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Hirata R, Nishi T, Nakamura M, Tago M. Refractory Iron-Deficiency Anemia and Vascular Malformation Concomitant with Aortic Stenosis: Heyde Syndrome. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e944440. [PMID: 39325680 PMCID: PMC11441710 DOI: 10.12659/ajcr.944440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 08/14/2024] [Accepted: 07/24/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Heyde syndrome is characterized by anemia due to angiodysplasia, aortic valve stenosis, and acquired von Willebrand syndrome. However, the awareness regarding Heyde syndrome in clinical practice is low. We report the case of an older woman with severe refractory iron-deficiency anemia and severe aortic stenosis who was diagnosed with Heyde syndrome. CASE REPORT A 70-year-old woman who had been experiencing exertional dyspnea for 3 months prior to presentation was diagnosed with iron-deficiency anemia, with a hemoglobin level of 69 g/L. She did not experience any episodes of bleeding, such as nosebleeds, gum bleeding, abnormal bleeding, or melena. Upper and lower gastrointestinal endoscopy revealed no evidence of bleeding, and oral iron supplementation failed to improve the anemia. Auscultation of the chest identified an ejection systolic murmur. Chest and abdominal computed tomography showed no significant lesions or active bleeding. Capsule endoscopy of the small intestine revealed capillary dilation. Echocardiography detected severe aortic valve stenosis. Blood test results revealed a deficiency in large von Willebrand factor multimers. Therefore, Heyde syndrome was diagnosed. Aortic valve replacement surgery was performed, which resulted in an improvement in anemia and the associated symptoms. CONCLUSIONS In cases of unexplained and treatment-resistant iron-deficiency anemia, especially if careful auscultation detects aortic stenosis, Heyde syndrome should be considered a differential diagnosis. Furthermore, screening for angiodysplasia in the gastrointestinal tract and prompt diagnosis through measurement of large von Willebrand factor multimers are imperative when investigating potential sources of bleeding.
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Roberts JC, Escobar MA, Acharya S, Hwang NX, Wang M, Hale S, Brighton S, Kouides PA. Retrospective chart review of GI bleeding in people with von Willebrand disease. Haemophilia 2024; 30:970-980. [PMID: 38751022 DOI: 10.1111/hae.15034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 02/07/2024] [Accepted: 05/01/2024] [Indexed: 07/18/2024]
Abstract
INTRODUCTION Gastrointestinal (GI) bleeding events (BEs) in von Willebrand disease (VWD) are difficult to diagnose and often recurrent. Limited data from clinical trials has led to lack of consensus on treatment options. AIM Describe current treatments and outcomes for GI BEs in people with VWD. METHODS This retrospective, observational, multicentre chart review study was conducted from January 2018 through December 2019 and included patients with inherited VWD with ≥1 GI BE in the preceding 5 years. Baseline characteristics, number and aetiology of BEs, associated GI-specific morbidities/lesions, treatment and outcomes were analysed descriptively. RESULTS Sixty bleeds were reported in 20 patients with type 1 (20%), type 2 (50%) and type 3 (30%) VWD. During the 5-year study period, 31 (52%) BEs had one identified or suspected cause; multiple causes were reported in 11 (18%). Most GI BEs (72%) were treated with a combination of von Willebrand factor (VWF), antifibrinolytics and/or other haemostatic or non-haemostatic treatments. Time to resolution did not differ by VWF treatment use; however, BEs treated with non-VWF treatments tended to resolve later. In patients with GI-specific morbidities/lesions, 84% resolved with first-line treatment; time to resolution tended to be longer than in patients without such morbidities/lesions. Thirteen BEs occurred in patients receiving prophylaxis and 47 in patients receiving on-demand treatment; 18 BEs resulted in a switch to prophylaxis after bleed resolution. CONCLUSIONS This study confirms the unmet need for the management of recurrent GI BEs in people with VWD and the need for prospective data, especially on prophylaxis.
