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Introduction: Arterial thoracic outlet syndrome (aTOS) is the least common among the 3 subtypes of thoracic outlet syndrome and can be the cause of posterior circulation infarction due to thrombus from a secondary thrombosed subclavian-axillary artery aneurysm., Case Report: Here, we report a case of a 51-year-old man who presented to our institute with sudden onset vertigo, dizziness, vomiting, gait imbalance, and visual field defects immediately after strenuous exercise. Computed tomography angiography revealed bilateral cervical ribs with aneurysmal dilatation of the left distal subclavian and proximal axillary arteries. The computed tomography also revealed subacute infarcts in the bilateral cerebellar hemispheres, as well as in the bilateral occipital lobes. Color Doppler evaluation of the subclavian artery after hyperabduction of the ipsilateral arm revealed a continuous reversal of flow in the subclavian artery, which reached the vertebral ostia. The left cervical rib was resected, aneurysm was repaired, and the patient remained asymptomatic on follow-up., Conclusion: Posterior circulation stroke caused by the ipsilateral thrombosed subclavian artery aneurysm in an adult patient with aTOS due to a complete cervical rib is rare. A high index of suspicion should be present for thoracic outlet syndrome in patients with stroke and upper-limb arterial claudication symptoms. Dynamic Doppler evaluation in such patients can be used to demonstrate the underlying pathomechanism, and definitive surgical treatment can prevent further ischemic episodes. Posterior circulation stroke caused by partially thrombosed distal subclavian and axillary artery aneurysms due to aTOS is rare., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The goals of this study were to investigate the treatment outcomes of acute thromboembolic occlusion of the superior mesenteric artery (ATOS) and identify prognostic factors after treatment., Methods: The clinical data of 62 patients with ATOS between 2013 and 2021 were retrospectively reviewed. Patients were stratified by the treatment strategy, complications and mortality were compared in different group., Results: Sixty-two consecutive patients were identified with ATOS. The median patient age was 69 years (interquartile range 58-79 years). Endovascular therapy was initiated in 21 patients, and 4 patients received conservative treatment. Open surgery was performed first in the remaining 37 patients. The technical success rates of the endovascular first group and open surgery group were 90.5% and 97.3%, respectively. One patient in the conservative treatment group had progression of ischemia to extensive bowel necrosis. There was no difference in 30-day mortality between these groups. Predictors of 30-day mortality included initial neutrophil count > 12* 103/dL, age over 60 years old and history of chronic renal insufficiency., Conclusions: Endovascular treatment or conservative treatment may be adopted in selected patients who do not exhibit signs and symptoms of bowel necrosis, and close monitoring for bowel necrosis is important. The increase in preoperative neutrophil count, age over 60 years old and history of chronic renal insufficiency were poor prognostic factors., (© 2024. The Author(s).)

Introduction: This study aimed to assess the relationship between preoperative international normalized ratio (INR) levels and major postoperative bleeding events after total shoulder arthroplasty (TSA)., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for TSA from 2011 to 2020. A final cohort of 2405 patients with INR within 2 days of surgery were included. Patients were stratified into four groups: INR ≤ 1.0, 1.0 < INR ≤ 1.25, 1.25< INR ≤ 1.5, and INR > 1.5. The primary outcome was bleeding requiring transfusion within 72 hours, and secondary outcome variables included complication, revision surgery, readmission, and hospital stay duration. Multivariable logistic and linear regression analyses adjusted for relevant comorbidities were done., Results: Of the 2,405 patients, 48% had INR ≤ 1.0, 44% had INR > 1.0 to 1.25, 7% had INR > 1.25 to 1.5, and 1% had INR > 1.5. In the adjusted model, 1.0 < INR ≤ 1.25 (OR 1.7, 95% CI 1.176 to 2.459), 1.25 < INR ≤ 1.5 (OR 2.508, 95% CI 1.454 to 4.325), and INR > 1.5 (OR 3.200, 95% CI 1.233 to 8.302) were associated with higher risks of bleeding compared with INR ≤ 1.0., Discussion: The risks of thromboembolism and bleeding lie along a continuum, with higher preoperative INR levels conferring higher postoperative bleeding risks after TSA. Clinicians should use a patient-centered, multidisciplinary approach to balance competing risks., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Rationale: Giant intracranial aneurysms pose a significant threat due to high mortality rates upon rupture, prompting interventions such as neurosurgical clipping or endovascular coiling., Patient Concerns: We present a rare case involving a 47-year-old female with a history of successfully treated ruptured giant intracranial aneurysms. Six months post-surgical clipping, she developed symptoms of acute ischemic stroke, prompting the decision for neurosurgical coiling and stent-assisted aneurysm coil embolization due to recurrent intracranial aneurysms., Diagnoses: Subsequently, occlusion occurred at the previously implanted stent site during embolization, necessitating exploration of alternative therapeutic options. Digital subtraction angiography confirmed stent occlusion in the right middle cerebral artery., Interventions: Despite an initial unsuccessful attempt using a direct aspiration first-pass technique, the patient underwent successful mechanical thrombectomy with a retrievable stent, leading to successful reperfusion. This study aims to highlight the challenges and therapeutic strategies in managing delayed cerebral vascular occlusion following stent-assisted coil embolization, emphasizing the significance of exploring alternative interventions to enhance patient outcomes., Outcomes: The patient achieved successful reperfusion, and the study underscores the importance of recognizing and addressing delayed cerebral vascular occlusion after stent-assisted coil embolization for recurrent cerebral aneurysms., Lessons: Our findings suggest that retrievable stent mechanical thrombectomy may serve as a viable therapeutic option in challenging scenarios, emphasizing the need for further exploration of alternative interventions to enhance patient care., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Cox-Maze procedure is currently the gold standard treatment for atrial fibrillation (AF). However, data on the effectiveness of the Cox-Maze procedure after concomitant mitral valve surgery (MVS) are not well established. The aim of this study was to assess the safety and efficacy of Cox-Maze procedure versus no-maze procedure n in AF patients undergoing mitral valve surgery through a systematic review of the literature and meta-analysis., Methods: A systematic search on PubMed/MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials (Cochrane Library, Issue 02, 2017) databases were performed using three databases from their inception to March 2023, identifying all relevant randomized controlled trials (RCTs) comparing Cox-Maze procedure versus no procedure in AF patients undergoing mitral valve surgery. Data were extracted and analyzed according to predefined clinical endpoints., Results: Nine RCTs meeting the inclusion criteria were included in this systematic review with 663 patients in total (341 concomitant Cox-Maze with MVS and 322 MVS alone). Across all studies with included AF patients undergoing MV surgery, the concomitant Cox-Maze procedure was associated with significantly higher sinus rhythm rate at discharge, 6 months, and 12 months follow-up when compared with the no-Maze group. Results indicated that there was no significant difference between the Cox-Maze and no-Maze groups in terms of 1 year all-cause mortality, pacemaker implantation, stroke, and thromboembolism., Conclusions: Our systematic review suggested that RCTs have demonstrated the addition of the Cox-Maze procedure for AF leads to a significantly higher rate of sinus rhythm in mitral valve surgical patients, with no increase in the rates of mortality, pacemaker implantation, stroke, and thromboembolism., (© 2024. The Author(s).)

Background: Morphologically, the risk of aortic aneurysm rupture is mainly evaluated based on its type (e.g., fusiform or saccular) and diameter. Based on the finite element analysis, peak wall stress has been identified as a more sensitive and specific predictor of rupture in recent years. Moreover, in finite analysis, the neck of aneurysm is the highest peak wall stress and is associated with the rupture point., Case Presentation: A saccular aortic aneurysm (84 mm) was incidentally detected during preoperative examination for chronic empyema in a 74-year-old male patient with a history of polycythemia. Aortic arch graft replacement using an open stent was performed., Conclusions: Morphologically, this case was associated with a very high risk of rupture; nevertheless, it did not rupture. In this case, a mural thrombus (likely formed due to polycythemia) covered the neck of aneurysm that is experiencing the highest peak wall stress and is associated with the rupture point. The mural thrombus decreased peak wall stress and could reduce the risk of rupture even for huge saccular aneurysms. Furthermore, the mural thrombus was fully occupied in aneurysms, such as during coil embolization. Thus, polycythemia could decrease the risk of rupture of huge saccular aneurysms., (© 2024. The Author(s).)

