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Chikasawa Y, Amano K, Shinozawa K, Bingo M, Miyashita R, Yamaguchi T, Mitsuhashi A, Inaba H, Hagiwara T, Kinai E. Comprehensive comparison of global coagulation assays to differentiate lupus anticoagulant from acquired hemophilia A in patients with prolonged APTT. Int J Hematol 2023; 118:577-588. [PMID: 37751038 DOI: 10.1007/s12185-023-03659-y] [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: 05/10/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/27/2023]
Abstract
There is no established method for differentiating acquired hemophilia A (AHA) from lupus anticoagulant (LA) positivity because both present with prolonged activated partial thromboplastin time. We compared various parameters of rotational thromboelastometry (ROTEM), thrombin generation assay (TGA), and clot waveform analysis (CWA) in patients with AHA (n = 10) and LA (n = 44). Compared with AHA, possible (n = 12) and definite (n = 32) LA showed significantly shorter clotting time (CT) in NATEM mode of ROTEM (> 3600 vs. 501/533). In TGA, peak height was significantly lower in AHA (16 vs. 242/174 nM). In CWA, CT was significantly longer (81 vs. 36/41 s) and Ad|min1| was lower (2.1 vs. 8.7/6.7) in AHA. Notably, CT by NATEM and peak height in TGA completely discriminated between AHA and LA, whereas Ad|min1| did not discriminate between them in 4 cases of AHA and 1 of LA. Comparison of 3 patients with both AHA and LA against a patient with only LA and markedly low FVIII activity (3.5%) showed that both CT by NATEM and peak height of TGA precisely classified the former 3 cases as AHA and the latter 1 case as LA, whereas Ad|min1| classified all 4 cases as AHA. ROTEM and TGA can comparably distinguish between AHA and LA.
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Affiliation(s)
- Yushi Chikasawa
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Keiko Shinozawa
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Masato Bingo
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ryui Miyashita
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Tomoko Yamaguchi
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ayano Mitsuhashi
- Department of Gene Research of Coagulation Disorders, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Inaba
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takeshi Hagiwara
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Božič Mijovski M, Antovic JP, Malmström RE, Mavri A. Biological Variation in Rotational Thromboelastometry in Patients with Atrial Fibrillation Receiving Rivaroxaban. J Cardiovasc Dev Dis 2022; 9:jcdd9070205. [PMID: 35877567 PMCID: PMC9321519 DOI: 10.3390/jcdd9070205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 01/25/2023] Open
Abstract
Rotational thromboelastometry (ROTEM) is a viscoelastic hemostasis test used primarily in the management of bleeding after trauma or in cardiac surgery. To allow safe and valid clinical interpretation of test results, objective specifications for analytical performance are needed, which are generally based on biological variation within (CVI) and between (CVG) individuals. The aim of this study was to evaluate biological variation in ROTEM in patients receiving rivaroxaban. Sixty patients with atrial fibrillation on stable rivaroxaban therapy were included, from whom blood was collected on six occasions: three times at trough and three at peak rivaroxaban concentrations. ROTEM® Extem and LowTF were measured as well as rivaroxaban concentration, PT, APTT, and anti-Xa. Within- (CVI) and between-subject (CVG) biological estimates were calculated. Knowledge of these biological variation components will help to establish the appropriate objective analytical performance specifications for ROTEM analysis.