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Affiliation(s)
- Jonathan C Roberts
- Bleeding & Clotting Disorders Institute, Dills Family Foundation Center for Research at BCDI, Peoria, Illinois, USA
- Departments of Pediatrics and Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Miguel A Escobar
- University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Suchitra Acharya
- Northwell Health Hemostasis and Thrombosis Center, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA
| | - Nina X Hwang
- Center for Inherited Blood Disorders, CHOC Children's Hospital, Orange, California, USA
| | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sarah Hale
- Takeda Pharmaceuticals U.S.A., Inc., Lexington, Massachusetts, USA
| | | | - Peter A Kouides
- Department of Medicine, Mary M. Gooley Hemophilia Center, Rochester, New York, USA
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Moser MM, Schoergenhofer C, Jilma B. Progress in von Willebrand Disease Treatment: Evolution towards Newer Therapies. Semin Thromb Hemost 2024; 50:720-732. [PMID: 38331000 DOI: 10.1055/s-0044-1779485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
von Willebrand disease (VWD) is a very heterogenous disease, resulting in different phenotypes and different degrees of bleeding severity. Established therapies (i.e., desmopressin, antifibrinolytic agents, hormone therapy for heavy menstrual bleeding, and von Willebrand factor [VWF] concentrates) may work in some subtypes, but not in all patients. In recent years, progress has been made in improving the diagnosis of VWD subtypes, allowing for more specific therapy. The impact of VWD on women's daily lives has also come to the fore in recent years, with hormone therapy, tranexamic acid, or recombinant VWF as treatment options. New treatment approaches, including the replacement of lacking factor VIII (FVIII) function, may work in those subgroups affected by severe FVIII deficiency. Reducing the clearance of VWF is an alternative treatment pathway; for example, rondaptivon pegol is a VWFA1 domain-binding aptamer which not only improves plasma VWF/FVIII levels, but also corrects platelet counts in thrombocytopenic type 2B VWD patients. These approaches are currently in clinical development, which will be the focus of this review. In addition, half-life extension methods are also important for the improvement of patients' quality of life. Targeting specific mutations may further lead to personalized treatments in the future. Finally, a few randomized controlled trials, although relatively small, have been published in recent years, aiming to achieve a higher level of evidence in future guidelines.
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Affiliation(s)
- Miriam M Moser
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Chan CHH, Passmore MR, Tronstad O, Seale H, Bouquet M, White N, Teruya J, Hogan A, Platts D, Chan W, Dashwood AM, McGiffin DC, Maiorana AJ, Hayward CS, Simmonds MJ, Tansley GD, Suen JY, Fraser JF, Meyns B, Fresiello L, Jacobs S. The Impact of Acute Exercise on Hemostasis and Angiogenesis Mediators in Patients With Continuous-Flow Left Ventricular Assist Devices: A Prospective Observational Pilot Study. ASAIO J 2024:00002480-990000000-00501. [PMID: 38833540 DOI: 10.1097/mat.0000000000002246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
Impaired primary hemostasis and dysregulated angiogenesis, known as a two-hit hypothesis, are associated with gastrointestinal (GI) bleeding in patients with continuous-flow left ventricular assist devices (CF-LVADs). Exercise is known to influence hemostasis and angiogenesis in healthy individuals; however, little is known about the effect in patients with CF-LVADs. The objective of this prospective observational study was to determine whether acute exercise modulates two-hit hypothesis mediators associated with GI bleeding in patients with a CF-LVAD. Twenty-two patients with CF-LVADs performed acute exercise either on a cycle ergometer for approximately 10 minutes or on a treadmill for 30 minutes. Blood samples were taken pre- and post-exercise to analyze hemostatic and angiogenic biomarkers. Acute exercise resulted in an increased platelet count (p < 0.00001) and platelet function (induced by adenosine diphosphate, p = 0.0087; TRAP-6, p = 0.0005; ristocetin, p = 0.0009). Additionally, high-molecular-weight vWF multimers (p < 0.00001), vWF collagen-binding activity (p = 0.0012), factor VIII (p = 0.034), angiopoietin-1 (p = 0.0026), and vascular endothelial growth factor (p = 0.0041) all increased after acute exercise. This pilot work demonstrates that acute exercise modulated two-hit hypothesis mediators associated with GI bleeding in patients with CF-LVADs.