Background: Diagnostic rates and risk factors for the subsequent development of chronic thromboembolic pulmonary hypertension (CTEPH) following pulmonary embolism (PE) are not well defined., Methods: Over a 10-year period (2010-2020), consecutive patients attending a PE follow-up clinic in Sheffield, UK (population 554 600) and all patients diagnosed with CTEPH at a pulmonary hypertension (PH) referral centre in Sheffield (referral population estimated 15-20 million) were included., Results: Of 1956 patients attending the Sheffield PE clinic 3 months following a diagnosis of acute PE, 41 were diagnosed with CTEPH with a cumulative incidence of 2.10%, with 1.89% diagnosed within 2 years. Of 809 patients presenting with pulmonary hypertension (PH) and diagnosed with CTEPH, 32 were Sheffield residents and 777 were non-Sheffield residents. Patients diagnosed with CTEPH at the PE follow-up clinic had shorter symptom duration (p<0.01), better exercise capacity (p<0.05) and less severe pulmonary haemodynamics (p<0.01) compared with patients referred with suspected PH. Patients with no major transient risk factors present at the time of acute PE had a significantly higher risk of CTEPH compared with patients with major transient risk factors (OR 3.6, 95% CI 1.11-11.91; p=0.03). The presence of three computed tomography (CT) features of PH in combination with two or more out of four features of chronic thromboembolic pulmonary disease at the index PE was found in 19% of patients who developed CTEPH and in 0% of patients who did not. Diagnostic rates and pulmonary endarterectomy (PEA) rates were higher at 13.2 and 3.6 per million per year, respectively, for Sheffield residents compared with 3.9-5.2 and 1.7-2.3 per million per year, respectively, for non-Sheffield residents., Conclusions: In the real-world setting a dedicated PE follow-up pathway identifies patients with less severe CTEPH and increases population-based CTEPH diagnostic and PEA rates. At the time of acute PE diagnosis the absence of major transient risk factors, CT features of PH and chronic thromboembolism are risk factors for a subsequent diagnosis of CTEPH., Competing Interests: Conflict of interest: C. Durrington reports support for the present manuscript from NIHR Sheffield Biomedical Research Centre, and also reports lecture honoraria from Janssen Pharmaceuticals, outside the submitted work. C.A. Elliot reports lecture honoraria and travel support from Janssen Pharmaceuticals, outside the submitted work. D. De-Fonseka reports a leadership role on the Pleural Specialist Advisory Group and Pleural Disease Guideline Committee for the British Thoracic Society, outside the submitted work. A.J. Swift reports support for the present manuscript from a Wellcome Trust fellowship, and also reports grants from Janssen Pharmaceuticals, NIHR and Wellcome Trust, and consulting fees from Janssen Pharmaceuticals, outside the submitted work. K. Dwivedi reports support for the present manuscript from Wellcome 4Ward North fellowship, and also reports grants from Janssen, and lecture honoraria from Royal College of Radiologists, and is a committee member for the Royal College of Radiologists Artificial Intelligence Working Group and Royal College of Radiologists RADIANT group, outside the submitted work. A. Charalampopoulos reports lecture honoraria from Janssen and Boehringer, outside the submitted work. A. Hameed reports lecture honoraria and travel support from Janssen, outside the submitted work. A.M.K. Rothman reports grants from a Wellcome Trust Clinical Research Career Development Fellowship (206632/Z/17/Z), MRC (experimental medicine grant MR/W026279/1), Abbott Laboratories, Medtronic Inc., Endotronix, SoniVie, NXT Biomedical, Gradient and Neptune Medical, outside the submitted work. N. Hamilton reports consulting fees and travel support from Janssen, lecture honoraria from MSD and Janssen, advisory board participation with Bayer, MSD, Janssen and Vifor, and a leadership role as pharmacist for the NHS Specialist Respiratory Clinical Reference Group, outside the submitted work. A.A.R. Thompson reports grants from the British Heart Foundation and NIHR, and lecture honoraria and travel support from Janssen-Cilag Ltd, outside the submitted work. R. Condliffe reports lecture honoraria and travel support from Janssen Pharmaceuticals, outside the submitted work. D.G. Kiely reports support for the present manuscript from NIHR Sheffield Biomedical Research Centre, and also reports grants from Janssen Pharmaceuticals, NIHR Sheffield Biomedical Research Centre and Ferrer, consulting fees and lecture honoraria from Janssen Pharmaceuticals, Ferrer, Altavant, MSD and United Therapeutics, travel support from Janssen, Ferrer, MSD and United Therapeutics, advisory board membership for Janssen and MSD, and leadership roles as a member of the Clinical Reference Group for Specialised Respiratory Medicine (NHS England) and lead of the UK National Audit of Pulmonary Hypertension, outside the submitted work. The remaining authors have no potential conflicts of interest to disclose., (Copyright ©The authors 2024. For reproduction rights and permissions contact permissions@ersnet.org.)

Systemic thromboembolism associated with atrial fibrillation (AF) is usually caused by thrombi in the left atrial appendage and acute onset. We experienced an unusual case of a woman in her 60s who presented to the outpatient district having bilateral intermittent claudication for more than 1 month, which turned out to be multiple thromboembolism from asymptomatic AF with tachycardia. She was also complicated with non-ischaemic dilated cardiomyopathy with reduced ejection fraction, consistent with arrhythmia-induced cardiomyopathy (AiCM), along with left atrial and left ventricular thrombi and thromboembolism in multiple organs. Rate control with beta-blockers was not effective. With the administration of amiodarone after adequate anticoagulation therapy, she returned to sinus rhythm, and the ejection fraction was restored. This case is instructive in that AiCM with AF can cause thrombosis in the left ventricle, and the patient may present with worsening intermittent claudication as a result of systemic embolism., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A multigravida in her late 20s was diagnosed with inferior vena cava thrombosis (IVCT) and PE at 26 weeks of pregnancy after a routine prenatal care visit. The patient denied any diseases that could cause IVCT, as well as the presence of any symptoms. Progressive thrombocytopenia was diagnosed in the period until the implantation of the inferior vena cava filter (IVCF). Due to a rupture of foetal membranes and chorioamnionitis, labour was induced at 32 weeks of pregnancy. The IVCF remained in place and anticoagulants were continued through the postpartum period for up to 6 months., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: Residual leaks are not infrequent after left atrial appendage occlusion. However, there is still uncertainty regarding their prognostic implications. The aim of this study is to evaluate the impact of residual leaks after left atrial appendage occlusion., Methods: A literature search was conducted until 19 February 2023. Residual leaks comprised peri-device leaks (PDLs) on transoesophageal echocardiography (TEE) or computed tomography (CT), as well as left atrial appendage patency on CT. Random-effects meta-analyses were performed to assess the clinical impact of residual leaks., Results: Overall 48 eligible studies (44 non-randomized/observational and 4 randomized studies) including 61 666 patients with atrial fibrillation who underwent left atrial appendage occlusion were analysed. Peri-device leak by TEE was present in 26.1% of patients. Computed tomography-based left atrial appendage patency and PDL were present in 54.9% and 57.3% of patients, respectively. Transoesophageal echocardiography-based PDL (i.e. any reported PDL regardless of its size) was significantly associated with a higher risk of thromboembolism [pooled odds ratio (pOR) 2.04, 95% confidence interval (CI): 1.52-2.74], all-cause mortality (pOR 1.16, 95% CI: 1.08-1.24), and major bleeding (pOR 1.12, 95% CI: 1.03-1.22), compared with no reported PDL. A positive graded association between PDL size and risk of thromboembolism was noted across TEE cut-offs. For any PDL of >0, >1, >3, and >5 mm, the pORs for thromboembolism were 1.82 (95% CI: 1.35-2.47), 2.13 (95% CI: 1.04-4.35), 4.14 (95% CI: 2.07-8.27), and 4.44 (95% CI: 2.09-9.43), respectively, compared with either no PDL or PDL smaller than each cut-off. Neither left atrial appendage patency, nor PDL by CT was associated with thromboembolism (pOR 1.45 and 1.04, 95% CI: 0.84-2.50 and 0.52-2.07, respectively)., Conclusions: Peri-device leak detected by TEE was associated with adverse events, primarily thromboembolism. Residual leaks detected by CT were more frequent but lacked prognostic significance., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Takotsubo syndrome (TTS) is a transient ventricular dysfunction with apical ballooning triggered by emotional and/or physical stress. A few risk factors have been observed in patients with recurrent TTS, for example, excessive sympathetic stimuli, medications, stress, and tumors. Clinical features can vary from chest pain to overt hemodynamic instability. Diagnosis requires both electrocardiographic features and invasive imaging such as angiography to rule out other causes of cardiomyopathy prior to diagnosis. In addition, renal infarcts presenting as a complication of TTS are relatively uncommon. In this case report, we discuss the case of a 61-year-old African American woman with a prior history of TTS being managed for abdominal pain who developed a recurrence of the TTS during the hospital course. Prompt diagnosis and management of the condition is crucial to improve outcomes especially in patients with thromboembolic phenomenon or hemodynamic instability. Further large-scale studies are warranted to determine outcomes of patients with recurrent Takotsubo cardiomyopathy with thromboembolic phenomenon., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Chronic thromboembolic pulmonary disease (CTEPD) consists of persistent pulmonary vascular obstruction on imaging and involves long-term functional limitations, with or without chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study was to evaluate the incidence and risk factors of both persistent pulmonary vascular defects and CTEPH after hospitalization in patients with COVID-19 and PE during a 2-year follow-up., Methods: A prospective observational study was carried out in a tertiary hospital center. Patients were hospitalized between March 2020 and December 2021 with a diagnosis of PE during SARS-CoV-2 infection. Patients received anticoagulant treatment for at least 3 months and were followed up for 2 years. Between the third and fourth months after discharge, all patients were evaluated for the presence of residual thrombotic defects by CTPA and/or perfusion pulmonary scintigraphy. Clinical findings, lung function tests with DLCO, exercise capacity, and echocardiograms were also assessed., Results: Of the 133 patients included, 18% had persistent thrombotic defects on lung imaging at follow-up. The incidence of CTEPD was 0.75% at 2 years of follow-up. Patients with persistent defects were significantly older, had a higher prevalence of systemic arterial hypertension, higher D-dimer and NT-proBNP levels, and more severe PE at diagnosis. Furthermore, there was a higher prevalence of right ventricular dysfunction on echocardiogram at diagnosis of PE (25.0% vs. 2.7%, p = 0.006). This was the only variable independently related to persistent defects in multivariate analyses (OR: 8.13 [95% CI: 1.82-36.32], p = 0.006)., Conclusion: The persistence of thrombotic defects after PE is a common finding after SARS-CoV-2 infection, affecting 18% of the population. However, the incidence of CTEPH appears to be lower (0.75%) in COVID-19-related PE compared to that previously observed in PE unrelated to COVID-19., (© 2024 S. Karger AG, Basel.)

