolism after EVAR occurs in approximately one in 10 patients, despite routine thrombo-embolism prophylaxis. Pulmonary embolism was associated with a higher 30 day mortality risk yet it was not the cause of death in any of these patients. [ABSTRACT FROM AUTHOR]

Aims: Atrial fibrillation (AF) is associated with a wide range of clinical presentations. Whether and how AF symptoms can affect prognosis is still unclear. Aims of the present analysis were to investigate potential predictors of symptomatic AF and to determine if symptoms are associated with higher incidence of cardiovascular (CV) events at 1-year follow-up.Methods and Results: The Euro Heart Survey on Atrial Fibrillation included 3607 consecutive patients with documented AF and available follow-up regarding symptoms status. Patients found symptomatic at baseline were classified into still symptomatic (SS group; n = 896) and asymptomatic (SA; n = 1556) at 1 year. Similarly, asymptomatic patients at baseline were classified into still asymptomatic (AA group; n = 903) and symptomatic (AS group; n = 252) at 1 year. Demographics, as well as clinical variables and medical treatments, were tested as potential predictors of symptoms persistence/development at 1-year. We also compared CV events between SS and SA groups, and AS and AA groups at 1-year follow-up. Both persistence and development of AF symptoms were associated with an increased risk of CV hospitalization, stroke, heart failure worsening, and thrombo-embolism. AF type, hypothyroidism, chronic heart failure, and chronic obstructive pulmonary disease (COPD), were independently associated with an increased risk of symptomatic status at 1-year follow-up between SS and SA groups.Conclusion: Persistence or development of symptoms after medical treatment are associated with an increased risk of CV events during a 1-year follow-up. Type of AF, along with hypothyroidism, COPD and chronic heart failure are significantly associated with symptoms persistence despite medical treatment. [ABSTRACT FROM AUTHOR]

We report a particularly interesting case in which a free-floating thrombus of unknown origin in the ascending aorta and extending into aortic arch with each heart beat was attached to a mildly atherosclerotic aortic wall. The thrombus was thought to have been the origin of a previous right axillary artery thrombo-embolism. The thrombus was removed directly from ascending aorta after putting the patient on circulatory arrest; the axillary artery thrombus was also removed simultaneously from the same incision with the help of Fogarty catheter placed antegradely. [ABSTRACT FROM AUTHOR]

Purpose Transcatheter aortic valve implantation (TAVI) has been associated with large incidence of ischemic events, whose sources are still unclear. In fact, sub-acute complications cannot be directly related to the severity of the calcification in the host tissues, nor with catheter manipulation during the implant. A potential cause could be local flow perturbations introduced by the implantation approach, resulting in thrombo-embolic consequences. In particular, contrary to the surgical approach, TAVI preserves the presence of the native leaflets, which are expanded in the paravalvular space inside the Valsalva sinuses. The purpose of this study is to verify if this configuration can determine hemodynamic variations which may promote blood cell aggregation and thrombus formation. Methods The study was performed in vitro, on idealized models of the patient anatomy before and after TAVI, reproducing a range of physiological operating conditions on a pulse duplicator. The fluid dynamics in the Valsalva sinuses was analyzed and characterized using phase resolved Particle Image Velocimetry. Results Comparison of the flow downstream the valve clearly indicated major alterations in the fluid mechanics after TAVI, characterized by unphysiological conditions associated with extended stagnation zones at the base of the sinuses. Conclusion The prolonged stasis observed in the Valsalva sinuses for the configuration modelling the presence of transcatheter aortic valves provides a fluid dynamic environment favourable for red blood cell aggregation and thrombus formation, which may justify some of the recently reported thromboembolic and ischemic events. This suggests the adoption of anticoagulation therapies following TAVI, and some caution in the patients׳ selection. [ABSTRACT FROM AUTHOR]