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Affiliation(s)
- Chris H H Chan
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- School of Engineering and Built Environment, Griffith University, Gold Coast, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Innovative Device & Engineering Applications Laboratory, Texas Heart Institute, Houston, Texas
| | - Margaret R Passmore
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Oystein Tronstad
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
| | - Helen Seale
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia
| | - Mahe Bouquet
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Nicole White
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia
| | - Jun Teruya
- Departments of Pathology & Immunology, Pediatrics, and Medicine, Baylor College of Medicine, Houston, Texas
| | - Airlie Hogan
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - David Platts
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Wandy Chan
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
- Cardio-Vascular Molecular and Therapeutics Translational Research Group, University of Queensland, Brisbane, Australia
| | - Alexander M Dashwood
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
- Cardio-Vascular Molecular and Therapeutics Translational Research Group, University of Queensland, Brisbane, Australia
| | - David C McGiffin
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Department of Cardiothoracic Surgery and Transplantation, The Alfred Hospital, Melbourne, Australia
- Department of Cardiothoracic Surgery, Monash University, Melbourne, Australia
| | - Andrew J Maiorana
- Allied Health Department, Fiona Stanley Hospital, Perth, Australia
- Curtin School of Allied Health, Curtin University, Perth, Australia
| | - Christopher S Hayward
- Heart Failure and Transplant Unit, St. Vincent's Hospital, Sydney, Australia
- Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Michael J Simmonds
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Geoff D Tansley
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- School of Engineering and Built Environment, Griffith University, Gold Coast, Australia
| | - Jacky Y Suen
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - John F Fraser
- From the Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Bart Meyns
- Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium; and
| | - Libera Fresiello
- Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium; and
- Group of Cardiovascular and Respiratory Physiology, University of Twente, Enschede, The Netherlands
| | - Steven Jacobs
- Department of Cardiovascular Sciences, Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium; and
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Subramani K, Bander J, Chen S, Suárez-Fariñas M, Venkatesan T, Subrahmanian S, Varshney R, Kini A, Sharma S, Rifkin DB, Cho J, Coller BS, Ahamed J. Evidence That Anemia Accelerates AS Progression Via Shear-Induced TGF-β1 Activation: Heyde's Syndrome Comes Full Circle. JACC Basic Transl Sci 2024; 9:185-199. [PMID: 38510715 PMCID: PMC10950403 DOI: 10.1016/j.jacbts.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/07/2023] [Accepted: 09/07/2023] [Indexed: 03/22/2024]
Abstract
The severity of aortic stenosis (AS) is associated with acquired von Willebrand syndrome (AVWS) and gastrointestinal bleeding, leading to anemia (Heyde's syndrome). We investigated how anemia is linked with AS and AVWS using the LA100 mouse model and patients with AS. Induction of anemia in LA100 mice increased transforming growth factor (TGF)-β1 activation, AVWS, and AS progression. Patients age >75 years with severe AS had higher plasma TGF-β1 levels and more severe anemia than AS patients age <75 years, and there was a correlation between TGF-β1 and anemia. These data are compatible with the hypothesis that the blood loss anemia of Heyde's syndrome contributes to AS progression via WSS-induced activation of platelet TGF-β1 and additional gastrointestinal bleeding via WSS-induced AVWS.
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Affiliation(s)
- Kumar Subramani
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Jeffrey Bander
- Icahn School of Medicine at Mount Sinai New York, New York, USA
| | - Sixia Chen
- University of Oklahoma Health Sciences Centers, Oklahoma City, Oklahoma, USA
| | | | - Thamizhiniyan Venkatesan
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Sandeep Subrahmanian
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Rohan Varshney
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Annapoorna Kini
- Icahn School of Medicine at Mount Sinai New York, New York, USA
| | - Samin Sharma
- Icahn School of Medicine at Mount Sinai New York, New York, USA