Objective: To analyze the risk factors of thrombosis in patients with JAK2 V617F mutation positive myeloproliferative neoplasms (MPN). Methods: A total of 223 MPN patients with JAK2 V617F mutation in the Second Hospital of Tianjin Medical University from September 2017 to May 2023 were retrospectively enrolled, including 111 males and 112 females, aged [ M ( Q 1 , Q 3 )] 57(21,66) years. According to the presence or absence of thromboembolism during follow-up, the patients were divided into thrombosis group ( n =102) and non-thrombosis group ( n =121). The clinical characteristics, laboratory characteristics, cytogenetics and other disease progression and survival of the two groups of patients were analyzed. As of March 31, 2023, the follow-up period [ M ( Q 1 , Q 3 )] was 6 (3, 10) years. The influencing factors of thrombosis in JAK2 V617F positive MPN patients were analyzed by using the Cox risk model. Results: Among 223 JAK2 V617F positive MPN patients, 144 were polycythemia vera (PV), 51 were essential thrombocythemia (ET) and 28 were primary myelofibrosis (PMF). The mutation rates of ASXL1 and BCORL1 genes in the thrombosis group were 19.6% (20/102) and 6.9% (7/102), respectively, which were higher than those in the non-thrombosis group [9.1% (11/121) and 0.8% (1/121)] (both P <0.05). The proportion of monocytes, C-reactive protein (CRP), interleukin-1β (IL)-1β, IL-8 and tumor necrosis factor-β (TNF-β) increased in the thrombosis group were higher than those in the non-thrombosis group (all P <0.05). Multivariate analysis showed that age≥60 years ( HR =2.132, 95% CI : 1.376-3.303, P =0.001), history of thrombosis ( HR =3.636, 95% CI : 2.121-6.202, P <0.001), ASXL1 mutation positive ( HR =2.245, 95% CI : 1.093-3.231, P =0.022) and elevated TNF-β ( HR =2.009, 95% CI : 1.113-3.624, P =0.021) were risk factors for thrombosis in JAK2 V617F positive MPN patients. Conclusions: In addition to age, history of thrombosis and positive ASXL1 mutation, elevated TNF-β is also an influencing factor of thrombosis in JAK2 V617F positive MPN patients. Intervention of inflammation may have a certain effect on the prevention and treatment of thrombosis.

Background: There is controversy regarding various aspects of simultaneous bilateral total knee replacement (SBTKR). We found disparity in the postoperative outcomes and complications associated with the procedure in the literature linked with the topic., Objective: To retrospectively analyze the need for blood transfusion after surgery and complications associated with total knee replacement according to the type of procedure (SBTKR or unilateral)., Methods: Retrospective cohort analytical study. We included 251 patients with severe knee osteoarthritis that were divided into two groups. 124 (49%) who underwent SBTKR and 127 upon whom unilateral total knee replacement (UTKR) was performed. Demographic data, days of hospitalization, complications within the first 90 days after surgery (thromboembolic events, superficial and deep infection, stiffness, death); and percentages of patients transfused with blood products during hospitalization were evaluated., Results: There were no statistical differences in the analysis of postoperative complications in the first 90 days after surgery. In the SBTKR group, 8 patients (6.5%) presented some thromboembolic complication during the postoperative period, while this event was observed in only 2 patients (1.5%) from the other group. The analysis showed a statistically significant drop in postoperative hemoglobin, on average that of 0.8 ​g/dl, in the SBTKR patient group compared to the UTKR group (95% CI 0.44-1.13; p ​< ​0.001). A higher proportion of patients who required transfusion were observed in the SBTKR group (40%) (OR ​= ​7.12; 95% CI 3.3-16; p ​< ​0.001). We analyzed the cause of postoperative transfusion in the patients who required transfusion taking into account two parameters: hemoglobin less than 8 ​g/dl and the clinical needs of the patients (symptoms of hypotension, decay, difficulty to rehabilitate without pain, dyspnea). 59 patients received transfusion (50 in the SBTKR group and 9 in the other group). Of these, 19 patients (32.2%) did not meet any transfusion criteria., Conclusion: We consider SBTKR a safe procedure, which does not increase postoperative complications compared to UTKR. Although there is an increase in blood loss in SBTKR, it does not generate clinical symptoms of relevance., Level of Evidence: Level III., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The prognostic effect of concomitant hypertrophic cardiomyopathy (HCM) on adverse events in patients with atrial fibrillation (AF) has not been evaluated in a multicenter prospective cohort study in Japan., Methods and results: Using the Hokuriku-Plus AF Registry, 1,396 patients with nonvalvular AF (1,018 men, 72.3±9.7 years old) were assessed prospectively; 72 (5.2%) had concomitant HCM. During a median follow-up of 5.0 years (interquartile range 3.5-5.3 years), 79 cases of thromboembolism (1.3 per 100 person-years) and 192 of heart failure (HF) (3.2 per 100 person-years) occurred. Kaplan-Meier analysis revealed that the HCM group had a significantly greater incidence of thromboembolism (P=0.002 by log-rank test) and HF (P<0.0001 by a log-rank test) than the non-HCM group. The Cox proportional hazards model demonstrated that persistent AF (adjusted hazard ratio 2.98, 95% confidence interval 1.56-6.21), the CHA 2 DS 2 -VASc score (1.35, 1.18-1.54), and concomitant HCM (2.48, 1.16-4.79) were significantly associated with thromboembolism. Conversely, concomitant HCM (2.81, 1.72-4.43), older age (1.07, 1.05-1.10), lower body mass index (0.95, 0.91-0.99), a history of HF (2.49, 1.77-3.52), and lower left ventricular ejection fraction (0.98, 0.97-0.99) were significantly associated with the development of HF., Conclusions: Concomitant HCM predicts the incidence of thromboembolism and HF in AF patients.

Direct oral anticoagulants (DOACs) represent the cornerstone therapy for cardioembolic events prevention in patients with nonvalvular atrial fibrillation (NVAF). In practice, the choice of one DOAC over another is guided by the decision-making process of the physician, which considers specific patient and drug characteristics. This study aimed to evaluate the clinical features and long-term outcomes of a real-world population treated with DOACs, where the use of the 4 different DOACs is quite equal. We conducted a retrospective observational, single-center, multidisciplinary study enrolling consecutive NVAF patients treated with one of the 4 DOACs. From an initial number of 753 patients, we excluded 72 patients because of loss to follow-up, at the end we enrolled 681:174 (23%) treated with dabigatran, 175 (23%) with apixaban, 190 (25%) with rivaroxaban, and 214 (29%) with edoxaban. Patients treated with apixaban were significantly older, more women represented (p <0.001), and with a higher cardioembolic and bleeding risk (p <0.001). Dabigatran was preferred in patients with liver failure (p = 0.008), whereas Apixaban and Edoxaban were chosen in chronic kidney disease (p = 0.002). At 3-year follow-up, 20 patients (2.7%) experienced a systemic thromboembolic event without significant differences in the 4 DOACs. In the same period, an International Society of Thrombosis and Hemostasis classification major bleeding event occurred in 26 patients (3.6%), more statistically correlated to edoxaban (6.1%) (p = 0.038). Thromboembolic events or major bleeding were higher in the edoxaban group (10%) compared with the others (p = 0.014). In our single-center real-world experience, the choice of the DOAC for a patient with NVAF was tailored to specific clinical features and drug pharmacokinetics of the patient. As a result, a small number of adverse events were observed., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

A 64-year-old man visited the outpatient department of our hospital for the first time due to bilateral lower limb edema, which he noticed 1 week before the visit. Pain suddenly developed in the left lower limb while the patient was in the waiting room. Nephrotic syndrome was suspected based on blood and urine test results. Acute arterial thromboembolism in the left lower limb associated with hypercoagulation due to nephrotic syndrome was suspected, and a diagnosis was made using computed tomography angiography. Arterial thrombectomy was urgently performed, and the limb was salvaged without sequelae. Based on renal biopsy, minimal change nephrotic syndrome was diagnosed, and the patient underwent remission induction with steroid therapy. Heparin was drip infused and apixaban was orally administered to prevent recurrent thrombosis. Nephrotic syndrome in the acute phase is often complicated by thrombosis. Particularly, arterial thromboembolism requires prompt treatment, and prophylactic anticoagulation therapy needs to be considered., (© 2023. The Author(s) under exclusive licence to The Japan Society of Nephrology.)

Background:  The Mobile Health (mHealth) Technology for Improved Screening and Optimized Integrated Care in atrial fibrillation (AF) (mAFA-II) cluster randomized trial assessed the efficacy of an integrated care approach in improving the prognosis of AF patients. In this study, we provide a reanalysis of the trial outcomes using the win ratio (WR) approach., Methods:  The mAFA-II trial allocated patients to receive a mHealth-technology implemented Atrial Fibrillation Better Care (ABC) pathway (mAFA intervention) or usual care. The primary outcome was the composite of all-cause death, ischemic stroke or systemic thromboembolism, and rehospitalization. The efficacy of the mAFA intervention was analyzed according to the WR method using the unmatched pairs approach, with the components of the primary outcome analyzed hierarchically as follows: (1) all-cause death; (2) ischemic stroke or thromboembolism; (3) rehospitalization. Results were reported as WR and 95% confidence intervals (CIs). In addition, we calculated win odds (WO) and 95% CI., Results:  A total of 3,324 patients were enrolled in the mAFA-II trial and included in this analysis (1,646 allocated to mAFA intervention and 1,678 to usual care). Among 2,761,988 unmatched pairs comparisons, the number of wins was higher in the mAFA intervention group, with a WR: 2.78 (95% CI: 1.85-4.17). WO confirmed the effect of mAFA intervention, although with a lower magnitude (WO: 1.06; 95% Cl: 1.04-1.08)., Conclusion:  In this posthoc WR analysis of the mAFA-II trial, a mHealth-technology-implemented integrated care approach was effective in reducing the risk of the primary composite outcome of all-cause death, ischemic stroke or thromboembolism, and rehospitalization, even when prioritizing fatal events., Competing Interests: G.F.R. reports consultancy for Boehringer Ingelheim and an educational grant from Anthos, outside the submitted work. No fees are directly received personally. G.Y.H.L. has been consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Anthos and Daiichi-Sankyo. No fees are directly received personally. All the disclosures happened outside the submitted work. All other authors have nothing to declare. G.Y.H.L. is coprincipal investigator of the AFFIRMO project on multimorbidity in AF, which has received funding from the European Union's Horizon 2020 research and innovation program under grant agreement No 899871., (Thieme. All rights reserved.)

