STS/SCA/AmSECT clinical practice guidelines: Anticoagulation during cardiopulmonary bypass

© 2018 American Society of Extra-Corporeal Technology. All Rights Reserved. Despite more than a half century of safe cardio-pulmonary bypass (CPB), the evidence base surrounding the conduct of anticoagulation for CPB has not been organized into a succinct guideline. For this and other reasons, there is enormous practice variability relating to the use and dosing of heparin, monitoring heparin anticoagulation, reversal of anticoagulation, and the use of alternative anticoagulants. To address this and other gaps, the Society of Thoracic Surgeons (STS), the Society of Cardiovascular Anesthesiologists (SCA), and the American Society of Extracorporeal Technology (AmSECT) developed an Evidence Based Workgroup. This was a group of interdisciplinary professionals gathered together to summarize the evidence and create practice recommendations for various aspects of CPB. To date, anticoagulation practices in CPB have not been standardized in accordance with the evidence base. This clinical practice guideline was written with the intent to fill the evidence gap and to establish best practices in anticoagulation for CPB using the available evidence. To identify relevant evidence a systematic review was outlined and literature searches were conducted in PubMed® using standardized MeSH terms from the National Library of Medicine list of search terms. Search dates were inclusive of January 2000 to December 2015. The search yielded 833 abstracts which were reviewed by two independent reviewers. Once accepted into the full manuscript review stage, two members of the writing group evaluated each of 286 full papers for inclusion eligibility into the guideline document. Ninety-six manuscripts were included in the final review. In addition, 17 manuscripts published prior to 2000 were included to provide method, context, or additional supporting evidence for the recommendations as these papers were considered sentinel publications. Members of the writing group wrote and developed recommendations based on review of the articles obtained and achieved more than two thirds agreement on each recommendation. The quality of information for a given recommendation allowed assessment of the level of evidence as recommended by the AHA/ACCF Task Force on Practice Guidelines. Recommendations were written in the three following areas 1) Heparin dosing and monitoring for initiation and maintenance of CPB, 2) Heparin contraindications and heparin alternatives, 3) Reversal of anticoagulation during cardiac operations. It is hoped that this guideline will serve as a resource and will stimulate investigators to conduct more research and expand upon the evidence base on the topic of anticoagulation for CPB

Antithrombotic Treatment in Patients With Hemophilia: an EHA-ISTH-EAHAD-ESO Clinical Practice Guidance

Cardiovascular disease is an emerging medical issue in patients with hemophilia (PWH) and its prevalence is increasing up to 15% in PWH in the United States. Atrial fibrillation, acute and chronic coronary syndromes, venous thromboembolism, and cerebral thrombosis are frequent thrombotic or prothrombotic situations, which require a careful approach to fine-tune the delicate balance between thrombosis and hemostasis in PWH when using both procoagulant and anticoagulant treatments. Generally, PWH could be considered as being naturally anticoagulated when clotting factors are 20 IU/dL in need for any form of antithrombotic therapy, usually treatment without additional clotting factor prophylaxis could be used, but careful monitoring for bleeding is recommended. For antiplatelet treatment, this threshold could be lower with single-antiplatelet agent, but again factor level should be at least 20 IU/dL for dual antiplatelet treatment. In this complex growing scenario, the European Hematology Association in collaboration with the International Society on Thrombosis and Haemostasis, the European Association for Hemophilia and Allied Disorders, the European Stroke Organization, and a representative of the European Society of Cardiology Working Group on Thrombosis has produced this current guidance document to provide clinical practice recommendations for health care providers who care for PWH

2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery

Authors/Task Force Members: Christa Boer (EACTA Chairperson)(Netherlands), Michael I. Meesters (Netherlands), Milan Milojevic (Netherlands), Umberto Benedetto (UK), Daniel Bolliger (Switzerland), Christian von Heymann (Germany), Anders Jeppsson (Sweden), Andreas Koster (Germany), Ruben L. Osnabrugge (Netherlands), Marco Ranucci (Italy), Hanne Berg Ravn (Denmark), Alexander B.A. Vonk (Netherlands), Alexander Wahba (Norway), Domenico Pagano (EACTS Chairperson)(UK),. Document Reviewers: Moritz W.V. Wyler von Ballmoos (USA), Mate Petricevic (Croatia), Arie Pieter Kappetein (Netherlands), Miguel Sousa-Uva (Portugal), Georg Trummer (Germany), Peter M. Rosseel (Netherlands), Michael Sander (Germany), Pascal Colson (France), Adrian Bauer (Germany)