| | - Daniel B. Rifkin
- Departments of Cell Biology and Medicine, New York University, New York, New York, USA
| | - Jaehyung Cho
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Barry S. Coller
- Laboratory of Blood and Vascular Biology, Rockefeller University, New York, New York, USA
| | - Jasimuddin Ahamed
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
- University of Oklahoma Health Sciences Centers, Oklahoma City, Oklahoma, USA
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6
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Connell NT, Caicedo J, Nieto N, Chatterjee S, Hait A, Gupta AK, Bullano M, Schultz BG. Real-world healthcare costs and resource utilization in patients with von Willebrand disease and angiodysplasia. Expert Rev Pharmacoecon Outcomes Res 2023:1-9. [PMID: 37183836 DOI: 10.1080/14737167.2023.2211270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To describe the economic burden among VWD patients with angiodysplasia compared to VWD patients without angiodysplasia and the general population. METHODS This was a retrospective analysis using the Merative MarketScan Commercial and Medicare Databases® (January 2011-September 2020). Selected patients had ≥1 medical claim for VWD or low VWF, ≥1 medical claim for AGD, and ≥3 GI-related bleeding episodes within a year. HCRU and all-cause costs were compared with the VWD (only) and the general cohorts. RESULTS The mean total all-cause costs were $150,101 among patients with VWD and angiodysplasia (n = 34), higher compared to $48,249 among matched VWD patients without angiodysplasia (n = 136) and $31,029 among matched individuals of the general population [n = 136; p-value < 0.0001]. The differences in costs between groups were primarily due to inpatient care. During the 12-month follow-up, VWD patients with symptomatic (n = 35), asymptomatic (n = 81), and suspected (n = 378) angiodysplasia had an average of 4.1, 0.6, and 3.8 gastrointestinal (GI) bleeds, respectively. Desmopressin, VWF concentrates, and aminocaproic acid were the most frequent treatments used. The most frequent procedures to treat GI-related bleeding and underlying lesions were blood transfusion and laser therapy. CONCLUSIONS Despite recent therapeutic advances, there is room for considerable reduction of the disease burden in patients with VWD and angiodysplasia.
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Affiliation(s)
- N T Connell
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - J Caicedo
- US Medical Affairs, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
| | - N Nieto
- US Medical Affairs, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
| | | | - A Hait
- Complete HEOR Solutions, North Wales, PA, USA
| | - A K Gupta
- Complete HEOR Solutions, North Wales, PA, USA
| | - M Bullano
- US Medical Affairs, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
| | - B G Schultz
- US Medical Affairs, Takeda Pharmaceuticals USA Inc, Lexington, MA, USA
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7
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Teitel J. Colorectal cancer screening in patients with inherited bleeding disorders: high cancer detection rate in patients with hemophilia. J Thromb Haemost 2023; 21:1104-1106. [PMID: 37121618 DOI: 10.1016/j.jtha.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 05/02/2023]
Affiliation(s)
- Jerome Teitel
- Division of Hematology, Faculty of Medicine, University of Toronto, Toronto, Canada; Division of Hematology and Oncology, St Michael's Hospital, Toronto, Canada.
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8
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Khalil F, Asleh R, Perue RK, Weinstein JM, Solomon A, Betesh-Abay B, Briasoulis A, Alnsasra H. Vascular Function in Continuous Flow LVADs: Implications for Clinical Practice. Biomedicines 2023; 11:biomedicines11030757. [PMID: 36979735 PMCID: PMC10045906 DOI: 10.3390/biomedicines11030757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
Left ventricular assist devices (LVADs) have been increasingly used in patients with advanced heart failure, either as a destination therapy or as a bridge to heart transplant. Continuous flow (CF) LVADs have revolutionized advanced heart failure treatment. However, significant vascular pathology and complications have been linked to their use. While the newer CF-LVAD generations have led to a reduction in some vascular complications such as stroke, no major improvement was noticed in the rate of other vascular complications such as gastrointestinal bleeding. This review attempts to provide a comprehensive summary of the effects of CF-LVAD on vasculature, including pathophysiology, clinical implications, and future directions.