Persistent sciatic artery is a rare anatomic variation due to the lack of regression during fetal development, associated sometimes with abnormalities of the iliofemoral arterial axis and predisposing the patients to aneurysm formation and thromboembolism, which can compromise the limb. In our department, we assisted a 59-year-old male with an acute limb ischemia as result of an incidental finding of a thrombosed persistent sciatic artery aneurysm.

Background: The optimal strategy for diagnosis and antithrombotic treatment of patients with antiphospholipid syndrome (APS)-associated acute ischemic stroke (AIS), transient ischemic attack (TIA), or other brain ischemic injury is poorly defined., Objectives: The survey goal was to capture variations in diagnosis and antithrombotic treatment of APS-associated ischemic stroke and related disorders to inform guidance and clinical trials to define optimal management., Methods: Professional colleagues, including key opinion leaders, were invited to complete a REDCap survey questionnaire initiated by the International Society on Thrombosis and Haemostasis Scientific and Standardisation Committee Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. The survey data were tallied using simple descriptive statistics., Results: There was generally good agreement on several aspects, including which patients to test for antiphospholipid antibodies (aPL), use of a lifelong vitamin K antagonist for AIS or recurrent TIA, and formal cognitive assessment for suspected cognitive impairment. There was less agreement on other aspects, including aPL testing for brain ischemic injury other than AIS/TIA or if an alternative cause for AIS or TIA exists; choice of aPL tests, their timing, and age cutoff; the aPL phenotype to trigger antithrombotic treatment; management for patent foramen ovale; antithrombotic treatment for first TIA or white matter hyperintensities; head magnetic resonance imaging specifications; and low-molecular-weight heparin dosing/anti-Xa monitoring in pregnancy. The survey highlighted that approximately 25% practice at dedicated APS clinics and <50% have a multidisciplinary team structure for patients with APS., Conclusion: Much of the variation in practice reflects the lack of evidence-based recommendations. The survey results should inform the development of a more uniform multidisciplinary consensus approach to diagnosis and antithrombotic treatment., Competing Interests: Declaration of competing interests H.C. reports lecture fees from Technoclone, paid to University College London Hospitals Charity. M.C. reports consulting for Bayer for products other than rivaroxaban. M.K. reports being GSK Global Medical Expert (Lupus), Dubai, United Arab Emirates. The other authors and remaining study group members have no competing interests to disclose., (Copyright © 2023 International Society on Thrombosis and Haemostasis. Published by Elsevier Inc. All rights reserved.)

With the increase in transcatheter procedures, the use of bioprosthetic valves has become more frequent in clinical practice. However, the optimal antithrombotic management of patients with bioprosthetic valves remains controversial. In this case report, we describe a patient with a bioprosthetic aortic valve who developed a thrombus while receiving effective dose direct oral anticoagulant (DOAC) therapy. A 73-year-old male patient with a bioprosthetic aortic valve replacement 2 years prior presented with a mobile thrombus and early degeneration of the valve, detected during routine follow-up while being treated with apixaban. Although the valve thrombus regressed after switching to a different anticoagulant drug, we observed that the decreased but still high gradient persisted due to the early degeneration. Anticoagulant management of bioprosthetic valve patients demands careful attention. Although evidence supporting the use of DOACs is growing, close patient follow-up and further evaluation in case of doubt remain critical. The development of a thrombus in a bioprosthetic valve patient who is receiving anticoagulation therapy, as in this case, highlights the need for optimal management to prevent thromboembolic complications and valve degeneration., (© 2023 Wiley Periodicals LLC.)

Direct oral anticoagulants (DOACs) are indicated for the prevention of stroke in nonvalvular atrial fibrillation. Although Food and Drug Administration labeling for DOACs uses estimated creatinine clearance according to the Cockcroft-Gault (C-G) equation, estimated glomerular filtration rate according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is often reported. The objectives of this study were to evaluate DOAC dosing discordance and to determine whether discordance based on various estimates of kidney function is associated with bleeding or thromboembolism. The study was an institutional review board approved retrospective analysis of patients at UPMC Presbyterian Hospital from January 1, 2010, to December 12, 2016. Data were obtained through electronic medical records. Adults who received a medication charge for rivaroxaban or dabigatran, had a diagnosis code for atrial fibrillation, and had a serum creatinine within 3 days of DOAC initiation were included. Doses were considered discordant if the calculated dose based on CKD-EPI did not match the patient's dose during index admission, if dosed correctly using C-G. Association of discordance with dabigatran, rivaroxaban, and clinical outcomes was determined using odds ratios and 95% confidence intervals. Rivaroxaban discordance was present among 49 of the 644 (8%) patients who were dosed correctly with C-G. Dabigatran discordance was present among 17 of the 590 (3%) patients who were dosed correctly. Discordance with rivaroxaban was found to increase the risk of thromboembolism when using CKD-EPI (odds ratio, 2.83; 95% CI, 1.02-7.79, P = .045) versus C-G. Our findings emphasize the need to dose DOACs, specifically rivaroxaban, appropriately in patients with nonvalvular atrial fibrillation., (© 2023, The American College of Clinical Pharmacology.)

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) requires lifelong anticoagulation. Long-term outcomes of CTEPH under current anticoagulants are unclear., Objectives: The CTEPH AC registry is a prospective, nationwide cohort study comparing the safety and effectiveness of direct oral anticoagulants (DOACs) and warfarin for CTEPH., Patients/methods: Patients with CTEPH, both tre atment-naïve and on treatment, were eligible for the registry. Inclusion criteria were patients aged ≥20 years and those who were diagnosed with CTEPH according to standard guidelines. Exclusion criteria were not specified. The primary efficacy outcome was a composite morbidity, and mortality outcome comprised all-cause death, rescue reperfusion therapy, initiation of parenteral pulmonary vasodilators, and worsened 6-minute walk distance and WHO functional class. The safety outcome was clinically relevant bleeding, including major bleeding., Results: Nine hundred twenty-seven patients on oral anticoagulants at baseline were analyzed: 481 (52%) used DOACs and 446 (48%) used warfarin. The 1-, 2-, and 3-year rates of composite morbidity and mortality outcome were comparable between the DOAC and warfarin groups (2.6%, 3.1%, and 4.2% vs 3.0%, 4.8%, and 5.9%, respectively; P = .52). The 1-, 2-, and 3-year rates of clinically relevant bleeding were significantly lower in DOACs than in the warfarin group (0.8%, 2.4%, and 2.4% vs 2.5%, 4.8%, and 6.4%, respectively; P = 0.036). Multivariable Cox proportional-hazards regression models revealed lower risk of clinically relevant bleeding in the DOAC group than the warfarin group (hazard ratio: 0.35; 95% CI: 0.13-0.91; P = .032)., Conclusion: This registry demonstrated that under current standard of care, morbidity and mortality events were effectively prevented regardless of anticoagulants, while the clinically relevant bleeding rate was lower when using DOACs compared with warfarin., Competing Interests: Declaration of competing interests K.H. received personal fees from Janssen Pharmaceuticals, Bayer Yakuhin, Nippon Shinyaku, and Pfizer, outside of the submitted work. K.A. received a grant from Konica Minolta and Daiichi Sankyo, outside of the submitted work. Y. Tamura received grants from Bayer Yakuhin, Nippon Shinyaku, and Mochida Pharmaceutical and personal fees from Bayer Yakuhin, Nippon Shinyaku, Daiichi Sankyo, and Janssen Pharmaceutical, outside of the submitted work. N.N. is member of the board of directors of the Japan Association for Medical Informatics. K. Todaka reports receiving a grant from Mochida Pharmaceutical and received a personal fee from Bayer Yakuhin, outside of the submitted work. Y. Taniguchi received grants from Janssen Pharmaceutical and Nippon Shinyak and received personal fees from Janssen Pharmaceutical and Nippon Shinyaku, outside of the submitted work. T.I. received personal fees from Janssen Pharmaceutical and Bayer Yakuhin, outside of the submitted work. I.T. received personal fees from Janssen Pharmaceutical and Nippon Shinyak and is affiliated with the division supported by endowments from Nippon Shinyaku, Nippon Boehringer Ingelheim, and Mochida Pharmaceutical, outside of the submitted work. J.Y. received a grant from Abbott Vascular Japan and received personal fees from Kaneka Medix, Boston Scientific Japan, Nihon Kohden, Philips Japan, Janssen Pharmaceutical, and Bayer Yakuhin, outside of the submitted work. N.I. received personal fees from Janssen Pharmaceutical, Bayer Yakuhin, Nippon Shinyaku, Daiichi Sankyo, and Bristol-Myers Squibb, outside of the submitted work. H.S. received a grant from Bayer Yakuhin and received personal fees from Actelion Pharmaceuticals Japan, Bayer Yakuhin, and Nippon Shinyaku, outside of the submitted work. T.K. reports receiving personal fees from Kaneka Medix, Abbott Medical Japan, and ACIST Japan, outside of the submitted work. M.H. received personal fees from Janssen Pharmaceutical and Bayer Yakuhin, outside of the submitted work. H.O. received grants from Daiichi Sankyo, Nippon Boehringer Ingelheim, Pfizer Japan, Eisai, GlaxoSmithKline, Mochida Pharmaceutical, Janssen Pharmaceutical, and Nippon Shinyaku, and received consulting fees from Terumo, Japan Lifeline, and Century Medical and personal fees from Bayer Yakuhin, Daiichi Sankyo, Pfizer Japan, and Nippon Shinyaku, outside of the submitted work. Y.F. received grants from Actelion Pharmaceuticals Japan, Janssen Pharmaceutical, Bayer Yakuhin, Nippon Shinyaku, Daiichi Sankyo, Pfizer Japa, and personal fees from Actelion Pharmaceuticals Japan, Janssen Pharmaceutical, Bayer Yakuhin, Nippon Shinyaku, Daiichi Sankyo, Pfizer Japan, and Bristol-Myers Squibb, outside of the submitted work. N.T. received personal fees from Janssen Pharmaceutical, Bayer Yakuhin, and Nippon Shinyaku, outside of the submitted work. H.M. received grants from Bayer and Nippon Shinyaku; received personal fees from Bayer Yakuhin, Nippon Shinyaku, Mochida Pharmaceutical, Kaneka Medix, and Janssen Pharmaceutical, , outside of the submitted work; is a member of the board of directors or advisory committees for the International CTEPH Association and Japanese Pulmonary Circulation and Pulmonary Hypertension Society; and is a member of the data safety monitoring boards for Janssen Pharmaceutical, United Therapeutics, and Bayer. K. Fukuda received grants from Bayer Yakuhin, Daiichi Sankyo, Nippon Boehringer Ingelheim, Pfizer, Eisai, Janssen Pharmaceutical, Nippon Shinyaku, GlaxoSmithKline, and Mochida Pharmaceutical, and received personal fees from Bayer Yakuhin, Daiichi Sankyo, Nippon Boehringer Ingelheim, Pfizer, Eisai, Janssen Pharmaceutical, Nippon Shinyaku, GlaxoSmithKline, and Mochida Pharmaceutical, outside of the submitted work. H.T. received grants from Mitsubishi Tanabe Pharma, IQVIA Services Japan, Medinet, Medical Innovation Kyushu, Kowa, Daiichi Sankyo, Johnson & Johnson, NEC, and Nippon Boehringer Ingelheim; received personal fees from Novartis Pharma, Ono Pharmaceutical, Nippon Boehringer Ingelheim, Bayer Yakuhin, Kowa, Teijin Pharma, Mitsubishi Tanabe Pharma, Pfizer Japan, Daiichi Sankyo, Novartis Pharma, Janssen Pharmaceutical, Pfizer Japan, Bayer Yakuhin, Otsuka Pharmaceutical, AstraZeneca, and Nippon Rinsho, outside the submitted work; and is the chairman of the Japan Heart Failure Society. Soiken Corp accessed and verified the data. The remaining authors K. Funakoshi, S.A., S.M., K. Tatsumi, and T.O. have no competing interests to disclose., (Copyright © 2023 International Society on Thrombosis and Haemostasis. Published by Elsevier Inc. All rights reserved.)