Risk of Chronic Oral Anticoagulation Therapy in Patients Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction - Retrospective Cross-Sectional Study

Background: Although chronic oral anticoagulation therapy reduces mortality and morbidity from thromboembolic diseases, the risk of bleeding and mortality may increase when patients on anticoagulation presents with acute ST elevation myocardial infarction (STEMI) where aggressive antiplatelet and further anticoagulation therapies are warranted. Objective: To study the characteristics of patients who are on oral anticoagulation therapy (OAC) at the time of presentation with acute STEMI. Design: Retrospective, cross-sectional study. Setting: All patients who presented to Christiana Care Health System, Newark, DE with acute ST elevation myocardial infarction with intent of primary percutaneous angioplasty between January 2009 and December 2010. Outcome Measures: Composite end-point of major bleeding, in-hospital death, cardiogenic shock, and cardiac arrest. Subgroup analysis of major bleeding and in-hospital mortality. Results: A total of 637 patients were enrolled into the study, the average age of the study population was 61 years, 71% male and 84% Caucasian patients. Of 637 patients, 20 (3.1%) were on OAC at the time of presentation. Both OAC and non-OAC groups differed in baseline characteristics including hypertension, diabetes mellitus, dyslipidemia, peripheral vascular disease, previous coronary artery disease, and pre procedural laboratory data including hemoglobin and INR (all p < 0.05). The groups also differed in the treatment procedures. Patients who were on OAC were more likely to receive bare metal stents and clopidogrel and less likely to be treated with newer antiplatelet agents (prasugrel and ticagrelor) and drug eluting stents (all p <0.05). However, the composite endpoint (death, bleeding, and transfusion) was similar in both groups. On multivariable logistic regression analysis, use of anticoagulation and baseline INR were not significant independent predictors of study endpoints. Pre procedural hemoglobin (OR: 0.88, 95%CI: 0.77-0.98, p=0.012) and requirement of IABP (OR: 4.13, 95% CI: 2.25-7.59, p<0.001) were independent risk factors for study end points. Limitations: Overall sample size for patients who were on anticoagulation was limited due to the low (3%) observed prevalence in the study population, however it is similar to other published studies. The inclusion bias resulting from prehospitalization deaths may influence the results. Conclusions: The contemporary management of acute ST elevation myocardial infarction does not seem to raise the risk of bleeding, in-hospital death, or blood transfusion in patients who are on full anticoagulation

Personalized medicine in interventional cardiology: pharmacologic and mechanical strategies to balance ischemic and bleeding complications during and after percutaneous cardiovascular interventions -- Searching for and fighting with a Chimera --

In the Greek mythology, the Chimera was a monstrous firebreathing hybrid creature of Lycia in Asia Minor, composed of the parts of more than one animal (usually depicted as a lion, with the head of a goat arising from its back, and a tail of snake). Homer's brief description in the Iliad is the earliest surviving literary reference. The term Chimera has come to describe any mythical or fictional animal with parts taken from various animals, or to describe anything composed of very disparate parts, or perceived as wildly imaginative, implausible, difficult to realize or utopian. Bellerophon was the hero who fought and killed the Chimera. When he arrived in Lycia, the Chimera was truly ferocious, and he could not harm the monster even while riding on Pegasus. He felt the heat of the breath the Chimera expelled, and was struck with an idea. He got a large block of lead and mounted it on his spear. Then he flew head-on towards the Chimera, holding out the spear as far as he could. Before he broke off his attack, he managed to lodge the block of lead inside the Chimera's throat. The beast's firebreath melted the lead, and blocked its air passage. The Chimera suffocated, and Bellerophon returned victorious to King Iobates. Percutaneous cardiovascular interventions are the cornerstone treatment of cardiovascular diseases. Antithrombotic therapy during and after these interventions is fundamental to prevent ischemic recurrences, but has the risk to increase bleeding complications. To find the optimal strategy to prevent ischemia without affecting bleeding in all patients is matter of ongoing discussion and research, and probably remains a chimera. Like Bellerophon searching for and fighting with the Chimera, clinicians should be aware of the trade-off of both bleeding and ischemia and their impact on patients’ health, thus searching for the optimal therapy which has not to face with a single animal (ischemia or bleeding), rather must account and balance for the effects on both these entities. In such a context, personalized medicine characterized by individualization of therapies patient-by-patient based on the individual risk/benefit profile appears to be a promising approach that clinicians might adopt to kill this nightmare