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Affiliation(s)
- Fouad Khalil
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD 57105, USA
| | - Rabea Asleh
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem P.O. Box 12000, Israel
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - Radha Kanneganti Perue
- Department of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jean-Marc Weinstein
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
| | - Adam Solomon
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Batya Betesh-Abay
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
| | - Alexandros Briasoulis
- Department of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Hilmi Alnsasra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva P.O. Box 653, Israel
- Department of Cardiology, Soroka University Medical Center, Rager Av., Beersheva P.O. Box 84101, Israel
- Correspondence: ; Tel.: +972-507107535
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Chornenki NLJ, Ocran E, James PD. Special considerations in GI bleeding in VWD patients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:624-630. [PMID: 36485078 PMCID: PMC9820382 DOI: 10.1182/hematology.2022000390] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Gastrointestinal (GI) bleeding is an important cause of morbidity and mortality in von Willebrand disease (VWD). It has been noted that GI bleeding caused by angiodysplasia is overrepresented in VWD patients compared to other causes. The bleeding from angiodysplasia is notoriously difficult to treat; recurrences and rebleeds are common. A growing body of basic science evidence demonstrates that von Willebrand factor negatively regulates angiogenesis through multiple pathways. VWD is clinically highly associated with angiodysplasia. The predisposition to angiodysplasia likely accounts for many of the clinical difficulties related to managing GI bleeding in VWD patients. Diagnosis and treatment are challenging with the current tools available, and much further research is needed to further optimize care for these patients with regard to acute treatment, prophylaxis, and adjunctive therapies. In this review we provide an overview of the available literature on GI bleeding in VWD and explore the molecular underpinnings of angiodysplasia-related GI bleeding. Considerations for diagnostic effectiveness are discussed, as well as the natural history and recurrence of these lesions and which therapeutic options are available for acute and prophylactic management.
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Affiliation(s)
| | - Edwin Ocran
- Department of Medicine, Queen's University, Kingston, Canada
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, Canada
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10
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Harris NS, Pelletier JP, Marin MJ, Winter WE. Von Willebrand factor and disease: a review for laboratory professionals. Crit Rev Clin Lab Sci 2021; 59:241-256. [DOI: 10.1080/10408363.2021.2014781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Neil S. Harris
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - J. Peter Pelletier
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Maximo J. Marin
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - William E. Winter
- Department of Pathology, Immunology & Laboratory Medicine, University of Florida, Gainesville, FL, USA
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11
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Translating the success of prophylaxis in haemophilia to von Willebrand disease. Thromb Res 2021; 199:67-74. [PMID: 33445035 DOI: 10.1016/j.thromres.2020.12.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION There is limited awareness of von Willebrand disease (VWD), leading to challenges in both diagnosis and defining the optimal treatment approach for these patients. Patients with VWD are typically treated on-demand, with short-term prophylaxis used during surgery. In contrast, early initiation, and long-term use of prophylaxis is the standard of care in patients with severe haemophilia and can be successfully used to prevent joint bleeding and reduce chronic arthropathy. AIM To provide an understanding of the current evidence for the prophylactic treatment of patients with VWD and compare this to the management of patients with haemophilia. METHODS Review of published literature using a non-systematic search of PubMed and reference lists of sourced articles. RESULTS The successes seen with prophylaxis in haemophilia provide the rationale for long-term prophylaxis in patients with severe forms of VWD; preventing spontaneous, excessive and sometimes life-threatening bleeding, and reducing chronic joint disease. Currently, there are a few clinical trials assessing the long-term benefits of prophylaxis in VWD, and guidelines for the optimal prophylaxis treatment approach are lacking. Greater attempts to provide comprehensive, long-term care for patients with VWD are needed but still lacking within the community. This review highlights the success of prophylaxis in haemophilia and how this knowledge might be applied and translated to patients with VWD. CONCLUSIONS Lessons can be learned from the use of prophylaxis in haemophilia and prophylaxis should be considered the standard of care for a subgroup of patients with severe VWD.
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12
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de Jong A, Dirven RJ, Boender J, Atiq F, Anvar SY, Leebeek FWG, van Vlijmen BJM, Eikenboom J. Ex vivo Improvement of a von Willebrand Disease Type 2A Phenotype Using an Allele-Specific Small-Interfering RNA. Thromb Haemost 2020; 120:1569-1579. [PMID: 32803740 PMCID: PMC7649061 DOI: 10.1055/s-0040-1715442] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder and is mainly caused by dominant-negative mutations in the multimeric protein von Willebrand factor (VWF). These mutations may either result in quantitative or qualitative defects in VWF. VWF is an endothelial protein that is secreted to the circulation upon endothelial activation. Once secreted, VWF multimers bind platelets and chaperone coagulation factor VIII in the circulation. Treatment of VWD focuses on increasing VWF plasma levels, but production and secretion of mutant VWF remain uninterrupted. Presence of circulating mutant VWF might, however, still affect normal hemostasis or functionalities of VWF beyond hemostasis. We hypothesized that inhibition of the production of mutant VWF improves the function of VWF overall and ameliorates VWD phenotypes. We previously proposed the use of allele-specific small-interfering RNAs (siRNAs) that target frequent
VWF
single nucleotide polymorphisms to inhibit mutant
VWF
. The aim of this study is to prove the functionality of these allele-specific siRNAs in endothelial colony-forming cells (ECFCs). We isolated ECFCs from a VWD type 2A patient with an intracellular multimerization defect, reduced VWF collagen binding, and a defective processing of proVWF to VWF. After transfection of an allele-specific siRNA that specifically inhibited expression of mutant VWF, we showed amelioration of the laboratory phenotype, with normalization of the VWF collagen binding, improvement in VWF multimers, and enhanced VWF processing. Altogether, we prove that allele-specific inhibition of the production of mutant VWF by siRNAs is a promising therapeutic strategy to improve VWD phenotypes.