Aims: Patients with atrial fibrillation (AF) are encountered and treated in different healthcare settings, which may affect the quality of care. We investigated the use of oral anticoagulant (OAC) therapy and the risk of thrombo-embolism (TE) and bleeding, according to the healthcare setting.Methods and Results: Using national Danish registers, we categorized non-valvular AF patients (2002-11) according to the setting of their first-time AF contact: hospitalization (inpatients), ambulatory (outpatients), or emergency department (ED). Event rates and hazard ratios (HRs), calculated using Cox regression analysis, were estimated for outcomes of TE and bleeding. We included 116 051 non-valvular AF patients [mean age 71.9 years (standard deviation 14.1), 51.3% males], of whom 55.2% were inpatients, 41.9% outpatients, and 2.9% ED patients. OAC therapy 180 days after AF diagnosis among patients with a CHADS2 ≥ 2 was 42.1, 63.0, and 32.4%, respectively. Initiation of OAC therapy was only modestly influenced by CHADS2 and HAS-BLED scores, regardless of the healthcare setting. The rate of TE was 4.30 [95% confidence interval (CI) 4.21-4.40] per 100 person-years for inpatients, 2.28 (95% CI 2.22-2.36) for outpatients, and 2.30 (95% CI 2.05-2.59) for ED patients. The adjusted HR of TE, with inpatients as reference, was 0.74 (95% CI 0.71-0.77) for outpatients and 0.89 (95% CI 0.79-1.01) for ED patients.Conclusion: In a nationwide cohort of non-valvular AF patients, outpatients were much more likely to receive OAC therapy and had a significantly lower risk of stroke/TE compared with inpatients and ED patients. However, across all settings investigated, OAC therapy was far from optimal. [ABSTRACT FROM AUTHOR]

Aims: Atrial fibrillation (AF) and thrombo-embolism (TE) are associated with reduced survival in hypertrophic cardiomyopathy (HCM), but the absolute risk of TE in patients with and without AF is unclear. The primary aim of this study was to derive and validate a model for estimating the risk of TE in HCM. Exploratory analyses were performed to determine predictors of TE, the performance of the CHA2 DS2 -VASc score, and outcome with vitamin K antagonists (VKAs).Methods and Results: A retrospective, longitudinal cohort of seven institutions was used to develop multivariable Cox regression models fitted with pre-selected predictors. Bootstrapping was used for validation. Of 4821 HCM patients recruited between 1986 and 2008, 172 (3.6%) reached the primary endpoint of cerebrovascular accident (CVA), transient ischaemic attack (TIA), or systemic peripheral embolus within 10 years. A total of 27.5% of patients had a CHA2 DS2 -VASc score of 0, of whom 9.8% developed TE during follow-up. Cox regression revealed an association between TE and age, AF, the interaction between age and AF, TE prior to first evaluation, NYHA class, left atrial (LA) diameter, vascular disease, and maximal LV wall thickness. There was a curvilinear relationship between LA size and TE risk. The model predicted TE with a C-index of 0.75 [95% confidence interval (CI) 0.70-0.80] and the D-statistic was 1.30 (95% CI 1.05-1.56). VKA treatment was associated with a 54.8% (95% CI 31-97%, P = 0.037) relative risk reduction in HCM patients with AF.Conclusions: The study shows that the risk of TE in HCM patients can be identified using a small number of simple clinical features. LA size, in particular, should be monitored closely, and the assessment and treatment of conventional vascular risk factors should be routine practice in older patients. Exploratory analyses show for the first time evidence for a reduction of TE with VKA treatment. The CHA2 DS2 -VASc score does not appear to correlate well with the clinical outcome in patients with HCM and should not be used to assess TE risk in this population. [ABSTRACT FROM AUTHOR]

OBJECTIVES Our aim in the present study was to determine the prevalence of haemostatic events in our Fontan patients, to identify predictive factors and to determine their association with haemodynamics and anticoagulant therapy. METHODS We retrospectively evaluated 424 Fontan patients and examined correlations between postoperative haemodynamics and anticoagulant regimens with haemostatic events. RESULTS After exclusion of 12 patients with a mechanical valve at the time of Fontan operation, our 412 patients were sub-divided into 21 groups based on the therapeutic duration of warfarin and antiplatelet agent therapy. During the early 5- to 10-year postoperative period, patients receiving warfarin showed higher central venous pressure and lower arterial oxygen saturation (Sat) (P < 0.05–0.001). During a mean follow-up of 11.2 years, 29 (7.0%) haemostatic events occurred. With regard to haemorrhagic events, haemoptysis was most common (n = 13, 45%), followed by cerebral bleeds in 3 (10%). Of thrombo-embolic events, thrombosis in the Fontan pathway was the most common (n = 7, 24%), followed by cerebral infarction in 3. Early haemorrhagic events were associated with late Fontan operation and use of preoperative renin–angiotensin system blockers, while late events were related to heterotaxy syndrome, male gender and low Sat (P < 0.05–0.01). A low Sat was the only predictor of early postoperative thrombo-embolic events (P = 0.0192). Among the three subgroup analyses of fixed anticoagulant regimens, the most frequent haemorrhagic events were associated with long-term use of warfarin (P = 0.0033). None of the anticoagulant regimens that included warfarin and/or antiplatelet agents were independently associated with haemostatic events throughout the follow-up. CONCLUSIONS Anticoagulant regimens in Fontan patients varied widely with a significant trend for warfarin use in patients with impaired haemodynamics. Low arterial oxygenation may predict haemostatic events. The relatively high prevalence of haemorrhagic complications indicates the need for individualized anticoagulant administration throughout the follow-up. [ABSTRACT FROM PUBLISHER]