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Affiliation(s)
- Mojca Božič Mijovski
- Department of Vascular Diseases, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia;
- Faculty of Pharmacy, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence:
| | - Jovan P. Antovic
- Department of Coagulation Research, Institute for Molecular Medicine and Surgery, Karolinska Institutet, 17177 Stockholm, Sweden;
- Department of Clinical Chemistry, Karolinska University Hospital, 17177 Stockholm, Sweden
| | - Rickard E. Malmström
- Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, 17177 Stockholm, Sweden;
- Clinical Pharmacology, Karolinska University Hospital, 17177 Stockholm, Sweden
| | - Alenka Mavri
- Department of Vascular Diseases, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia;
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The Non-Activated Thromboelastometry (NATEM) Assay's Application among Adults and Neonatal/Pediatric Population: A Systematic Review. Diagnostics (Basel) 2022; 12:diagnostics12030658. [PMID: 35328210 PMCID: PMC8947108 DOI: 10.3390/diagnostics12030658] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/21/2022] [Accepted: 03/03/2022] [Indexed: 02/06/2023] Open
Abstract
The non-activated thromboelastometry (NATEM) assay is a point-of-care assay that can provide a comprehensive insight into the actual hemostatic mechanism. However, there are very limited data about its use in clinical practice. The aim of this study was to systematically review the literature for any data regarding the use of NATEM in several clinical settings. A systematic review of PubMed and Scopus databases was conducted through 20 January 2022 for studies evaluating the use of the NATEM assay in different clinical settings. The literature search yielded a total of 47 publications, 30 of which met the eligibility criteria for this review. Evaluation of NATEM’s detecting ability for hemostasis disorders is limited in the literature. The results of the included studies indicate that NATEM seems to be a sensitive method for the detection of hyperfibrinolysis and may have an advantage in the diagnosis of hemostatic disorders. It could be more informative than the other ROTEM assays for detecting changes in coagulation parameters in patients who receive anticoagulants. However, the reported outcomes are highly varying among the included studies. NATEM has a high sensitivity to detect hypo- or hypercoagulability and provides a detailed insight into the whole hemostatic process from clot formation to clot breakdown. It could be a useful technique in variable fields of medicine, not only in adults, but also in pediatric and neonatal populations, to guide different hemostatic treatments and predict coagulation disorders or mortality/morbidity; this issue remains to be further investigated.
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Pavoni V, Gianesello L, Conti D, Ballo P, Dattolo P, Prisco D, Görlinger K. "In Less than No Time": Feasibility of Rotational Thromboelastometry to Detect Anticoagulant Drugs Activity and to Guide Reversal Therapy. J Clin Med 2022; 11:1407. [PMID: 35268498 PMCID: PMC8911211 DOI: 10.3390/jcm11051407] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023] Open
Abstract
Anticoagulant drugs (i.e., unfractionated heparin, low-molecular-weight heparins, vitamin K antagonists, and direct oral anticoagulants) are widely employed in preventing and treating venous thromboembolism (VTE), in preventing arterial thromboembolism in nonvalvular atrial fibrillation (NVAF), and in treating acute coronary diseases early. In certain situations, such as bleeding, urgent invasive procedures, and surgical settings, the evaluation of anticoagulant levels and the monitoring of reversal therapy appear essential. Standard coagulation tests (i.e., activated partial thromboplastin time (aPTT) and prothrombin time (PT)) can be normal, and the turnaround time can be long. While the role of viscoelastic hemostatic assays (VHAs), such as rotational thromboelastometry (ROTEM), has successfully increased over the years in the management of bleeding and thrombotic complications, its usefulness in detecting anticoagulants and their reversal still appears unclear.
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Affiliation(s)
- Vittorio Pavoni
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care Area, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy; (V.P.); (D.C.)
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, 50134 Florence, Italy
| | - Duccio Conti
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care Area, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy; (V.P.); (D.C.)