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Affiliation(s)
- Annika de Jong
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Richard J Dirven
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Johan Boender
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ferdows Atiq
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Seyed Yahya Anvar
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bart J M van Vlijmen
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
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Allerkamp H, Lehner S, Ekhlasi-Hundrieser M, Detering C, von Depka Prondzinski M, Pfarrer C. Expression of angiogenic factors in the uteroplacental unit is altered at time of placentation in a porcine model of von Willebrand disease type 1. Reprod Biol 2019; 19:412-420. [PMID: 31806575 DOI: 10.1016/j.repbio.2019.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/27/2019] [Accepted: 09/29/2019] [Indexed: 11/15/2022]
Abstract
Von Willebrand disease (VWD) affects blood coagulation and correlates with angiodysplasia. Data on VWD-affected women point to slightly increased miscarriage rates. We aimed to investigate the impact of VWD on angiogenesis in the uteroplacental unit of pregnant pigs of a model of VWD type 1 (T1). Uteri, placentae, and embryos were harvested at time of placentation (day 29 to 31) from four sows (two wildtype (WT) and two heterozygous for a von Willebrand factor (VWF) mutation diagnosed with T1). T1 sows were bred to a T1 boar creating embryos of three different genotypes: WT, T1 or homozygous for the VWF mutation corresponding with VWD type 3 (T3). Uteroplacental tissues were examined histologically. Embryos were genotyped. Gene expression of angiogenic factors possibly related to VWF was determined by quantitative real-time PCR. Corresponding protein expression was analyzed by immunohistochemistry. Genotyping revealed 35.3% WT, 52.9% T1 and 5.9% T3 embryos (5.9% not classified confidently). No histological alterations were found. Gene expression of VEGF was significantly increased in T1 placentae while expression of ANG1, ANG2, TIE2, and ITGB3 was significantly reduced, confirmed on protein level for different cell types. TIE2/TIE1 ratios were significantly lower in T1 placentae. Distribution of embryo genotypes indicates selection favoring the WT. Significant expression differences of angiogenic factors in placentae suggest influence of VWF on these factors during placentation, although angiodysplasia was not observed. The alterations concerning VEGF/VEGFR-2 signaling, integrin expression and the ANG/TIE system may influence angiogenesis and vascular adaptation during placentation and thus the overall outcome of pregnancy.
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Affiliation(s)
- Hanna Allerkamp
- Werlhof Institute, Department of Fundamental and Clinical Research, Schillerstr. 23, 30159 Hannover, Germany.