Introduction. Venous thromboembolism is a multifactorial disease defined by multiple interactions between genetic and acquired risk factors. After coronary heart disease and stroke, venous thromboembolism is the most common cause of cardiovascular death and disability. Material and Methods. In order to investigate the clinical characteristics of first venous thromboembolism, 447 women younger than 45 and 174 over 45 years of age with confirmed venous thromboembolism, who had been tested for the presence of thrombophilia in the period 1998-2012, were included in the study. Results. Proximal deep vein thrombosis occurred most often among young women, while distal deep vein thrombosis was the most frequent in the older group. The most common reported risk for venous thromboembolism observed in 49.8% of the young women was pregnancy and puerperium, while 25.2% of them developed venous thromboembolism without any obvious cause. Among women over the age of 45, venous thromboembolism developed without an obvious cause in 38.5%, while malignant disease was identified as the most important risk factor in 23% of them. Thrombophilia was observed in 48.7% of the young women in comparison to 28.7% of the older ones (p < 0.0001). As for venous thromboembolism recurrence, it developed in 26.3% of young women and 17.8% of the older ones (p = 0.03). Conclusion. Younger women developed more severe forms of thrombosis than the older ones. Inherited risk factor for thrombosis was detected in almost half of all young women, and in every fourth elderly women. With the exception of factor V Leiden mutation, other types of congenital thrombophilia are almost negligible among older women. Therefore, thrombophilia testing in case of first thrombosis is fully justified only in young women. [ABSTRACT FROM AUTHOR]

Cancer patients are at high risk of thrombo-embolism and haemorrhage – which is exacerbated in the perioperative period. The pathogenesis of this haemostatic dysfunction is complex and involves the interplay of multiple factors. A detailed understanding of the disease pathophysiology, including mechanisms of haemostasis and laboratory assessment, is imperative in the decision making. Thrombo-embolism is an important and preventable complication of cancer surgery – with appropriate application of thromboprophylaxis. The key outstanding issues surround timing of initiation, regimen and duration of therapy. A major limitation in both our understanding and our pre-emptive management of the haemostatic dysfunction is a lack of sensitive and specific tests of haemostatic potential that can provide predictive power for risk stratification. Routine laboratory tests do not accurately recognise hyper- or hypocoagulable states, or test the clinical effects of procoagulant or anticoagulant interventions. We need further development of cellular-based assays that incorporate all the components of the haemostatic system. [Copyright &y& Elsevier]

Abstract: The most frequent risk in endovascular aneurysm treatment is thromboembolic complications. Thus adjuvant pharmaceuticals are largely focused on preventing and treating these latter. Additionally symptomatic treatment of subarachnoid hemorrhage (SAH) and treatments to avoid vasospasm will enter into play in cases of ruptured aneurisms. Consensus exists in the literature neither for the necessity of heparin or antiplatelets nor for the doses to be administered. The principles and rationale of the use of these medications are reviewed with a discussion of protocols according with clinical situations and technical choices. [ABSTRACT FROM AUTHOR]

