Blutgerinnungsmanagement nach mechanischem Herzklappenersatz

Patient Self-Management of oral Anticoagulation after mechanical heart valve replacement – Long term experience of the Department of Heart Surgery Ludwig-Maximilians-University Munich. Objectives: Lifelong oral anticoagulation treatment (OAT) is necessary after mechanical heart valve replacement. This study was conducted to find out differences in bleeding and thromboembolic complications between Patient Self-Management (PSM) of OAT with portable coagulometers and Conventional Patient Management (CPM) by the home physician. We also wanted to find out in which group more anticoagulation-values were within the therapeutic range and in which group quality of life is better. Methods: 444 Patients were included in this retrospective study (PSM-group n=160, CPM-group n=260, 24 patients were lost to follow up). Follow-up time was 95,0 (+/-23,5) months in PSM-group and 104,9 (+/- 28,5) months in CPM-group. Patients underwent mechanical heart valve replacement in our centre between 1982 and 1998. PSM-education began 1992. Follow-up time was 95,0 (+/-23,5) months in PSM-group and 104,9 (+/- 28,5) months in CPM-group. In PSM-group age was 61,2 (+/- 10,2) years, in CPM-group 66,4 (+/- 8,1) years at follow-up. Patients in PSM-group were trained using portable coagulometers and dose adjusting their coumarin-derivate (mostly Marcumar). Results: Patients in PSM-group measured their coagulation values 3,74 (+/-3,41) times per month, in CPM-group 1,53 (+/- 1,07) times per month. In the PSM-group, 73% of coagulation values measured were within the therapeutic range. In the CPM-group 57% of the values were within the therapeutic range. Grade 2 or 3 bleeding complications were 2,2% per patient year in PSM-group and 2,7% in CPM-group. Grade 2 or 3 thromboembolic complications were 0,58% per patient year in PSM-group and 1,7% in CPM-group. Quality-of-life aspects were significantly better in PSM-group than in CPM-group. Conclusions: PSM improves long-time OAT after mechanical heart valve replacement. More anticoagulation values were within the therapeutic range and fewer thromboembolic complications appeared in PSM-group. Quality of life was better in PSM-group. For that reason we offer and recommend PSM to all suitable patients after mechanical heart valve replacement

Blutgerinnungsmanagement nach mechanischem Herzklappenersatz

Patient Self-Management of oral Anticoagulation after mechanical heart valve replacement – Long term experience of the Department of Heart Surgery Ludwig-Maximilians-University Munich. Objectives: Lifelong oral anticoagulation treatment (OAT) is necessary after mechanical heart valve replacement. This study was conducted to find out differences in bleeding and thromboembolic complications between Patient Self-Management (PSM) of OAT with portable coagulometers and Conventional Patient Management (CPM) by the home physician. We also wanted to find out in which group more anticoagulation-values were within the therapeutic range and in which group quality of life is better. Methods: 444 Patients were included in this retrospective study (PSM-group n=160, CPM-group n=260, 24 patients were lost to follow up). Follow-up time was 95,0 (+/-23,5) months in PSM-group and 104,9 (+/- 28,5) months in CPM-group. Patients underwent mechanical heart valve replacement in our centre between 1982 and 1998. PSM-education began 1992. Follow-up time was 95,0 (+/-23,5) months in PSM-group and 104,9 (+/- 28,5) months in CPM-group. In PSM-group age was 61,2 (+/- 10,2) years, in CPM-group 66,4 (+/- 8,1) years at follow-up. Patients in PSM-group were trained using portable coagulometers and dose adjusting their coumarin-derivate (mostly Marcumar). Results: Patients in PSM-group measured their coagulation values 3,74 (+/-3,41) times per month, in CPM-group 1,53 (+/- 1,07) times per month. In the PSM-group, 73% of coagulation values measured were within the therapeutic range. In the CPM-group 57% of the values were within the therapeutic range. Grade 2 or 3 bleeding complications were 2,2% per patient year in PSM-group and 2,7% in CPM-group. Grade 2 or 3 thromboembolic complications were 0,58% per patient year in PSM-group and 1,7% in CPM-group. Quality-of-life aspects were significantly better in PSM-group than in CPM-group. Conclusions: PSM improves long-time OAT after mechanical heart valve replacement. More anticoagulation values were within the therapeutic range and fewer thromboembolic complications appeared in PSM-group. Quality of life was better in PSM-group. For that reason we offer and recommend PSM to all suitable patients after mechanical heart valve replacement