Safety and outcome of coronary interventions with special reference to anticoagulation and stent type

University of Turku, Faculty of Medicine, Department of Cardiology and Cardiovascular Medicine, Doctoral Programme of Clinical Investigation, Heart Center, Turku University Hospital, Turku, Finland Division of Internal Medicine, Department of Cardiology, Seinäjoki Central Hospital, Seinäjoki, Finland Heart Center, Satakunta Central Hospital, Pori, Finland Annales Universitatis Turkuensis Painosalama Oy, Turku, Finland 2015 Antithrombotic therapy during and after coronary procedures always entails the challenging establishment of a balance between bleeding and thrombotic complications. It has been generally recommended to patients on long-term warfarin therapy to discontinue warfarin a few days prior to elective coronary angiography or intervention to prevent bleeding complications. Bridging therapy with heparin is recommended for patients at an increased risk of thromboembolism who require the interruption of anticoagulation for elective surgery or an invasive procedure. In study I, consecutive patients on warfarin therapy referred for diagnostic coronary angiography were compared to control patients with a similar disease presentation without warfarin. The strategy of performing coronary angiography during uninterrupted therapeutic warfarin anticoagulation appeared to be a relatively safe alternative to bridging therapy, if the international normalized ratio level was not on a supratherapeutic level. In-stent restenosis remains an important reason for failure of long-term success after a percutaneous coronary intervention (PCI). Drug-eluting stents (DES) reduce the problem of restenosis inherent to bare metal stents (BMS). However, a longer delay in arterial healing may extend the risk of stent thrombosis (ST) far beyond 30 days after the DES implantation. Early discontinuation of antiplatelet therapy has been the most important predisposing factor for ST. In study II, patients on long-term oral anticoagulant (OAC) underwent DES or BMS stenting with a median of 3.5 years’follow-up. The selective use of DESs with a short triple therapy seemed to be safe in OAC patients, since late STs were rare even without long clopidogrel treatment. Major bleeding and cardiac events were common in this patient group irrespective of stent type. In order to help to predict the bleeding risk in patients on OAC, several different bleeding risk scorings have been developed. Risk scoring systems have also been used also in the setting of patients undergoing a PCI. In study III, the predictive value of an outpatient bleeding risk index (OBRI) to identify patients at high risk of bleeding was analysed. The bleeding risk seemed not to modify periprocedural or long-term treatment choices in patients on OAC after a percutaneous coronary intervention. Patients with a high OBRI often had major bleeding episodes, and the OBRI may be suitable for risk evaluation in this patient group. Optical coherence tomography (OCT) is a novel technology for imaging intravascular coronary arteries. OCT is a light-based imaging modality that enables a 12–18 µm tissue axial resolution to visualize plaques in the vessel, possible dissections and thrombi as well as, stent strut appositions and coverage, and to measure the vessel lumen and lesions. In study IV, 30 days after titanium-nitride-oxide (TITANOX)-coated stent implantation, the binary stent strut coverage was satisfactory and the prevalence of malapposed struts was low as evaluated by OCT. Long-term clinical events in patients treated with (TITANOX)-coated bio-active stents (BAS) and paclitaxel-eluting stents (PES) in routine clinical practice