Abstract: The number of neuroendovascular treatments of both ruptured and unruptured aneurysms has increased substantially in the last two decades. Complications of endovascular treatments of cerebral aneurysms are rare but can potentially lead to acute worsening of the neurological status, to new neurological deficits or death. Some of the possible complications, such as vascular access site complications or systemic side effects associated with contrast medium (e.g. contrast medium allergy, contrast induced nephropathy) can also be encountered in diagnostic angiography. The most common complications of endovascular treatment of cerebral aneurysms are related to acute thromboembolic events and perforation of the aneurysm. Overall, the reported rate of thromboembolic complications ranges between 4.7% and 12.5% while the rate of intraprocedural rupture of cerebral aneurysms is about 0.7% in patients with unruptured aneurysms and about 4.1% in patients with previously ruptured aneurysms. Thromboembolic and hemorrhagic complications may occur during different phases of endovascular procedures and are related to different technical, clinical and anatomic reasons. A thorough knowledge of the different aspects of these complications can reduce the risk of their occurrence and minimize their clinical sequelae. A deep understanding of complications and of their management is thus part of the best standard of care. [ABSTRACT FROM AUTHOR]

Abstract: Tamoxifen is a selective oestrogen receptor modulator used in pre-menopausal oestrogen receptor positive breast cancer patients as adjuvant endocrine treatment. Increased risk of venous thrombo-embolism with the use of Tamoxifen is well known from published literature. This risk further increases in patients undergoing surgical procedures of high risk involving prolonged period of immobilization, therefore withholding Tamoxifen treatment in the immediate peri-operative period should be considered as a risk reducing measure. In the absence of nationally agreed guidelines on the safe duration for stoppage of treatment in the pre and post operative period without worsening cancer prognosis, operating surgeons and individual trusts have adopted their own guidelines based on individual experience. From the available evidence in the literature on the VTE risk assessments based on age, operative procedure and pharmacokinetics of the Tamoxifen drug we would like to propose a working algorithm for selecting the right patient group and safe treatment stoppage durations. These proposed guidelines are formulated taking all the risk factors of VTE, operative risks, pharmacokinetics of the drug and chemotherapy risks into consideration. With this guidance, we aim to help surgeons across different specialities in the decision making process through a structured evidence based approach. [Copyright &y& Elsevier]

Aims It is presently unknown whether patients with atrial fibrillation (AF) are at increased risk of thrombo-embolic adverse events after interruption of warfarin treatment. The purpose of this study was to assess the risk and timing of thrombo-embolism after warfarin treatment interruption. Methods and results A retrospective, nationwide cohort study of all patients in Denmark treated with warfarin after a first hospitalization with AF in the period 1997–2008. Incidence rate ratios (IRRs) of thrombo-embolic events and all-cause mortality were calculated using the Poisson regression analyses. In total, 48 989 AF patients receiving warfarin treatment were included. Of these, 35 396 patients had at least one episode of warfarin treatment interruption. In all, 8255 deaths or thrombo-embolic events occurred during treatment interruption showing an initial clustering of events with 2717, 835, 500, and 427 events occurring during 0–90, 91–180, 181–270, and 271–360 days after treatment interruption, respectively. Correspondingly, the crude incidence rates were 31.6, 17.7, 12.3, and 11.4 events per 100 patient-years. In a multivariable analysis, the first 90-day interval of treatment interruption was associated with a markedly higher risk of death or thrombo-embolism (IRR 2.5; 95% confidence interval 2.3–2.8) vs. the interval of 271–360 days. Conclusion In patients with AF, an interruption of warfarin treatment is associated with a significantly increased short-term risk of death or thrombo-embolic events within the first 90 days of treatment interruption. [ABSTRACT FROM PUBLISHER]

Chronic heart failure (HF) with either reduced or preserved ejection fraction is common and remains an extremely serious disorder with a high mortality and morbidity. Many complications related to HF can be related to thrombosis. Epidemiological and pathophysiological data also link HF to an increased risk of thrombosis, leading to the clinical consequences of sudden death, stroke, systemic thrombo-embolism, and/or venous thrombo-embolism. This consensus document of the Heart Failure Association (EHFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Thrombosis reviews the published evidence and summarizes ‘best practice’, and puts forward consensus statements that may help to define evidence gaps and assist management decisions in everyday clinical practice. In HF patients with atrial fibrillation, oral anticoagulation is recommended, and the CHA2DS2-VASc and HAS-BLED scores should be used to determine the likely risk–benefit ratio (thrombo-embolism prevention vs. risk of bleeding) of oral anticoagulation. In HF patients with reduced left ventricular ejection fraction who are in sinus rhythm there is no evidence of an overall benefit of vitamin K antagonists (e.g. warfarin) on mortality, with risk of major bleeding. Despite the potential for a reduction in ischaemic stroke, there is currently no compelling reason to use warfarin routinely for these patients. Risk factors associated with increased risk of thrombo-embolic events should be identified and decisions regarding use of anticoagulation individualized. Patient values and preferences are important determinants when balancing the risk of thrombo-embolism against bleeding risk. New oral anticoagulants that offer a different risk–benefit profile compared with warfarin may appear as an attractive therapeutic option, but this would need to be confirmed in clinical trials. [ABSTRACT FROM AUTHOR]