Whether there are differences in direct oral anticoagulants efficacy and safety in patients with atrial fibrillation (AF) combined with hypertension is unclear. We therefore conducted a multicenter retrospective cohort study to assess the differences in the efficacy and safety of direct oral anticoagulants in patients with AF combined with hypertension. This multicenter retrospective cohort study was based on data from 15 centers in China and included 2086 patients with AF. We divided the patients into dabigatran and rivaroxaban groups according to their direct oral anticoagulants. Propensity score matching was used to balance the covariates between the groups. Due to our limited sample size, the number of cases of some clinical events with low incidence was small. During a mean follow-up period of 10 months, a total of 268 (12.9%) bleeding events occurred, including 27 (1.3%) major bleeding events and 241 (11.6%) minor bleeding events, and 45 (2.2%) thromboembolic events. In patients with AF combined with hypertension, rivaroxaban was associated with a higher major bleeding incidence than dabigatran (odds ratio [OR], 2.89 [95% confidence interval [CI, 1.22-6.87]; P = .012). In contrast, the risk of thromboembolism and minor bleeding was similar for rivaroxaban (OR, 0.55 [95%CI, 0.29-1.01]; P = .069) and dabigatran (OR, 0.82 [95%CI, 0.63-1.08]; P = .150). Based on the results of this study, in patients with AF and hypertension treated with direct oral anticoagulants, the incidence of thromboembolism and minor bleeding was not statistically different between dabigatran and rivaroxaban, but compared with rivaroxaban, dabigatran was associated with a lower risk of major bleeding., (© 2023, The American College of Clinical Pharmacology.)

Thromboembolic disease is associated with a high mortality. It can be divided into two groups: embolism from a venous and embolism from an arterial side. This article gives an overview on thromboembolic disease (with a focus on pulmonary embolism and ischemic stroke) from a cardiologist's perspective.The therapeutic options for acute pulmonary embolism range from anticoagulation to fibrinolysis to interventional recanalization and surgery. The deciding factor for choice of therapy is the risk of early death. Besides clinical parameters, laboratory markers like cardiac troponin and right ventricular function on echocardiography or CTPA (computed tomography pulmonary angiography) are used to determine the early mortality risk. In hemodynamically instable patients, immediate thrombolysis is required, whereas patients with intermediate and low risk can be treated with anticoagulation. Interventional recanalization is currently being studied in patients at risk for development of CTEPH (chronic thromboembolic pulmonary hypertension) or an intermediate risk of early mortality.In ischemic stroke, early interdisciplinary workup involving a cardiologist is paramount. Post stroke screening should include monitoring for arrythmias (especially atrial fibrillation) and transthoracic echocardiography as well as sonography of extra- and intracranial arteries. If no embolic source can be detected (embolic stroke of undetermined source), transesophageal echo can be helpful to detect intracardiac shunts like patent foramen ovale (PFO) or intracardiac tumors. Post stroke care includes secondary prevention measures like risk factor modification and lipid lowering therapy as well as anticoagulation. In high risk for paradoxical embolization, interventional PFO closure can be performed. Interventional closure of the left atrial appendage (LAA) can be discussed in patients with both high thromboembolic and bleeding risk., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Inflammatory bowel disease (IBD) is a spectrum of chronic immune-mediated diseases that affect the gastrointestinal tract and other extraintestinal systems, behaving as a systemic disease. Thromboembolic phenomena are a frequent complication in IBD, because of hypercoagulability states associated with disease activity, and their presence has a negative impact on prognosis and patient survival. Due to this, the control of the inflammatory activity of IBD is one of the pillars in the control of thromboembolic events. Biological drugs are associated with rapid control of the inflammatory process, however, the security profile for the reactivation of latent infections, particularly tuberculosis, is always discussed. We present the case of a 37-year-old patient who presented with deep vein thrombosis in the left lower limb and later with massive pulmonary thromboembolism. During his evaluation, he was diagnosed with Crohn's disease (CD). When carrying out the studies prior to the use of biologics, PPD and quantiferon tests were positive. After discussing the case, we decided to start treatment with ustekinumab.

Sickle cell disease (SCD) is a genetic hemoglobinopathy caused by the abnormal hemoglobin S (HbS) in red blood cells. As a result of its deoxygenation and polymerization, the properties and formation of red blood cells become altered, which ultimately leads to the development of SCD. Chronic inflammatory processes produced by hemolytic and vaso-occlusive episodes, define SCD clearly. These processes result in various effects, including organ damage and increased mortality in people suffering from the disease. Thromboembolism, a potentially fatal disease, is common in patients with sickle cell disease. Despite the known association between hypercoagulability and SCD, thromboembolism is often overlooked as a major complication of SCD. However, thromboembolism affects nearly one-quarter of adult patients and appears to be a risk factor for death in SCD. It has been well documented that in SCD, hemostatic alterations and thrombotic events are associated with endothelium and leukocyte activation. In SCD, inflammatory pathways play an important role in the activation of coagulation and the generation of platelet activation. Although among other mechanisms, it also involves the activation of tissue factors, the expression of adhesion molecules, and the stimulation of innate immune responses. So, mouse model studies may provide novel mechanistic pathways. These studies on mice models are yet to be applied to humans which will lead to the development of clinical lab treatments and therapeutic drugs. Additionally, SCD is a condition that responds favorably to biological treatments like gene therapy. SCD patients now have more potentially curative alternatives with recent developments in hematopoietic stem cell (HSC) transplantation and gene therapy platforms, including Lentiglobin vectors. In the present review, a discussion of the pathophysiology and thromboinflammation of sickle cell disease, along with its global burden in terms of both diagnosis and treatment, is presented.

BACKGROUND Still's disease is a rare multisystemic autoinflammatory disorder. The diagnosis of adult-onset Still's disease (AoSD) can be challenging due to the rarity and overlapping features with many other systemic disorders. Complications of the illness can involve many systems in the human body. One of the least documented hematological complications of AoSD is thromboembolic phenomena. CASE REPORT This text outlines the presentation of a 43-year-old woman with a known diagnosis of AoSD, whose disease-modifying anti-rheumatic drugs (DMARDs) had been tapered and stopped due to remission. She presented with respiratory symptoms and features of an AoSD flare. Lack of complete improvement on antibiotic therapy and reinitiating of DMARDs prompted seeking an alternative/concurrent diagnosis. The work-up yielded a pulmonary embolism (PE) on the background of having no other risk factors for thrombosis. CONCLUSIONS In the reviewed literature, there is a close association between hyperferritinemia and AoSD complicated with venous thromboemboli (VTEs). A rigorous search for alternative diagnoses as well as other potential uncommon complications of AoSD is needed when working-up patients with AoSD, especially those that are not getting better on therapy. Given the rarity of AoSD, meticulous data collection may be useful in understanding the pathophysiology and features of presentation of the illness, including complications such as VTEs.