| | - Piercarlo Ballo
- Cardiology Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy;
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy;
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany;
- Medical Department, Tem Innovations, 81829 Munich, Germany
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Görlinger K, Almutawah H, Almutawaa F, Alwabari M, Alsultan Z, Almajed J, Alwabari M, Alsultan M, Shahwar D, Yassen KA. The role of rotational thromboelastometry during the COVID-19 pandemic: a narrative review. Korean J Anesthesiol 2021; 74:91-102. [PMID: 33440114 PMCID: PMC8024216 DOI: 10.4097/kja.21006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 02/08/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is currently recognized as a global health crisis. This viral infection is frequently associated with hypercoagulability, with a high incidence of thromboembolic complications that can be fatal. In many situations, the standard coagulation tests (SCT) fail to detect this state of hypercoagulability in patients with COVID-19 since clotting times are either not or only mildly affected. The role of viscoelastic tests such as rotational thromboelastometry (ROTEM®) during this pandemic is explored in this review. COVID-19-associated coagulopathy, as measured using the rotational thromboelastometry parameters, can vary from hypercoagulability due to increased fibrin polymerization and decreased fibrinolysis to bleeding from hypocoagulability. The use of a multimodal diagnostic and monitoring approach, including both rotational thromboelastometry and SCT, such as plasma fibrinogen and D-dimer concentrations, is recommended. Rotational thromboelastometry provides comprehensive information about the full coagulation status of each patient and detects individual variations. Since COVID-19-associated coagulopathy is a very dynamic process, the phenotype can change during the course of infection and in response to anticoagulation therapy. Data from published literature provide evidence that the combination of rotational thromboelastometry and SCT analysis is helpful in detecting hemostasis issues, guiding anticoagulant therapy, and improving outcomes in COVID-19 patients. However, more research is needed to develop evidence-based guidelines and protocols.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Tem Innovations, Munich, Germany
| | - Hawra Almutawah
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Fatimah Almutawaa
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Maryam Alwabari
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Zahra Alsultan
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Jumanah Almajed
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Mahmoud Alwabari
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Maryam Alsultan
- College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Duri Shahwar
- Division of Anesthesia, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
| | - Khaled Ahmed Yassen
- Division of Anesthesia, Department of Surgery, College of Medicine, King Faisal University, Al-Ahsa, Hofuf, Saudi Arabia
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Jud Schefer R, Heimgartner L, Stirn M, Sigrist NE. Determination of reference intervals for single vial rotational thromboelastometry (ROTEM) parameters and correlation with plasmatic coagulation times in 49 clinically healthy dogs. Res Vet Sci 2020; 129:129-136. [PMID: 31982776 DOI: 10.1016/j.rvsc.2020.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 01/05/2023]
Abstract
The objectives of this prospective study were determination of reference intervals (RI) for rotational thromboelastometry (ROTEM) parameters in single use reagents and to evaluate correlations between plasmatic coagulation times and ROTEM parameters. Blood was sampled from a jugular vein in 49 client-owned healthy dogs and ex-tem S, in-tem S, fib-tem S and ap-tem S parameters, prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, haematology, blood chemistry and venous blood gas analysis was performed. Determination of RI was performed using Excel add-in Reference Value Advisor and correlations between PT, aPTT and fibrinogen with selected ROTEM parameters were determined by Spearman correlation. Ex-tem S maximum clot firmness (MCF) RI are smaller compared to RI in people and liquid ex-tem in dogs while maximum lysis was comparable to those in people but smaller than previously reported in dogs. A strong correlation was found between fibrinogen measured by Clauss and fib-tem S and in-tem S MCF (r = 0.541, P < .001 and r = 0.610, P < .001, respectively). PT showed a significant but moderate correlation with ex-tem S CT (r = 0.340, P = .030), in-tem S CFT (r = 0.433, P = .003), fib-tem S CT (r = 0.426, P = .009) and ap-tem S CT (r = 0.354, P = .015) while aPTT was not significantly correlated with any of the evaluated parameters. In conclusion, this study provides single use reagent ROTEM parameter RIs that are different from RI determined with liquid reagents. Significant correlations between fibrinogen concentrations measured by Clauss and clot firmness of fib-tem S and in-tem S profiles and between PT and clotting times of all reagents were identified.
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Affiliation(s)
- Rahel Jud Schefer
- Division of Emergency and Critical Care Medicine, Department of Small Animals, Vetsuisse Faculty of the University of Zurich, Switzerland.
| | - Lara Heimgartner
- Division of Emergency and Critical Care Medicine, Department of Small Animals, Vetsuisse Faculty of the University of Zurich, Switzerland
| | - Martina Stirn
- Clinical laboratory, Department for Clinical Diagnostics and Services, Vetsuisse Faculty of the University of Zurich, Switzerland
| | - Nadja E Sigrist
- Division of Emergency and Critical Care Medicine, Department of Small Animals, Vetsuisse Faculty of the University of Zurich, Switzerland.