| | - Stefanie Lehner
- Werlhof Institute, Department of Fundamental and Clinical Research, Schillerstr. 23, 30159 Hannover, Germany
| | - Mahnaz Ekhlasi-Hundrieser
- Werlhof Institute, Department of Fundamental and Clinical Research, Schillerstr. 23, 30159 Hannover, Germany
| | - Carsten Detering
- Werlhof Institute, Department of Fundamental and Clinical Research, Schillerstr. 23, 30159 Hannover, Germany
| | - Mario von Depka Prondzinski
- Werlhof Institute, Department of Fundamental and Clinical Research, Schillerstr. 23, 30159 Hannover, Germany
| | - Christiane Pfarrer
- University of Veterinary Medicine Hannover Foundation, Institute for Anatomy, Bischofsholer Damm 15, 30173 Hannover, Germany
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Allerkamp H, Lehner S, Ekhlasi-Hundrieser M, Detering C, Pfarrer C, Depka Prondzinski MV. Characterization of a Porcine Model for Von Willebrand Disease Type 1 and 3 Regarding Expression of Angiogenic Mediators in the Nonpregnant Female Reproductive Tract. Comp Med 2019; 69:401-412. [PMID: 31526432 DOI: 10.30802/aalas-cm-19-000003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Von Willebrand disease (VWD), a blood coagulation disorder, is also known to cause angiodysplasia. Hitherto, no animal model has been found with angiodysplasia that can be studied in vivo. In addition, VWD patients tend to have a higher incidence of miscarriages for reasons unknown. Thus, we aimed to examine the influence of von Willebrand factor (VWF) on the female reproductive tract histology and the expression and distribution of angiogenic factors in a porcine model for VWD types 1 and 3. The disease-causing tandem duplication within the VWF gene occurred naturally in these pigs, making them a rare and valuable model. Reproductive organs of 6 animals (2 of each mutant genotype and 2 wildtype (WT) animals) were harvested. Genotype plus phenotype were confirmed. Several angiogenic factors were chosen for possible connections to VWF and analyzed alongside VWF by immunohistochemistry and quantitative gene expression studies. VWD type 3 animals showed angiodysplasia in the uterus and shifting of integrin αVβ₃ from the apical membrane of uterine epithelium to the cytoplasm accompanied by increased vascular endothelial growth factor (VEGF) expression. Varying staining patterns for angiopoietin (Ang)-2 were observed among the genotypes. As compared with WT, the ovaries of the VWD type 3 animals showed decreased gene expression of ANG2 and increased gene expression of TIE (tyrosine kinase with immunoglobulin and epidermal growth factor homology domains) 2, with some differences in the ANG/TIE-system among the mutant genotypes. In conclusion, severely reduced VWF seems to evoke angiodysplasia in the porcine uterus. Varying distribution and expression of angiogenic factors suggest that this large animal model is promising for investigation of influence of VWF on angiogenesis in larger groups.
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Affiliation(s)
- Hanna Allerkamp
- Department of Fundamental and Clinical Research, Werlhof Institute, Hannover, Lower Saxony, Germany; Institute of Anatomy, University of Veterinary Medicine Hannover Foundation, Hannover, Lower Saxony, Germany;,
| | - Stefanie Lehner
- Department of Fundamental and Clinical Research, Werlhof Institute, Hannover, Lower Saxony, Germany
| | | | - Carsten Detering
- Department of Fundamental and Clinical Research, Werlhof Institute, Hannover, Lower Saxony, Germany
| | - Christiane Pfarrer
- Institute of Anatomy, University of Veterinary Medicine Hannover Foundation, Hannover, Lower Saxony, Germany
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de Jong A, Weijers E, Dirven R, de Boer S, Streur J, Eikenboom J. Variability of von Willebrand factor-related parameters in endothelial colony forming cells. J Thromb Haemost 2019; 17:1544-1554. [PMID: 31265169 PMCID: PMC6852380 DOI: 10.1111/jth.14558] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/03/2019] [Accepted: 06/25/2019] [Indexed: 01/01/2023]
Abstract
Essentials Endothelial colony forming cells (ECFCs) are a powerful tool to study vascular diseases ex vivo. Separate ECFC lines show variations in morphology and von Willebrand factor-related parameters. Maximum cell density is correlated with von Willebrand factor expression in ECFCs. Variations in ECFC lines are dependent on the age and mesenchymal state of the cells. ABSTRACT: Background Endothelial colony forming cells (ECFCs) are cultured endothelial cells derived from peripheral blood. ECFCs are a powerful tool to study pathophysiological mechanisms underlying vascular diseases, including von Willebrand disease. In prior research, however, large variations between ECFC lines were observed in, among others, von Willebrand factor (VWF) expression. Objective Understand the relation between phenotypic characteristics and VWF-related parameters of healthy control ECFCs. Methods ECFC lines (n = 16) derived from six donors were studied at maximum cell density. Secreted and intracellular VWF antigen were measured by ELISA. The angiogenic capacity of ECFCs was investigated by the Matrigel tube formation assay. Differences in expression of genes involved in angiogenesis, aging, and endothelial to mesenchymal transition (EndoMT) were measured by quantitative PCR. Results Different ECFC lines show variable morphologies and cell density at maximum confluency and cell lines with a low maximum cell density show a mixed and more mesenchymal phenotype. We identified a significant positive correlation between maximum cell density and VWF production, both at protein and mRNA level. Also, significant correlations were observed between maximum cell density and several angiogenic, aging and EndoMT parameters. Conclusions We observed variations in morphology, maximum cell density, VWF production, and angiogenic potential between healthy control ECFCs. These variations seem to be attributable to differences in aging and EndoMT. Because variations correlate with cell density, we believe that ECFCs maintain a powerful tool to study vascular diseases. It is however important to compare cell lines with the same characteristics and perform experiments at maximum cell density.