Bridging intravenous thrombolysis in patients with atrial fibrillation

Atrial fibrillation; Intravenous thrombolysis; Oral anticoagulationFibrilación auricular; Trombólisis intravenosa; Anticoagulación oralFibril·lació auricular; Trombolisi intravenosa; Anticoagulació oralBackground and purpose: 40% of acute ischemic stroke patients treated by mechanical thrombectomy (MT) have a clinical history of atrial fibrillation (AF). The safety of bridging intravenous thrombolysis (IVT) (MT + IVT) is currently being discussed. We aimed to analyze the interaction between oral anticoagulation (OAC) status or AF with bridging IVT, regarding the occurrence of symptomatic intracranial hemorrhage (sICH) and functional outcome. Materials and Methods: Multicentric observational cohort study (BEYOND-SWIFT registry) of consecutive patients undergoing MT between 2010 and 2018 (n = 2,941). Multinomial regression models were adjusted for prespecified baseline and plausible pathophysiological covariates identified on a univariate analysis to assess the association of AF and OAC status with sICH and good outcomes (90-day modified Rankin Scale score 0–2). Results: In the total cohort (median age 74, 50.6% women), 1,347 (45.8%) patients had AF. Higher admission National Institutes of Health Stroke Scale (NIHSS) score (aOR 1.04 [95% 1.02–1.06], per point of increase) and prior medication with Vitamin K antagonists (VKA) (aOR 2.19 [95% 1.27–3.66]) were associated with sICH. Neither AF itself (aOR 0.71 [95% 0.41–1.24]) nor bridging IVT (aOR 1.08 [0.67–1.75]) were significantly associated with increased sICH. Receiving bridging IVT (aOR 1.61 [95% 1.24–2.11]) was associated with good 90-day outcome, with no interaction between AF and IVT (p = 0.92). Conclusion: Bridging IVT appears to be a reasonable clinical option in selected patients with AF. Given the increased sICH risk in patients with VKA, subgroup analysis of the randomized controlled trials should analyze whether patients with VKA might benefit from withholding bridging IVT.This study was funded by the Bangerter-Rhyner Foundation and the Swiss Academy of Medical Sciences. Open access funding provided by University of Bern

Endovascular thrombectomy for basilar artery occlusion stroke: Analysis of the German Stroke Registry‐Endovascular Treatment

Background and purpose Acute ischemic stroke due to basilar artery occlusion (BAO) causes the most severe strokes and has a poor prognosis. Data regarding efficacy of endovascular thrombectomy in BAO are sparse. Therefore, in this study, we performed an analysis of the therapy of patients with BAO in routine clinical practice. Methods Patients enrolled between June 2015 and December 2019 in the German Stroke Registry-Endovascular Treatment (GSR-ET) were analyzed. Primary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3), substantial neurological improvement (≥8-point National Institute of Health Stroke Scale [NIHSS] score reduction from admission to discharge or NIHSS score at discharge ≤1), and good functional outcome at 3 months (modified Rankin Scale [mRS] score of 0–2). Results Out of 6635 GSR-ET patients, 640 (9.6%) patients (age 72.2 ± 13.3, 43.3% female) experienced BAO (median [interquartile range] NIHSS score 17 [8, 27]). Successful reperfusion was achieved in 88.4%. Substantial neurological improvement at discharge was reached by 45.5%. At 3-month follow-up, good clinical outcome was observed in 31.1% of patients and the mortality rate was 39.2%. Analysis of mTICI3 versus mTICI2b groups showed considerable better outcome in those with mTICI3 (38.9% vs. 24.4%; p = 0.005). The strongest predictors of good functional outcome were intravenous thrombolysis (IVT) treatment (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.76–5.23) and successful reperfusion (OR 4.92, 95% CI 1.15–21.11), while the effect of time between symptom onset and reperfusion seemed to be small. Conclusions Acute reperfusion strategies in BAO are common in daily practice and can achieve good rates of successful reperfusion, neurological improvement and good functional outcome. Our data suggest that, in addition to IVT treatment, successful and, in particular, complete reperfusion (mTICI3) strongly predicts good outcome, while time from symptom onset seemed to have a lower impact