Goal: to study thrombosis prevalence and predictors of thrombi organization in atrial auricles in persistent non-valvular atrial fibrillation (NVAF) in patients undergoing transesophageal echocardiography (TEE) 4 weeks after oral anticoagulant therapy (OAC). Materials and methods: a total of 133 consecutive patients with NVAF, who underwent TЕE before electrical cardioversion (ECV) were included in the study. Results: The mean age of the participants was 60,3±0,9 years, 95 (71,4%) were men. The mean term of the last AF episode was 6,5±0,6 months. Duration of AF less than 1 year was in 47 (35,3%) patients, from 1 to 5 years – in у 61 (45,8%) patients, over 5 years – in 25 (18,8%) patients. 14 (10,5%) patients had underlying coronary artery disease (CAD), 84 (63,2%) patients had arterial hypertension, 31 (23,3%) had both CAD and arterial hypertension, 4 (3,0%) had cardiomyopathy, 80 (60,2%) were obese. NYHA I FC of heart failure (HF) was diagnozed in 8 (6,0%) patients, II FC – in 94 (70,7%) patients and III FC – in 31 (23,3%) patients. GFR > 90 ml/min/1,73m² was in 9 (6,8%) patients, in 74 (55,6%) it was decreased to 60-89 ml/min/1,73m², in 50 (37,6%) patients GFR was 30-59 ml/min/1,73m². In stratification of risk of thromboembolism complications (TEC) 91 (68,4%) fell into the high-risk group with the CHA2DS2-VASc score ≥ 2, 32 (24,1%) patients were in the moderate-risk group and 10 (7,5%) had CHA2DS2-VASc score 0. TEE was performed in all patients 4 weeks after effective OAC therapy. In 40 (37,6%) patients thrombi were detected in the left atrial auricle and in 26 (65,0%) patients they were organized. In 10 (7,5%) patients thrombis were detected in right atrial auricles and in 7 (70,0%) patients they were organized. In 63 (47,4%) patients thrombi were found in both atrial auricles and in 25 (39,7%) patients they were organized. Correlation was found between detection of non-organized thrombi, duration of AF less than 1 year and increase of total cholesterol. Thrombus organization was assotiated with AF duration more than 1 year. Conclusions: Clinical predictors linked with detection of non-organized atrial auricles thrombi in NVAF patients 4 weeks after OAC therapy are duration of AF less than 1 year, increase of total cholesterol, while thrombi organization is assotiated with AF duration more than 1 year.

Background: Sociodemographic disparities in atrial fibrillation (AF) management and thromboembolic prophylaxis have previously been reported, which may involve inequitable access to left atrial appendage occlusion (LAAO) during cardiac surgery. The present study aimed to evaluate the association of LAAO utilization with sex, race, and hospital region among patients with AF undergoing heart valve operations., Methods: Adults with AF undergoing valve replacement/repair in the 2012-2019 National Inpatient Sample were identified and stratified based on concurrent LAAO. Multivariable linear and logistic regressions were developed to identify factors associated with LAAO utilization. Mortality, complications including stroke and thromboembolism, hospitalization costs and length of stay (LOS) were secondarily assessed., Results: Of 382,580 patients undergoing valve operations, 18.7% underwent concomitant LAAO. Over the study period, the proportion of female patients receiving LAAO significantly decreased from 44.8% to 38.9% (p<0.001). Upon risk adjustment, female (AOR 0.93 [95% CI 0.89-0.97]) and Black patients (0.91 [0.83-0.99]) had significantly reduced odds of undergoing LAAO compared to males and Whites, respectively. Additionally, hospitals in the Midwest (1.38 [1.24-1.51]) and West (1.26 [1.15-1.36]) had increased likelihood of LAAO whereas Northeast hospitals (0.85 [0.77-0.94)] had decreased odds relative to the South. Furthermore, LAAO was associated with decreased stroke (0.71 [0.60-0.84]) and thromboembolism (0.68 [0.54-0.86]), $4,200 reduction in costs and 1-day decrement in LOS., Conclusions: Female and Black patients had significantly lower odds while Midwest and Western hospitals had greater odds of LAAO utilization. Enhancing access to LAAO during valvular surgery is warranted to improve clinical and financial outcomes for patients with AF., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Ng et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Rationale: Ulcerative colitis (UC) is an autoimmune disease of unknown etiology, sometimes associated with anemia and thrombocytosis. Platelets (PLTs) play a role in amplifying inflammatory and immune responses in chronic inflammation. This study discusses the diagnosis and treatment of a case of UC combined with secondary thrombocytosis and reviews the relevant literature. We report an interaction between thrombocytosis and UC to raise clinicians' awareness of this condition., Patient Concerns: In the current report, we discuss the case of a 30-year-old female patient who presented with frequent diarrhea and thrombocytosis., Diagnosis: Severe UC combined with intestinal infection was diagnosed based on colonoscopy and intestinal biopsy. The patient had a PLT count >450 × 109/L and was diagnosed with reactive thrombocytosis., Interventions and Outcomes: The patient was discharged from the hospital in remission after receiving vedolizumab and anticoagulant treatment., Lessons: In patients with severe UC with thrombocytosis, clinicians should pay attention to PLTs promoting inflammatory progression, as well as screening for venous thromboembolism risk and prophylactic anti-venous thromboembolism therapy at the time of dosing to avoid adverse effects., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Non-Bacterial Thrombotic Endocarditis (NBTE) is a common form of aseptic thrombotic endocarditis that primarily affects mitral valves and less frequently aortic valves. NBTE is caused by systemic inflammatory reactions. This condition induces valve thickening or attached sterile mobile vegetation. NBTE is mostly asymptomatic; however, major clinical manifestations result from systemic emboli rather than valve dysfunction. When significant damage occurs, valvular insufficiency or stenosis can appear and promote heart failure occasionally requiring valve replacement surgery. NBTE is associated with hypercoagulable states, systemic lupus erythematous (SLE), antiphospholipid syndrome, or malignancies., Case Presentation: We report successful biological aortic valve replacement surgery including cardiopulmonary bypass for a 78-year-old man with NBTE and voluminous vegetation on the aortic valve inducing moderate aortic insufficiency and acute heart failure. The histopathological analysis of the valve sample showed myxoid degeneration, fibrous remodeling, and partial necrosis without any bacteria, thus indicating marantic endocarditis. Initially, the patient presented to the emergency department with an acute stroke. He was already using Apixaban treatment for a history of atrial fibrillation and cardioembolic stroke. Because of the recurrence of stroke and appearance of aortic vegetation, the investigations were extended. The antiphospholipid antibodies were positive without any indication of bacterial endocarditis. The malignancy screening was positive for basal cell carcinoma (BCC). The surgery and postoperative course were uneventful, and the patient was discharged with vitamin K antagonists (VKA). To our knowledge, NBTE with such a volume is rare and its apparent association with BCC has not been previously reported., Conclusion: Outside of SLE and antiphospholipid syndrome, NBTE is a rare and underdiagnosed disease associated with thromboembolic events. Adequate anticoagulation is a cornerstone of its treatment. Anticoagulation management during perioperative care and valve surgery deserves specific attention and helps to protect the patient from embolic complications. In the case of stroke and thromboembolic events of unclear cause or suspected NBTE, echocardiography and thrombophilia assessments including an immunological workup are recommended., (© 2023. The Author(s).)

Objectives: Data on prognostic implications of new-onset postoperative atrial fibrillation (POAF) after surgical aortic valve replacement (SAVR) is limited. We sought to explore associations between POAF, early initiated oral anticoagulation (OAC) and long-term outcome after SAVR and combined SAVR + coronary artery bypass grafting (CABG)., Methods: This is a retrospective, population-based study including all isolated SAVR (n = 7038) and combined SAVR and CABG patients (n = 3854) without a history of preoperative atrial fibrillation (AF) in Sweden 2007-2017. Individual patient data were merged from 4 nationwide registries. Inverse probability of treatment weighting-adjusted Cox regression models were employed separately in SAVR and SAVR + CABG patients. The median follow-up time was 4.7 years (range 0-10 years)., Results: POAF occurred in 44.5% and 50.7% of SAVR and SAVR + CABG patients, respectively. In SAVR patients, POAF was associated with increased long-term risk of death [adjusted hazard ratio (aHR) 1.21 (95% confidence interval 1.06-1.37)], ischaemic stroke [aHR 1.32 (1.08-1.59)], any thromboembolism, heart failure hospitalization and recurrent AF. In SAVR + CABG, POAF was associated with death [aHR 1.31 (1.14-1.51)], recurrent AF and heart failure, but not with ischaemic stroke [aHR 1.04 (0.84-1.29)] or thromboembolism. OAC was dispensed within 30 days after discharge to 67.0% and 65.9%, respectively, of SAVR and SAVR + CABG patients with POAF. Early initiated OAC was not associated with reduced risk of death, ischaemic stroke or thromboembolism in any group of patients., Conclusions: POAF after SAVR is associated with an increased risk of long-term mortality and morbidity. Further studies are warranted to clarify the role of OAC in SAVR patients with POAF., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

We report data on survival and complications for a longitudinal cohort of 709 transfusion-dependent β-thalassemia major patients (51.1% males) born between 1970 and 1997 and followed through 2020 at seven major centers in Italy. Overall survival probability at 30 years was 83.6% (95%CI: 78.5-89.1) in the oldest birth cohort (1970-1974) compared with 93.3% (95%CI: 88.6-98.3) in the youngest birth cohort (1985-1997) (p = 0.073). Females showed better survival than males (p = 0.022). There were a total of 93 deaths at a median age of 23.2 years with the most frequent disease-related causes being heart disease (n = 53), bone marrow transplant (BMT) complication (n = 10), infection (n = 8), liver disease (n = 4), cancer (n = 3), thromboembolism (n = 2) and severe anemia (n = 1). There was a steady decline in the number of deaths due to heart disease from the year 2000 onwards and no death from BMT was observed after the year 2010. A progressive decrease in the median age of BMT was observed in younger birth cohorts (p < 0.001). A total of 480 (67.7%) patients developed ≥1 complication. Patients in younger birth cohorts demonstrated better complication-free survival (p < 0.001) which was comparable between sexes (p = 0.230). Independent risk factors for death in multivariate analysis included heart disease (HR: 4.63, 95%CI: 1.78-12.1, p = 0.002), serum ferritin >1000 ng/mL (HR: 15.5, 95%CI: 3.52-68.2, p < 0.001), male sex (HR: 2.75, 95%CI: 0.89-8.45, p = 0.078), and splenectomy (HR: 6.97, 95%CI: 0.90-54.0, p < 0.063). Survival in patients with β-thalassemia major continues to improve with adequate access to care, best practice sharing, continued research, and collaboration between centers., (© 2023 Wiley Periodicals LLC.)