Aims Heart failure (HF) increases the risk of stroke and thrombo-embolism (TE) in non-valvular atrial fibrillation (NVAF), and is incorporated in stroke risk stratification scores. We aimed to establish the role of ejection fraction (EF) in risk prediction in patients with NVAF and HF. Methods and results Patients with NVAF, history of HF, and measured EF were included in a retrospective analysis. Patients with HF and preserved ejection fraction (HFPEF) were defined as those with clinical HF and EF ≥50% in this study. Among 7156 patients with NVAF, 1276 (17.8%) patients with HF and measured EF were included. Of these, 747/1276 (58.5%) patients were on vitamin K antagonists. The stroke/TE event rate per 100 person-years was 1.05 [95% confidence interval (CI) 0.87–1.25]. Patients with HFPEF were more likely to be female (P < 0.001), older (P < 0.001), and hypertensive (P < 0.001), and less likely to have prior vascular disease (P < 0.001). There were no differences in rates of stroke (P = 0.17) and stroke/TE (P = 0.11) between patients with HFPEF and those with HF and reduced EF. There were no significant differences in rates of all-cause mortality when patients were stratified by EF. In multivariate analyses, only previous stroke (hazard ratio 2.36, 95% CI 1.45–3.86) and vascular disease (1.57, 1.07–2.30) increased the risk of stroke/TE amongst NVAF patients with HF, but EF <35% did not (0.75, 0.44–1.30). Conclusion In NVAF patients with HF, there were no differences in rates of stroke, TE, or death between EF categories. Only previous stroke and vascular disease (and not decreased EF) independently increased risk of stroke/TE in multivariate analyses. [ABSTRACT FROM PUBLISHER]

Purpose: Atrial fibrillation (AF) is one of the major risk factors for ischemic stroke, and 90% of thromboembolisms in these patients arise from the left atrial appendage (LAA). Recently, it has been documented that an LAA occlusion device (OD) is not inferior to warfarin therapy, and that it reduces mortality and risk of stroke in patients with AF. Materials and Methods: We implanted LAA-ODs in 5 Korean patients (all male, 59.8±7.3 years old) with long-standing persistent AF or permanent AF via a percutaneous trans-septal approach. Results: 1) The major reasons for LAA-OD implantation were high risk of recurrent stroke (80%), labile international neutralizing ratio with hemorrhage (60%), and 3/5 (60%) patients had a past history of failed cardioversion for rhythm control. 2) The mean LA size was 51.3±5.0 mm and LAA size was 25.1 x 30.1 mm. We implanted the LAA-OD (28.8±3.4 mm device) successfully in all 5 patients with no complications. 3) After eight weeks of anticoagulation, all patients switched from warfarin to anti-platelet agent after confirmation of successful LAA occlusion by transesophageal echocardiography. Conclusion: We report on our early experience with LAA-OD deployment in patients with 1) persistent or permanent AF who cannot tolerate anticoagulation despite significant risk of ischemic stroke, or 2) recurrent stroke in patients who are unable to maintain sinus rhythm. [ABSTRACT FROM AUTHOR]