Bridging intravenous thrombolysis in patients with atrial fibrillation.

Background and purpose 40% of acute ischemic stroke patients treated by mechanical thrombectomy (MT) have a clinical history of atrial fibrillation (AF). The safety of bridging intravenous thrombolysis (IVT) (MT + IVT) is currently being discussed. We aimed to analyze the interaction between oral anticoagulation (OAC) status or AF with bridging IVT, regarding the occurrence of symptomatic intracranial hemorrhage (sICH) and functional outcome. Materials and Methods Multicentric observational cohort study (BEYOND-SWIFT registry) of consecutive patients undergoing MT between 2010 and 2018 (n = 2,941). Multinomial regression models were adjusted for prespecified baseline and plausible pathophysiological covariates identified on a univariate analysis to assess the association of AF and OAC status with sICH and good outcomes (90-day modified Rankin Scale score 0-2). Results In the total cohort (median age 74, 50.6% women), 1,347 (45.8%) patients had AF. Higher admission National Institutes of Health Stroke Scale (NIHSS) score (aOR 1.04 [95% 1.02-1.06], per point of increase) and prior medication with Vitamin K antagonists (VKA) (aOR 2.19 [95% 1.27-3.66]) were associated with sICH. Neither AF itself (aOR 0.71 [95% 0.41-1.24]) nor bridging IVT (aOR 1.08 [0.67-1.75]) were significantly associated with increased sICH. Receiving bridging IVT (aOR 1.61 [95% 1.24-2.11]) was associated with good 90-day outcome, with no interaction between AF and IVT (p = 0.92). Conclusion Bridging IVT appears to be a reasonable clinical option in selected patients with AF. Given the increased sICH risk in patients with VKA, subgroup analysis of the randomized controlled trials should analyze whether patients with VKA might benefit from withholding bridging IVT. Registration clinicaltrials.gov; Unique identifier: NCT03496064

Endovascular Stroke Treatment and Risk of Intracranial Hemorrhage in Anticoagulated Patients.

Background and Purpose- We aimed to determine the safety and mortality after mechanical thrombectomy in patients taking vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Methods- In a multicenter observational cohort study, we used multiple logistic regression analysis to evaluate associations of symptomatic intracranial hemorrhage (sICH) with VKA or DOAC prescription before thrombectomy as compared with no anticoagulation. The primary outcomes were the rate of sICH and all-cause mortality at 90 days, incorporating sensitivity analysis regarding confirmed therapeutic anticoagulation. Additionally, we performed a systematic review and meta-analysis of literature on this topic. Results- Altogether, 1932 patients were included (VKA, n=222; DOAC, n=98; no anticoagulation, n=1612); median age, 74 years (interquartile range, 62-82); 49.6% women. VKA prescription was associated with increased odds for sICH and mortality (adjusted odds ratio [aOR], 2.55 [95% CI, 1.35-4.84] and 1.64 [95% CI, 1.09-2.47]) as compared with the control group, whereas no association with DOAC intake was observed (aOR, 0.98 [95% CI, 0.29-3.35] and 1.35 [95% CI, 0.72-2.53]). Sensitivity analyses considering only patients within the confirmed therapeutic anticoagulation range did not alter the findings. A study-level meta-analysis incorporating data from 7462 patients (855 VKAs, 318 DOACs, and 6289 controls) from 15 observational cohorts corroborated these observations, yielding an increased rate of sICH in VKA patients (aOR, 1.62 [95% CI, 1.22-2.17]) but not in DOAC patients (aOR, 1.03 [95% CI, 0.60-1.80]). Conclusions- Patients taking VKA have an increased risk of sICH and mortality after mechanical thrombectomy. The lower risk of sICH associated with DOAC may also be noticeable in the acute setting. Improved selection might be advisable in VKA-treated patients. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064. Systematic Review and Meta-Analysis: CRD42019127464