Background: As a major complication of non-valvular atrial fibrillation (NVAF), left atrial appendage (LAA) thrombosis is associated with cerebral ischemic strokes, as well as high morbidity. Due to insufficient incorporation of risk factors, most current scoring methods are limited to the analysis of relationships between clinical characteristics and LAA thrombosis rather than detecting potential risk. Therefore, this study proposes a clinical data-driven machine learning method to predict LAA thrombosis of NVAF., Methods: Patients with NVAF from January 2014 to June 2022 were enrolled from Southwest Hospital. We selected 40 variables for analysis, including demographic data, medical history records, laboratory results, and the structure of LAA. Three machine learning algorithms were adopted to construct classifiers for the prediction of LAA thrombosis risk. The most important variables related to LAA thrombosis and their influences were recognized by SHapley Addictive exPlanations method. In addition, we compared our model with CHADS2 and CHADS2-VASc scoring methods., Results: A total of 713 participants were recruited, including 127 patients with LAA thrombosis and 586 patients with no obvious thrombosis. The consensus models based on Random Forest and eXtreme Gradient Boosting LAA thrombosis prediction (RXTP) achieved the best accuracy of 0.865, significantly outperforming CHADS2 score and CHA2DS2-VASc score (0.757 and 0.754, respectively). The SHAP results showed that B-type natriuretic peptide, left atrial appendage width, C-reactive protein, Fibrinogen and estimated glomerular filtration rate are closely related to the risk of LAA thrombosis in nonvalvular atrial fibrillation., Conclusions: The RXTP-NVAF model is the most effective model with the greatest ROC value and recall rate. The summarized risk factors obtained from SHAP enable the optimization of the treatment strategy, thereby preventing thromboembolism events and the occurrence of cardiogenic ischemic stroke., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Background:  The ABO blood group system is linked to hemostasis via its relationship with von Willebrand factor (VWF) and factor VIII (FVIII). In the current study, we investigated the association of the ABO system with clinical outcomes as well as VWF and platelet function in patients with left ventricular assist devices (LVADs)., Methods:  Bleeding and thromboembolic complications were assessed in 111 patients during 1 year after LVAD implantation. In 67 LVAD patients, VWF antigen, VWF activity, VWF ristocetin cofactor, VWF collagen-binding, and FVIII activity were assessed. Platelet surface P-selectin and activated glycoprotein IIb/IIIa were determined by flow cytometry, and soluble P-selectin was measured with an enzyme-linked immunoassay. Platelet aggregation was assessed by light transmission and impedance aggregometry., Results:  Thirty-six patients (32.4%) experienced a bleeding and 22 patients (19.8%) a thromboembolic event. In univariate analyses, patients with blood group O had numerically more bleeding complications and less thromboembolic events as compared to patients with blood group non-O (both p ≥ 0.05). After multivariable adjustment, blood group O was significantly associated with a higher risk of bleeding (hazard ratio 2.42 [95% confidence interval 1.03-5.70], p  = 0.044) but not linked to thromboembolic complications., Conclusion:  Patients with blood group O had significantly lower levels of VWF and FVIII (all p  < 0.05), whereas P-selectin expression in response to thrombin-receptor activating peptide and soluble P-selectin were higher as compared to patients with blood group non-O (both p  < 0.05). LVAD patients with blood group O are at an increased bleeding risk, potentially due to lower VWF and FVIII levels., Competing Interests: T.S. received research grants from Abbott, CorWave, and Medtronic, and is a consultant for Abbott and Medtronic. D.W. is a consultant and proctor for Abbott and Medtronic. D.Z. received research grants from Abbott and Medtronic, is an advisory board member for Abbott, Medtronic, and Berlin Heart, and is a proctor for Abbott and Medtronic. T.G. received research grants from Boehringer-Ingelheim, Bristol Myers Squibb, Medtronic, and Abbott, and lecture fees from Amgen, Boehringer-Ingelheim, Bayer, Bristol Myers Squibb, Vifor, Daiichi Sankyo, Pfizer, and Novartis. The other authors have no relevant conflicts of interest to declare., (Thieme. All rights reserved.)

Background: Thromboembolism is less common in children than in adults, but it is frequently associated with Mycoplasma pneumoniae infection in many cases. This study aimed to investigate the clinical characteristics of pediatric M. pneumoniae pneumonia complicated with thromboembolism., Methods: Hospitalized patients with M. pneumoniae pneumonia complicated by thromboembolism were enrolled from January 2012 to December 2021 in Beijing Children's Hospital, Capital Medical University, China. The data on clinical manifestations, laboratory tests, and treatment were evaluated., Results: A total of 49 cases were enrolled, with a mean age of 7.9 years old, including 27 boys and 22 girls. Consolidation of pulmonary lobe or segment was observed in 95.9% (47/49) of the cases, whereas interstitial change was found only in two patients; 85.7% (42/49) of patients had pleural effusion. Pulmonary vascular thromboembolism was most common in 35 patients, whereas 13 cases had thromboembolism of multiple anatomic sites. The levels of C-reaction protein, lactate dehydrogenase, and erythrocyte sedimentation rate were all increased, with a mean value of 54.08 ± 52.27 g/L, 451.12 ± 218.76 U/L, 43.40 ± 29.43 mm/h, respectively. Blood coagulation test showed that all 49 patients had elevated D-dimer values (median 3.81 ng/ml, range, 0.34-48 ng/ml) and normal PT. aPTT.LA was positive in 74.3% (26/35) of the cases. aCL-IgM was positive in 66.7% (26/39) of the cases. aβ2GPI-IgM was positive in 79.4% (27/34) of the cases. The prognosis was generally good in this group., Conclusion: Pulmonary arteriovenous thromboembolism is the most common thromboembolism complicated in MPP, and cerebral artery embolism and cardiac thrombosis are common in extrapulmonary thromboembolism. In the cases of MPP with thromboembolic complications, pulmonary consolidation with pleural effusion is the main characteristic. About two thirds of the cases are positive for antiphospholipid antibodies., (© 2023 The Authors. The Clinical Respiratory Journal published by John Wiley & Sons Ltd.)

Backround: Venous thromboembolic disease (VTED) is a frequent cause of hospitalization and mortality. Whole blood viscosity (WBV) participates in the pathogenesis of thrombosis., Objective: To identify the most frequent etiologies and their association with WBV index (WBVI) in hospitalized patients with VTED., Material and Methods: Observational, cross-sectional, retrospective, analytical study, Group 1: cases (patients diagnosed with VTED) and Group 2: controls without thrombosis. Risk factors for VTED were described and WBVI was calculated from total proteins and hematocrit. Descriptive and inferential statistics were used with Chi-squared test, Fisher's exact test, Mann Whitney U test, bivariate and multivariate logistic regression analysis., Results: We included 146 patients and 148 controls, age 46.3 ±17.7 vs. 58 ± 18.2 years, of both sexes (female, 65.1%). The most frequent etiology was neoplastic (23.3%), followed by diseases with cardiovascular risk (17.8%). Independent risk factors for VTED were age, chronic kidney disease, presence of liver disease or solid neoplasia. WBVI was similar in patients with VTED as in those without thrombosis. We found an association of the presence of deep vein thrombosis and diseases with cardiovascular risk (p = 0.040)., Conclusions: The presence of chronic kidney disease, liver disease, and solid neoplasia are independent risk factors for VTED. The WBVI is a simple and rapid diagnostic tool in the evaluation of patients with VTED., (© 2023 Revista Médica del Instituto Mexicano del Seguro Social.)