Abstract: Background: Both cancer patients and patients undergoing surgery are thought to be at an increased risk of thrombo-embolic events. Consequently, low-molecular-weight heparin (LMWH) is administered to all such patients perioperatively. There is a lack of consensus in guidelines regarding the timing of administration and the dosage of thromboprophylactic agents. Studies have shown that thrombo-elastography (TEG) is a useful test in assessing global haemostatic function, and has been validated in monitoring the dosage of LMWH. In this study, we assess the coagulation status of patients undergoing thoracic surgery with TEG, and the effectiveness of administered LMWH for thromboprophylaxis. Methods: Thirty patients with primary lung cancer (LC) and 30 with benign lung disease (BL) were studied prospectively. Patients were randomised to receive subcutaneous LMWH 40mg once or twice per day perioperatively. Their coagulation status was monitored with TEG preoperatively and postoperatively for 3 consecutive days. Results: Preoperative TEG parameters (k time, alpha angle and maximum amplitude (MA)) were within the normal range in both the LC and BL groups. Preoperative r time was prolonged in both the groups, but with no significant difference between the two groups (p >0.05). Postoperatively, r time was prolonged in some patients receiving LMWH twice daily, suggesting a possible adequate thromboprophylaxis in these patients only. Conclusion: This study demonstrates that the majority of patients with LC are not hypercoagulable. We also showed that LMWH once or twice a day might not provide sufficient thromboprophylaxis. We advocate screening for patients demonstrating hypercoagulable states and ensuring adequate thromboprophylaxis in this group of patients with careful monitoring. [Copyright &y& Elsevier]

Abstract: The Confidential Enquiry into Maternal Deaths has provided important information about the causes of death, areas of sub-standard care, and vulnerable groups of women in the UK. The latest report has identified obesity as an important emerging theme. Thromboembolism is the most common direct cause and cardiac disease the most common indirect cause of maternal mortality. Deaths from suicide were fewer than in the previous triennium. Early recognition of serious illness and effective, multidisciplinary, team working are key to avoiding potentially avoidable maternal deaths. [Copyright &y& Elsevier]

This article discusses the complications of neurointerventional treatment of cerebral aneurysms, which include thromboembolic complications, clot at the aneurysm neck and parent vessel occlusion. Topics include analyzing the computed tomography (CT) and the digital subtraction angiography (DSA) and schematic outline of the clotting pathway and its interaction with the platelets.

Irrespective of aetiology, the nephrotic syndrome presents a range of potentially serious complications. These include thrombo-embolism, infection and hyperlipidaemia. Despite the prevalence of the nephrotic state among renal patients, there has been little prospective analysis of the therapeutic approach to these potentially life-threatening events even though their pathogenesis has been examined in some detail. Most of these complications are more prevalent once the albumin concentration falls below 20 g/L and it is recognized that restoration of serum albumin significantly diminishes their frequency. However, this may be difficult to achieve, especially in adults. The problems of thrombo-embolism and infection are of immediate concern but, in persistent cases, the additional issues of hyperlipidaemia and loss of bone density also require consideration for therapy. Thus, in addition to specific attempts to reduce proteinuria, it is recommended that high-risk nephrotic patients receive anticoagulation, pneumococcal vaccination and lipid lowering therapy. Strategies for the preservation of bone density should also be considered, particularly in patients who receive high-dose corticosteroids. Among a range of non-specific treatments for proteinuria, angiotensin-converting enzyme inhibitors appear best in terms of efficacy and safety. Prospective trials are required to clarify the longitudinal impact of these generic strategies on the protection of the persistently nephrotic patient. [ABSTRACT FROM AUTHOR]

The purpose of the study was to assess the clinical safety and efficacy of the “RecoveryTM” (Bard) inferior vena cava (IVC) filter. We retrospectively evaluated the clinical and imaging data of patients who had a “RecoveryTM” IVC filter placed between January 2003 and December 2004 in our institution. The clinical presentation, indications, and procedure-related complications during placement and retrieval were evaluated. Follow-up computed tomography (CT) examinations of the abdomen and chest were evaluated for filter-related complications and pulmonary embolism (PE), respectively. “Recovery” filters were placed in 96 patients (72 males and 24 females; age range: 16–87 years; mean: 46 years). Twenty-four patients presented with PE, 13 with deep vein thrombosis (DVT) and 2 with both PE and DVT. The remaining 57 patients had no symptoms of thromboembolism. Indications for filter placement included contraindication to anticoagulation ( n = 27), complication of anticoagulation ( n = 3), failure of anticoagulation ( n = 5), and prophylaxis ( n = 61). The device was successfully deployed in the infrarenal ( n = 95) or suprarenal ( n = 1) IVC through a femoral vein approach. Retrieval was attempted in 11 patients after a mean period of 117 days (range: 24–426). The filter was successfully removed in nine patients (82%). Failure of retrieval was due to technical difficulty ( n = 1) and the presence of thrombus in the filter ( n = 1). One of the nine patients who had the filter removed developed IVC thrombus after retrieval and another had an intimal tear of the IVC. Follow-up abdominal CT ( n = 40) at a mean of 80 days (range: 1–513) showed penetration of the IVC by the filter arms in 11, of which 3 had fracture of filter components. In one patient, a broken arm migrated into the pancreas. Asymmetric deployment of the filter legs was seen in 12 patients and thrombus within the filter in 2 patients. No filter migration or caval occlusion was encountered. Follow-up chest CT ( n = 27) at a mean of 63 days (range: 1–386) showed PE in one patient (3%). During clinical follow-up, 12 of 96 patients developed symptoms of PE and only 1 of the 12 had PE on CT. There was no fatal pulmonary embolism in our group of patients following “Recovery” filter placement. However, the current version of the filter is associated with structure weakness, a high incidence of IVC wall penetration, and asymmetric deployment of the filter legs. [ABSTRACT FROM AUTHOR]