Introduction of CTA-index as Simplified Measuring Method for Thrombus Perviousness.

PURPOSE Thrombus features on admission CT are useful imaging markers for clot characterization, stroke pathogenesis and outcome prediction. In this context, thrombus perviousness is a promising parameter, but reliable assessment in daily clinical practice is demanding. The aim of the present study was to evaluate an easy to assess measuring method for thrombus permeability at the time of admission. METHODS The CTA-index, which measures relative thrombus attenuation on admission CTA, was compared to the known perviousness parameter in a cohort of 101 patients with large-vessel occlusions of the middle cerebral artery and correlated to clinical outcome parameters (mRS after 90 days, ≤2 rated as favorable). For validation, this correlation was tested in a second independent cohort (n = 87), and possible associations between the CTA-index and outcome measurements (NIHSS/mRS/mTICI) were assessed. RESULTS In the first cohort a coherence between conventional perviousness measurements and the CTA-index was shown. The CTA-index differed significantly between favorable (-0.55 ± 0.16) and non-favorable outcomes (-0.64 ± 0.14, p = 0.01). In the validation cohort this result could be independently reproduced (-0.52 ± 0.13/-0.70 ± 0.09, p < 0.01). The CTA-index showed an association with low NIHSS at discharge (p < 0.01), favorable outcome after 90 days (p < 0.001) and with better reperfusion (measured by mTICI score, p = 0.04). CONCLUSION The CTA-index is an easy to assess imaging parameter on admission CTA in the acute stroke phase and is associated with angiographic and clinical outcome. It can be considered as a simplified measuring method for thrombus perviousness, which is known to provide useful information for further stroke progress and clinical course as well as therapeutic and rehabilitative decisions

Early Thrombectomy Protects the Internal Capsule in Patients With Proximal Middle Cerebral Artery Occlusion.

BACKGROUND AND PURPOSE Proximal middle cerebral artery (MCA) occlusions impede blood flow to the noncollateralized lenticulostriate artery territory. Previous work has shown that this almost inevitably leads to infarction of the dependent gray matter territories in the striate even if perfusion is restored by mechanical thrombectomy. Purpose of this analysis was to evaluate potential sparing of neighboring fiber tracts, ie, the internal capsule. METHODS An observational single-center study of patients with proximal MCA occlusions treated with mechanical thrombectomy and receiving postinterventional high-resolution diffusion-weighted imaging was conducted. Patients were classified according to internal capsule ischemia (IC+ versus IC-) at the postero-superior level of the MCA lenticulostriate artery territory (corticospinal tract correlate). Associations of IC+ versus IC- with baseline variables as well as its clinical impact were evaluated using multivariable logistic or linear regression analyses adjusting for potential confounders. RESULTS Of 92 included patients with proximal MCA territory infarctions, 45 (48.9%) had an IC+ pattern. Longer time from symptom-onset to groin-puncture (adjusted odds ratio, 2.12 [95% CI, 1.19-3.76] per hour), female sex and more severe strokes were associated with IC+. Patients with IC+ had lower rates of substantial neurological improvement and functional independence (adjusted odds ratio, 0.26 [95% CI, 0.09-0.81] and adjusted odds ratio, 0.25 [95% CI, 0.07-0.86]) after adjustment for confounders. These associations remained unchanged when confining analyses to patients without ischemia in the corona radiata or the motor cortex and here, IC+ was associated with higher National Institutes of Health Stroke Scale motor item scores (β, +2.8 [95% CI, 1.5 to 4.1]) without a significant increase in nonmotor items (β, +0.8 [95% CI, -0.2 to 1.9). CONCLUSIONS Rapid mechanical thrombectomy with successful reperfusion of the lenticulostriate arteries often protects the internal capsule from subsequent ischemia despite early basal ganglia damage. Salvage of this eloquent white matter tract within the MCA lenticulostriate artery territory seems strongly time-dependent, which has clinical and pathophysiological implications