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Affiliation(s)
- Annika de Jong
- Department of Internal medicinedivision of Thrombosis and HemostasisEinthoven Laboratory for Vascular and Regenerative MedicineLeiden University Medical CenterLeidenthe Netherlands
| | - Ester Weijers
- Department of Internal medicinedivision of Thrombosis and HemostasisEinthoven Laboratory for Vascular and Regenerative MedicineLeiden University Medical CenterLeidenthe Netherlands
| | - Richard Dirven
- Department of Internal medicinedivision of Thrombosis and HemostasisEinthoven Laboratory for Vascular and Regenerative MedicineLeiden University Medical CenterLeidenthe Netherlands
| | - Suzan de Boer
- Department of Internal medicinedivision of Thrombosis and HemostasisEinthoven Laboratory for Vascular and Regenerative MedicineLeiden University Medical CenterLeidenthe Netherlands
| | - Jasmin Streur
- Department of Internal medicinedivision of Thrombosis and HemostasisEinthoven Laboratory for Vascular and Regenerative MedicineLeiden University Medical CenterLeidenthe Netherlands
| | - Jeroen Eikenboom
- Department of Internal medicinedivision of Thrombosis and HemostasisEinthoven Laboratory for Vascular and Regenerative MedicineLeiden University Medical CenterLeidenthe Netherlands
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Significant gynecological bleeding in women with low von Willebrand factor levels. Blood Adv 2019; 2:1784-1791. [PMID: 30042144 DOI: 10.1182/bloodadvances.2018017418] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 06/19/2018] [Indexed: 01/11/2023] Open
Abstract
Gynecological bleeding is frequently reported in women with von Willebrand disease (VWD). Low von Willebrand factor (VWF) may be associated with significant bleeding phenotype despite only mild plasma VWF reductions. The contribution of gynecological bleeding to this phenotype has yet to be described. The optimal clinical bleeding assessment tool (BAT) to evaluate bleeding remains unclear. Using a standardized approach to phenotypic assessment, we evaluated gynecological bleeding and directly compared the Condensed Molecular and Clinical Markers for the Diagnosis and Management of type 1 VWD (Condensed MCMDM-1 VWD) and International Society on Thrombosis and Haemostasis (ISTH) BAT scores in 120 women enrolled in the Low von Willebrand in Ireland Cohort study. Heavy menstrual bleeding (HMB) was reported in 89% of female participants; 45.8% developed iron deficiency. Using identical data, Condensed MCMDM-1 VWD menorrhagia domain scores were significantly lower than ISTH BAT scores (2 vs 3; P < .0001), the discrepant results related to 40% of women not seeking medical consultation for HMB, reducing the sensitivity of the Condensed score. For those who reported HMB to physicians, the low VWF diagnosis was not expedited (age at diagnosis 34.2 vs 33.4 years in women failing to present; P = .7). Postpartum hemorrhage (PPH) was self-reported in 63.5% of parous women (n = 74); 21.6% required transfusion, critical care, radiological, or surgical intervention. Our data demonstrate that gynecological bleeding is frequently reported in women with low VWF; despite pregnancy-related increases in plasma VWF levels, these women may experience PPH. Defining the optimal management approach for these patients requires further research. This trial was registered at www.clinicaltrials.gov as #NCT03167320.
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Saeed O, Patel SR, Jorde UP. Bleeding and Angiogenesis During Continuous-Flow Left Ventricular Assist Device Support. Circ Heart Fail 2018; 11:e005483. [PMID: 30354369 DOI: 10.1161/circheartfailure.118.005483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Omar Saeed
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Snehal R Patel
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Ulrich P Jorde
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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