Aims The objective of this study is to characterize the incidence of peri-operative severe adverse events (AEs) related to the post-operative use of heparin in patients undergoing pacemaker surgery. Methods and results We retrospectively compared the outcome of 38 patients with mechanical valves (MVs) and 76 patients with atrial fibrillation (AF) with control cases matched for gender, age, and surgical details. Heparin was systematically used post-operatively in MV patients, but left to clinical judgment in AF patients. The relative risk for severe haemorrhagic AEs was 11 (CI 1.5–81.1, P<0.01) in the MV group when compared with matched controls and 8 (CI 1.0–62.5, P<0.05) in the AF group. Overall, the relative risk of heparin use in the post-operative period was 14 (CI 1.88–104, P=0.0006) and the post-operative stay was prolonged from 7 days in this group when compared with control cases (P<0.0001).The variables associated with haemorrhage were the delay to restart heparin after surgery and the presence of an MV. [ABSTRACT FROM PUBLISHER]

SUMMARY A prospective study was performed to evaluate the usefulness of CT pelvic venography (CTV) in the detection of pelvic vein thrombosis in patients referred for CT pulmonary angiography (CTPA) for suspected pulmonary embolism. Fifty consecutive patients referred for CTPA had CTV performed at the time of CTPA. All patients had duplex ultrasound (DUS) of the lower limb veins for evaluation of deep venous thrombosis (DVT) within 24 h of the CT study. Twelve (24%) of the 50 patients had pulmonary embolism diagnosed on CTPA. Associated DVT was detected in six of these patients; two cases were detected by CTV alone, while one case was detected by both CTV and DUS. The remaining three cases had DVT diagnosed by DUS alone. In the 38 patients with a negative CTPA, three patients had venous thrombus diagnosed by CTV. Of these three patients, two had a negative DUS study. CTV therefore led to a definitive imaging diagnosis of thrombo-embolic disease in two (4%) more patients. CTV adds little time and cost to the CTPA examination and leads to a moderate increase in definite imaging diagnosis of thrombo-embolic disease. [ABSTRACT FROM AUTHOR]

Premedication is any drug or therapy administered before surgery. In the past this has mainly been used for the control of autonomic responses to anaesthetic agents, and for facilitating gas induction when this was the norm. Premedication declined from being almost universal until the 1980s to a much lower level today. The decline has been associated with a change in the type of premedication from sedative and antisialagogue to analgesia, anti-reflux and other diverse agents aimed at optimizing the patient's peri-operative state. [ABSTRACT FROM AUTHOR]

Objective: This study is conducted to compare the risk of thrombo-embolism during different phases of menstrual cycles. Methodology:105 healthy premenopausal unmarried females of 18 -21 years with a history of previous three normal menstrual cycles and 32 age matched male volunteers were recruited in the study. The phase of menstrual cycle of female volunteers was established by taking menstrual history. Bleeding time was determined by Duke's method. Results: Bleeding time in 105 females was 73.03±1.89 Seconds and in 32 males was 69.33±4.94 Seconds which were not significantly different statistically (p=0.063). Among females, 69 volunteers were in follicular phase of their hormonal cycle. Bleeding time in 29 females in early follicular phase was 70.86±3.38 Seconds and 40 females in late follicular phase was 68.25±4.03 Seconds. Statistically significant difference was not seen (p=0.095) when the two phases were compared. Bleeding time is not found to be reduced in late follicular phase as compared to early follicular phase, even high concentration of estrogen is present in the body in this phase as per normal menstrual physiology. Conclusion: High Estrogen in normal menstrual cycle does not increase thrombo-embolic risk in healthy women. [ABSTRACT FROM AUTHOR]