The “Flying Intervention Team”: A Novel Stroke Care Concept for Rural Areas

Background: Endovascular treatment of large vessel occlusion in acute ischemic stroke patients is difficult to establish in remote areas, and time dependency of treatment effect increases the urge to develop health care concepts for this population. Summary: Current strategies include direct transportation of patients to a comprehensive stroke center (CSC) ("mothership model") or transportation to the nearest primary stroke center (PSC) and secondary transfer to the CSC ("drip-and-ship model"). Both have disadvantages. We propose the model "flying intervention team." Patients will be transported to the nearest PSC; if telemedically identified as eligible for thrombectomy, an intervention team will be acutely transported via helicopter to the PSC and endovascular treatment will be performed on site. Patients stay at the PSC for further stroke unit care. This model was implemented at a telestroke network in Germany. Fifteen remote hospitals participated in the project, covering 14,000 km(2) and a population of 2 million. All have well established telemedically supported stroke units, an angiography suite, and a helicopter pad. Processes were defined individually for each hospital and training sessions were implemented for all stroke teams. An exclusive project helicopter was installed to be available from 8 a.m. to 10 p.m. during 26 weeks per year. Key Messages: The model of the flying intervention team is likely to reduce time delays since processes will be performed in parallel, rather than consecutively, and since it is quicker to move a medical team rather than a patient. This project is currently under evaluation (clinicaltrials NCT04270513)

CT Marker in Emergency Imaging of Acute Basilar Artery Occlusion: Thrombosis vs. Embolism

Purpose: Acute basilar artery occlusion, a neurovascular emergency leading to high rates of morbidity and mortality, is usually diagnosed by CT imaging. The outcome is partly dependent on etiology, with a worse outcome in occlusions with underlying basilar artery stenosis. As this occlusion type requires a more complex angiographic therapy, this study aimed to develop new CT markers in emergency admission imaging to rapidly identify underlying stenosis. Methods: A total of 213 consecutive patients (female n = 91, age in years (mean/SD/range): 72/13/28&ndash;97), who received endovascular treatment at a single comprehensive stroke center for acute basilar artery occlusion, were included in this study. After applying strict inclusion criteria for imaging analyses, novel CT imaging markers, such as &lsquo;absolute density loss&rsquo; (ADL) and relative thrombus attenuation (CTA-index), that measure perviousness, were assessed for n = 109 patients by use of CT-angiography and correlated to different occlusion patterns (thrombotic vs. embolic). Inter-observer agreement was assessed using an intraclass correlation coefficient for independent measures of a radiologist and a neuroradiologist. Associations between the imaging markers and clinical and interventional parameters were tested. Results: CT markers differ between the subgroups of basilar artery occlusions with and without underlying stenosis (for ADL: 169 vs. 227 HU (p = 0.03), for CTA-index: 0.55 vs. 0.70 (p &lt; 0.001)), indicating a higher perviousness in the case of stenosis. A good inter-rater agreement was observed for ADL and CTA-index measures (ICC 0.92/0.88). For the case of embolic occlusions, a more pervious thrombus correlates to shorter time intervals, longer procedure times, and worse reperfusion success (p-values &lt; 0.05, respectively). Conclusions: ADL and CTA-index are easy to assess in the emergency setting of acute basilar artery occlusion with the use of routinely acquired CT-angiography. They show a high potential to differentiate thrombotic from embolic occlusions, with an impact on therapeutic decisions and angiographic procedures. Measurements can be quickly performed with good reliability, facilitating implementation in clinical practice