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Abstract
Supplemental Digital Content is available in the text. Objectives: Recent data suggest that early increased fibrinolysis may be associated with unfavorable prognosis in cardiac arrest. The current study aimed to assess whether there is an optimal fibrinolysis cutoff value as determined by thrombelastometry at hospital admission to predict poor outcome in a cohort of adult patients with out-of-hospital cardiac arrest. Design: Prospective observational cohort study. Setting: Emergency department of a 2.100-bed tertiary care facility in Vienna, Austria, Europe. Patients: Patients with out-of-hospital cardiac arrest of presumed cardiac origin, subjected to targeted temperature management, who had achieved return of spontaneous circulation at admission were analyzed. Interventions: None. Measurements and Main Results: Fibrinolysis was assessed by thrombelastometry at the bedside immediately after hospital admission and is given as maximum lysis (%). The outcome measure was the optimal cutoff for maximum lysis at hospital admission to predict poor outcome (a composite of Cerebral Performance Category 3–5 or death) at day 30, assessed by receiver operating characteristic curve analysis. Seventy-eight patients (61% male, median 59 yr) were included in the study from March 2014 to March 2017. Forty-two patients (54%) had a poor 30-day outcome including 23 nonsurvivors (30%). The maximum lysis cutoff at admission predicting poor 30-day outcome with 100% specificity (95% CI, 90–100%) was greater than or equal to 20%. Tissue-type plasminogen activator antigen levels were likewise elevated in patients with poor neurologic outcome or death 52 ng/mL (interquartile range, 26–79 ng/mL) versus 29 ng/mL (interquartile range, 17–49 ng/mL; p = 0.036). Conclusions: Increased fibrinolysis at admission assessed by thrombelastometry specifically predicts poor outcome in cardiac arrest with presumed cardiac etiology.
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Samaha E, Schwameis M, Schranz S, Watschinger B, Buchmüller A, Jilma B. Acetylsalicylic acid decreases clotting in combination with enoxaparin during haemodialysis in vitro. Nephrol Dial Transplant 2019; 34:509-515. [PMID: 30053218 DOI: 10.1093/ndt/gfy229] [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: 04/07/2018] [Accepted: 06/16/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anticoagulation is a cornerstone in haemodialysis (HD) therapy to avoid clotting of blood when it comes into contact with the dialysis membrane. Although heparins are usually administered as anticoagulants, they are not always sufficient to maintain adequate HD. We investigated the additional effect of acetylsalicylic acid compared with standard anticoagulation on maintaining adequate flow properties during HD in vitro. METHODS We collected blood from 42 healthy volunteers, between 18 and 60 years of age, into bags filled with 1, 1.5 or 2 mg enoxaparin, with (treatment group) or without (control group) 100 mg of aspirin. Blood was evaluated before, during and at the end of each experiment to determine coagulation parameters, whole blood aggregation and thromboelastogram measurements. Transmembrane pressure was recorded as indirect estimate of dialysis patency. The primary endpoint was time to filter clotting. RESULTS Addition of acetylsalicylic acid significantly prolonged the time to circuit clotting from 120 (105-150) min to >180 min (120-180) min (P = 0.047) and allowed lowering the enoxaparin concentration from 2 mg per circuit to 1 mg without an increase in clotting. Furthermore, it reduced the transmembrane pressure from 46 to 4 mmHg (P < 0.001) after 4 h of dialysis. Acetylsalicylic acid better preserved the platelet count (128 versus 116 × 10E9/L, P = 0.01) and improved platelet aggregation at the end of the dialysis procedure. CONCLUSION Adding acetylsalicylic acid to HD circuits lowered the transmembrane pressure, better preserved platelet function and prolonged the time to circuit clotting, which in sum increases haemodialyser performance and may facilitate a more effective HD.
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Affiliation(s)
- Eslam Samaha
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine II, Division of Pulmonology, Medical University of Vienna, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Sabine Schranz
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bruno Watschinger
- Department of Internal Medicine III, Division of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Anja Buchmüller
- Bayer Healthcare AG, Nordrhein-Westfalen, Wuppertal, Germany
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Thromboelastometry. Reproducibility of duplicate measurement performed by the RoTem® device. Thromb Res 2018; 172:139-141. [DOI: 10.1016/j.thromres.2018.10.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/09/2018] [Accepted: 10/29/2018] [Indexed: 11/24/2022]
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