Assays which detect the release of platelet proteins and of pep tides during thrombogenesis and are considered markers of activation of platelets and the coagulation system have recently been developed. This study was designed to utilize these haemostasis-related markers to lest the hypothesis that a prethrombotic state is related to the presence, aetiology and severity of heart failure. Seventy patients with heart failure were evaluated and data were compared with 36 normal volunteers and 41 patients with coronary artery disease without heart failure (CAD). Thrombogenesis was documented using assays which measure platelet function, thrombin activity and fibrinolysis. Platelet function was measured by determining plasma concentrations of platelet factor 4 (PF4) and beta-thromboglobulin (BTG). Thrombin antithrombin III complexes (TAT) and fibrinopeptide A (FPA) were determined to evaluate thrombin activity. Fibrinolyric activity was assessed by measuring D-Dimer levels. Patients with heart failure, when compared to normals, had increased plasma levels of BTG (89±62 IU. ml vs 50±59 IU. ml, <0.01), TAT (4.6±4.3 μg. l vs 2.3±0.64 μg. l, <0.005 and D-Dimer levels (506±444 IU. ml vs 191±144 IU. ml, < 0.0001). Patients with heart failure, when compared to the CAD group, had increased plasma levels of D-Dimer (506±444 ng. ml vs 191±144 ng. ml, P <0.05). Aetiology of heart failure did not affect these measurements. Patients with severe heart failure, as determined by high plasma norepinephrine concentration or low ejection fraction, were more likely to have activation of platelets and the coagulation system. Our study indicates that patients with heart failure have evidence of increased platelet and thrombin activation and fibrinolytic activity. These abnormalities are most pronounced in patients with severe heart failure. [ABSTRACT FROM PUBLISHER]

Tranexamic acid (TA) act as anti-fi brinolytic agent and is widely used to limit bleeding in clinical practice. Tranexemic acid bind with plasminogen and prevent its conversion to plasmin, which limits the fi brinolytic pathway, so there is a theoretical risk of increasing thrombosis with high or prolonged therapy with TA. We encountered a case of acute arterial thrombosis following inadvertent administration of high dose of TA. A 27-years-old male with no other co-morbidity was ordered intravenous 1 gm TA to control excessive bleeding from previous bladder injury, but by mistake, he received 10 gm of TA. The patient developed signs and symptoms of acute ischemia in the right lower limb, which was diagnosed as acute iliac arterial thrombosis by computed tomography (CT) angiography. The patient was managed with systemic heparinization, fasciotomy for impending gangrene and other supportive care following which he recovered fully within a few days. Caution should be exercised for all prophylactic use, especially with high dosage or prolonged therapy with TA. [ABSTRACT FROM AUTHOR]

Abstract: Premedication is any drug or therapy administered before surgery. In the past this has mainly been used for the control of autonomic responses to anaesthetic agents, and for facilitating gas induction when this was the norm. Premedication declined from being almost universal until the 1980s to a much lower level today. The decline has been associated with a change in the type of premedication from sedative and antisialagogue to analgesia, anti-reflux and other diverse agents aimed at optimizing the patient''s peri-operative state. [Copyright &y& Elsevier]

Prominent ventricular trabeculations are seen in a fetal heart. Isolated ventricular non-compaction (IVNC) is a rare form of primary cardiomyopathy. It usually presents with heart failure, arrhythmias and very rarely with thrombo-embolic manifestation. The left ventricle is involved in the majority of the cases. Echocardiography is the principal modality for the diagnosis of this condition. IVNC may be misdiagnosed as dilated or hypertrophic cardiomyopathy wherein the prognosis and management do differ significantly. We report a case of a 38-yearold male with IVNC involving both the ventricles, who presented very unusually as stroke resulting from a cardiogenic embolus. [ABSTRACT FROM AUTHOR]