were examined in study V. At the 3-year follow-up, BAS resulted in better long-term outcome when compared with PES with an infrequent need for target vessel revascularization. Keywords: anticoagulation, restenosis, thrombosis, bleeding, optical coherence tomography, titaniumSEPELVALTIMOIDEN PALLOLAAJENNUSHOIDON TURVALLISUUS JA TULOKSET VERENOHENNUSHOIDON AIKANA JA ERI STENTTITYYPEILLÄ Sydänkeskus, Turun yliopistollinen keskussairaala, Kardiologia ja kardiovaskulaarilääketiede, Kliininen Tohtoriohjelma, Turun yliopisto Sisätautien yksikkö, Sydänosasto, Seinäjoen keskussairaala, Seinäjoki Sydänkeskus, Satakunnan keskussairaala, Pori Annales Universitatis Turkuensis Painosalama Oy, Turku, Finland 2015 Hyytymisenestolääkkeiden käyttö sepelvaltimotoimenpiteiden yhteydessä ja niiden jälkeen on haastavaa tasapainottelua vuotojen ja hyytymien aiheuttamien komplikaatioiden välillä. Aikaisemmin on suositeltu verenohennushoidon lopettamista muutama päivä ennen suunniteltua sepelvaltimotoimenpidettä. Potilailla, joilla on korkea tukosriski, on suositeltu hepariinin käyttöä ns. siltahoitona verenohennuslääkehoidon tauon aikana. Tutkimuksessa todettiin, että sepelvaltimoiden varjoainekuvaus voidaan tehdä varsin turvallisesti ilman hepariini siltahoitoa keskeytymättömän verenohennushoidon aikana, jos verenohennustaso on suositellulla hoitoalueella. Lääkeainestenteillä on pystytty vähentämään metallistenteille yleistä suonen uudelleenahtautumista sepelvaltimon pallolaajennuksella hoidetussa kohdassa. Lääkeaineen hidastaessa stentatun suonen alueen parantumista riski hyytymän kehittymiseen lääkeverkon sisälle on suurentunut, ja riski voi jatkua merkittävästi kauemmin kuin 30 vuorokautta. Tehokkaalla hyytymisenestolääkityksellä pyritään estämään stentinsisäisten hyytymien kehittyminen. Aikainen hyytymisenestolääkityksen lopettaminen on todettu tämän ongelman merkittävimmäksi riskitekijäksi. Tutkimuksessa osoitettiin verenohennuspotilailla 3,5 vuoden seurannassa vähän myöhäisiä stenttitrombeja, vaikka käytettiin lääkeainestenttejä ja lyhyttä klopidogreelihoitoa hyytymien estossa. Kuitenkin pallolaajennetuilla verenohennuspotilailla todettiin paljon verenvuoto – ja muita komplikaatioita. Lukuisia pisteytyksiä on kehitetty verenohennuspotilaan vuotoriskin arvioimiseksi. Samoja pisteytyksiä on käytetty myös pallolaajennuspotilaan vuotoriskin arviointiin. Tutkimuksessa tarkasteltiin outpatient bleeding risk index (OBRI) -pisteytyksen kykyä löytää korkean vuotoriskin pallolaajennuspotilaat. Korkeat OBRI-pisteet saaneilla potilailla esiintyi enemmän vuotoja, mikä viittaa OBRI-pisteytyksen käyttökelpoisuuteen tässä potilasjoukossa. Valokerroskuvaus on uusi tekniikka, jolla voidaan kuvata sepelvaltimoa suonen sisältä. Valokerroskuvauksella voidaan erottaa kudoksia 12–18 mikrometrin tarkkuudella. Sillä kuvautuvat hyvin suonen sisäpinnan plakit, mahdolliset seinämän repeämät ja hyytymät sekä stentin asettuminen suonen seinämää vasten ja stentin peittyminen suonen parantuessa. Myös suonen koon ja kohteiden tarkka mittaus on mahdollista. Titaani-typpioksidilla (TITANOX) päällystettyjen stenttien todettiin valokerroskuvauksella arvioituna pääsääntöisesti peittyneen kudoksella jo 30 vuorokauden kuluttua pallolaajennuksesta. Myös stentin asettuminen suonen seinämään oli hyvä. Tutkimuksessa todettiin kolmen vuoden seurannassa TITANOX-päällysteisellä stentillä hoidetuilla potilailla merkittävästi vähemmän sydänkomplikaatioita paklitakseli-päällysteisillä lääkestenteillä hoidettuihin potilaisiin verrattuna. Uusintatoimenpiteitä tarvittiin enemmän lääkestenteillä hoidetuilla potilailla. Avainsanat: antikoagulaatio, restenoosi, tromboosi, verenvuoto valokerroskuvaus, titaaniSiirretty Doriast