Systemic lupus erythematosus is a chronic autoimmune disease that affects most tissues. Cardiovascular events are critical, life-threatening, long-term complications of systemic lupus erythematosus (SLE). We report our single-center experience of performing cardiovascular surgery in patients with SLE while avoiding postoperative complications. We also suggest a new approach for cardiopulmonary bypass and perioperative management. We applied the antiphospholipid antibody syndrome (APS) severity classification published by the Japan Intractable Disease Information Center to patients with SLE for perioperative management. Patients with Grade III or higher severity are treated with a slightly relaxed version of catastrophic APS therapy. This treatment modality includes glucocorticoids, anticoagulation, intravenous immunoglobulin, and plasma exchange. Between April 2010 and January 2021, 26 patients (2 males, 24 females) with SLE underwent cardiovascular surgery. The mean age was 74.2 ± 13.0 years (38-84 years). The primary outcomes were in-hospital mortality and long-term results, and the secondary outcomes were related to bleeding/embolization and coagulation function/platelet count. A subset analysis was performed to examine treatment efficacy in the APS Grade III or higher group. Of the 26 patients, 17 underwent valve surgery, 4 underwent isolated coronary artery bypass grafting, and 5 underwent thoracic aortic aneurysm surgery. There were no in-hospital deaths or associated bleeding/embolic complications. Postoperative antithrombin III decreased in patients who underwent valvular and aortic surgery, and platelet counts recovered to preoperative levels within 7 to 10 days. The 5- and 10-year survival rates were 80.5% and 53.7%, respectively. In addition, there were 10 patients with APS Grade III or higher, but there was no significant difference in the frequency of complications other than platelet recovery after treatment. The surgical outcome of open-heart surgery in patients with SLE was good. Surgical treatment of cardiovascular disease in these patients is difficult and complex. We focused on blood coagulation abnormalities and treated each patient by selecting the best individual treatment protocol according to the severity of the disease, taking into account the risk of bleeding and thrombosis. Management of blood coagulation function in these patients is essential, and careful therapeutic management should be considered during open-heart surgery., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Polycythemia vera (PV) is a subtype of myeloproliferative neoplasms (MPN), with the highest incidence. Thromboembolism is the most common complication of PV, which has significant effects on the quality of life and survival of patients. To standardize the diagnosis, treatment and prevention strategies of thromboembolism associated with PV, the Myelodysplastic Syndrome/Myeloproliferative Neoplasms (MDS/MPN) Association affiliated to Chinese Medicine Education Association has reached the following consensus based on available proofs from evidence-based medicine after repeated considerations. The consensus covers risk stratification, diagnosis and treatment of PV, multidisciplinary management of PV thromboembolism, and patient follow-up, thereby providing the reference for the standardized diagnosis, treatment and management of thromboembolism for Chinese PV patients.

Background & Aims: Understanding the epidemiology of bleeding and thromboembolism (clotting) in liver cirrhosis provides important data for future studies and policymaking; however, head-to-head comparisons of bleeding and clotting remain limited., Methods: This is a populational retrospective cohort study using the US National Readmission Database of 2018 to compare the incidence and outcomes of bleeding and clotting events in patients with liver cirrhosis. The primary outcomes were the 11-month incidence proportion of bleeding and clotting events., Results: Of 1 304 815 participants, 26 569 had liver cirrhosis (45.0% women, mean age 57.2 [SD, 12.7] years). During the 11-month follow-up, in patients with cirrhosis, for bleeding and clotting events, the incidence proportions was 15.3% and 6.6%; the risk-standardized all-cause mortality rates were 2.4% and 1.0%; the rates of intensive care intervention were 4.1% and 1.9%; the rates of rehabilitation transfer were .2% and .2%; the cumulative length of stays were 45 100 and 23 566 days; total hospital costs were 147 and 84 million US dollars; total hospital charges were 620 and 365 million US dollars. Compared to non-cirrhosis, liver cirrhosis was associated with higher rates of bleeding (adjusted hazard ratio, 3.02 [95% CI, 2.85-3.20]) and portal vein thrombosis (PVT) (18.46 [14.86-22.92]), and slightly lower risks of other non-PVT venous thromboembolic events (.82 [.75-.89])., Conclusions: Bleeding is more common than thromboembolism in patients with liver cirrhosis, causes higher morbidity, mortality and resource utilization. Liver cirrhosis is an independent risk factor for bleeding and PVT, but not non-PVT thromboembolism including venous thromboembolism, acute myocardial infarction and ischemic stroke., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: Endovascular treatment (EVT) has become a popular option for the treatment of basilar artery (BA) trunk aneurysms because microsurgery of these lesions is difficult due to narrow surgical fields and perforating arteries or cranial nerves in the brainstem. The purpose of this study is to report our experiences using EVT for ruptured BA trunk aneurysms in the acute period and to evaluate the risk factors for periprocedural complications., Methods: From October 2004 to December 2020, a total of 27 consecutive patients with ruptured BA trunk aneurysms were treated with EVT. All patients met the following criteria: presence of ruptured BA trunk aneurysms and treatment with EVT for those aneurysms within 72 hours of rupture. The incidence of and risk factors for periprocedural complications were evaluated retrospectively., Results: Among the 27 patients, periprocedural complications occurred in 4 patients (14.8%); mass effect inducing cranial neuropathy due to brainstem compression in 1 (3.7%) and brainstem infarction in 3 (11.1%). Hemorrhagic complications did not occur within 30 days. Subacute or delayed thromboembolic complications were not observed during the follow-up period. Large/giant aneurysm (odds ratio [OR], 6.417; 95% confidence interval [CI], 1.732-18.031; P = 0.045) and stent-assisted coiling (OR, 4.145; 95% CI, 1.018-14.212; P = 0.031) remained independent risk factors for periprocedural complications based on multiple logistic regression analysis., Conclusions: When performing stent-assisted coiling for ruptured large/giant BA trunk aneurysms, awareness of and caution regarding periprocedural complications, such as brainstem infarction caused by thromboembolism or brainstem compression due to mass effect, are necessary.

Objective: Recent studies have suggested an impact of the ABO-blood group type on thromboembolic and haemorrhagic events following trauma and surgical procedures. However, only limited data are available on the impact of ABO-blood group types in neurosurgical patients. The goal of the present study was to evaluate the role of the ABO-blood group type on the frequency of thromboembolic and haemorrhagic complications in patients treated surgically for intracranial meningiomas at our institution., Methods: We retrospectively analysed the medical records of consecutive patients undergoing resection of intracranial meningiomas at our institution during a period of 12.5 years (2006-2018). Clinical characteristics, modalities of surgical treatment, histopathological results and the postoperative course of patients were analysed with specific focus on ABO-blood group typing results, need for transfusion of blood products, events of postoperative thromboembolism and intracranial re-haemorrhage requiring surgical revision, as well as in-hospital mortality., Results: A total of 1,782 patients were included in this study. Based on the ABO-blood group type, patients were subdivided into four categories, corresponding to their ABO-blood group: Blood group A ( n  = 773; 43%); blood group B ( n  = 222; 12%); blood group AB ( n  = 88; 5%); and blood group O ( n  = 699; 39%). Intracranial re-haemorrhage requiring re-craniotomy and haematoma evacuation occurred in a total of 49 patients (2.7%). Thromboembolic events such as pulmonary embolism occurred in a total of 27 patients (1.5%). Statistical analysis showed no significant differences regarding the ABO-blood group type in patients suffering from re-haemorrhage or thromboembolism compared with patients with uneventful course after surgery. The overall in-hospital mortality rate was 0.17% ( n  = 3)., Conclusion: Our findings suggest a lack of relevance of the ABO-blood group type regarding haemorrhagic and thromboembolic complications in patients undergoing neurosurgical meningioma resection.

Background: Neurologic complications from recreational use of nitrous oxide (N 2 O), which are attributed to vitamin B12 deficiency, have been well documented. With increasing dosages and frequency of N 2 O use, an additional association with thromboembolisms is becoming apparent., Objectives: To assess thrombotic complications of recreational N 2 O use., Methods: All medical charts at the largest hospital in Amsterdam were searched for N 2 O use and subsequent neurologic and/or thrombotic events. For patients with thrombotic events, we extracted data on the risk factors for arterial and venous thrombosis as well as serum vitamin B12 and homocysteine concentrations., Results: Between January 2015 and May 2021, 326 patients who reported recreational use of N 2 O were identified; of these, 17 (5%) patients presented with severe thrombotic events associated with N 2 O (71% men; median age, 26 years [range, 18-53 years]), 5 patients presented with arterial thrombosis (3 with acute coronary syndrome, 1 with femoral artery thrombosis, and 1 with middle cerebral artery thrombus), and 12 patients presented with venous thromboembolisms (10 with pulmonary embolisms, 1 with portal vein thrombosis and 1 with cerebral vein thrombosis). Additionally, homocysteine were concentrations severely increased (median, 125 μmol/L [range, 22-253 μmol/L]; reference, <15 μmol/L). Patients reported use of 400 to 6000 g (ie, 50-750 balloons) of N 2 O in 1 day. Fifty percent of these patients had experienced neurologic symptoms before the thrombotic event., Conclusion: We describe an alarming incidence of serious thrombotic events among young adults after excessive recreational use of N 2 O, accompanied by extremely high homocysteine concentrations. The upward trend in the recreational use of N 2 O warrants more awareness of its dangers among both users and medical professionals. Furthermore, these findings could reopen the discussion on possible associations between hyperhomocysteinemia and thrombosis mediated through N 2 O., (Copyright © 2022 International Society on Thrombosis and Haemostasis. Published by Elsevier Inc. All rights reserved.)

Trauma-induced coagulopathy (TIC) is a risk factor for death and is associated with deviations in thrombin generation. TIC prevalence and thrombin levels increase with age. We assayed in vivo and ex vivo thrombin generation in injured patients (n = 418) to specifically investigate how age impacts thrombin generation in trauma and to address the prognostic ability of thrombin generation. Biomarkers of thrombin generation were elevated in young (< 40 years) and older (≥ 40 years) trauma patients. In vivo thrombin generation was associated with Injury Severity Score (ISS) and this association was stronger in young than older patients. In vivo thrombin generation decreased faster after trauma in the young than the older patients. Across age groups, in vivo thrombin generation separated patients dying/surviving within 30 days at a level comparable to the ISS score (AUC 0.80 vs. 0.82, p > 0.76). In vivo and ex vivo thrombin generation also predicted development of thromboembolic events within the first 30 days after the trauma (AUC 0.70-0.84). In conclusion, younger trauma patients mount a stronger and more dynamic in vivo thrombin response than older patients. Across age groups, in vivo thrombin generation has a strong ability to predict death and/or thromboembolic events 30 days after injury., (© 2023. The Author(s).)