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Introna M, Broggi M, Ferroli P, Martino D, Pinto C, Carpenedo M, Gemma M. Perioperative ROTEM® evaluation in a patient affected by severe VII factor deficiency undergoing microvascular decompression craniotomy for hemifacial spasm. J Clin Monit Comput 2024:10.1007/s10877-024-01183-w. [PMID: 38850455 DOI: 10.1007/s10877-024-01183-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
The potential use of TEG/ROTEM® in evaluating the bleeding risk for rare coagulation disorders needs to be assessed, considering the common mismatch among laboratory tests and the clinical manifestations. As a result, there is currently no published data on the use of viscoelastic tests to assess coagulation in FVII deficient patients undergoing elective neurosurgery. We describe the case of a patient affected by severe FVII deficiency who underwent microvascular decompression (MVD) craniotomy for hemifacial spasm (HFS). The ROTEM® did not show a significant coagulopathy according to the normal ranges, before and after the preoperative administration of the recombinant activated FVII, but a substantial reduction in EXTEM and FIBTEM Clotting Times was noted. The values of coagulation in standard tests, on the contrary, were indicative of a coagulopathy, which was corrected by the administration of replacement therapy. Whether this difference between ROTEM® and standard tests is due to the inadequacy of thromboelastographic normal ranges in this setting, or to the absence of clinically significant coagulopathy, has yet to be clarified. Neurosurgery is a typical high bleeding risk surgery; additional data is required to clarify the potential role for thromboelastographic tests in the perioperative evaluation of the FVII deficient neurosurgical patients.
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Affiliation(s)
- Michele Introna
- Neurointensive Care Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy.
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Morgan Broggi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Donato Martino
- Neurointensive Care Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Carmela Pinto
- Neurointensive Care Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Monica Carpenedo
- Hematology Unit, ASST Fatebenefratelli-Sacco, Ospedale L. Sacco, Polo Didattico Università degli Studi di Milano, Milano, Italy
| | - Marco Gemma
- Neurointensive Care Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Huang C, Yu Y, Zhai N, Mo W, Lin F. Patient with congenital factor VII deficiency undergoing brain tumor neurosurgery successfully treated with recombinant factor VIIa and fresh frozen plasma: A case report and literature review. Medicine (Baltimore) 2023; 102:e36694. [PMID: 38206717 PMCID: PMC10754550 DOI: 10.1097/md.0000000000036694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/27/2023] [Indexed: 01/13/2024] Open
Abstract
RATIONALE Congenital factor VII deficiency is the most common among rare bleeding disorders, characterized by spontaneous or traumatic bleeding. The clinical manifestation is heterogeneous, ranging from asymptomatic phenotype to life-threatening hemorrhages. Intracranial hemorrhage is a common complication of brain tumor neurosurgery, which significantly challenges the perioperative management of patients with hemostatic defects. PATIENT CONCERNS This report presented a 55-year-old man with congenital factor VII deficiency, who had no history of hemorrhage or family history. He underwent a craniotomy for the treatment of papillary craniopharyngioma. DIAGNOSES The patient was diagnosed as papillary craniopharyngioma, factor VII deficiency, and atrial fibrillation. INTERVENTIONS To prevent bleeding, a total of 8 doses of recombinant activated factor VII and 1 dose of fresh frozen plasma were administered as the perioperative replacement therapy. This scheme was guided by a pharmacodynamic evaluation, laboratory tests, and imaging examinations. OUTCOMES No excessive surgical bleeding was observed during the 22-day treatment. The patient was found to have compound heterozygous mutations, Ala304Thr (c.910G > A) and IVS5-2A > G (c.572-2A > G), in the F7 gene. LESSONS This is the first reported case in which surgical hemorrhage secondary to brain tumor resection was successfully controlled in the presence of congenital factor VII deficiency. Perioperative coagulation state, hemostasis, and thrombosis events should be closely observed, and the interval and dosage of recombinant factor VIIa should be adjusted accordingly.
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Affiliation(s)
- Chaoyu Huang
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangxi Medical University, Key Laboratory of Clinical Laboratory Medicine of Guangxi Department of Education, Nanning, Guangxi, China
| | - Yongjia Yu
- Department of Neurosurgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ningneng Zhai
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangxi Medical University, Key Laboratory of Clinical Laboratory Medicine of Guangxi Department of Education, Nanning, Guangxi, China
| | - Wuning Mo
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangxi Medical University, Key Laboratory of Clinical Laboratory Medicine of Guangxi Department of Education, Nanning, Guangxi, China
| | - Faquan Lin
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangxi Medical University, Key Laboratory of Clinical Laboratory Medicine of Guangxi Department of Education, Nanning, Guangxi, China
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Cassel A, Rosenberg N, Muhammad E, Livnat T, Dardik R, Berl M, Preis M. Novel mutation in coagulation factor VII (Carmel mutation): Identification and characterization. Res Pract Thromb Haemost 2021; 5:e12407. [PMID: 34027285 PMCID: PMC8117812 DOI: 10.1002/rth2.12407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Measurement of factor VII (FVII) activity does not enable prediction of bleeding tendency in individuals with inherited FVII deficiency. OBJECTIVE To characterize the molecular and functional features of FVII in a family with FVII deficiency and correlate them with the bleeding tendency. PATIENTS/METHODS We studied 7 family members with very low FVII activity using prothrombin time (PT), activated factor VII (FVIIa), FVII activity level, and thrombin generation. The factor 7 gene was sequenced and the mutation was analyzed by prediction software. RESULTS The proband has very low FVII activity (0%-4%), with PT ranging between 5% to 18% depending on the tissue factor (TF) origin. Direct sequencing demonstrated a single homozygous nucleotide substitution G > A in exon 6, predicting a novel missense mutation Cys164Tyr. Three members of the family were found to be heterozygous carriers of this mutation. One of them was a compound heterozygote, carrying both the Cys164Tyr and Ala244Val mutation (linked to Arg353Gln polymorphism). Her FVII activity and antigen levels were 3%-7% and 8%, respectively. The other heterozygous carriers demonstrated FVII activity of 41%-54%, FVII antigen of 46%-66%, and FVIIa activity of 30%. FVIIa was undetectable in the homozygous and compound heterozygous subjects. Thrombin generation was normal in the presence of calcium, but no response to TF addition was observed in the homozygous proband, and a reduced response was observed in the compound heterozygous subject. CONCLUSION The patient homozygous for the "Carmel" mutation has mild clinical manifestations despite very low FVII activity, which correlates with thrombin generation results.
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Affiliation(s)
- Aliza Cassel
- Institute of HematologyCarmel Medical CenterHaifaIsrael
| | - Nurit Rosenberg
- The Israeli National HemophiliaSheba Medical CenterTel HashomerIsrael
- Sackler School of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Emad Muhammad
- Institute of HematologyCarmel Medical CenterHaifaIsrael
| | - Tami Livnat
- The Israeli National HemophiliaSheba Medical CenterTel HashomerIsrael
- Sackler School of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Rima Dardik
- The Israeli National HemophiliaSheba Medical CenterTel HashomerIsrael
- Sackler School of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Miriam Berl
- Institute of HematologyCarmel Medical CenterHaifaIsrael
| | - Meir Preis
- Institute of HematologyCarmel Medical CenterHaifaIsrael
- Ruth and Bruce Rappaport Faculty of MedicineIsrael Institute of TechnologyTechnion, HaifaIsrael
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Abstract
Rare bleeding disorders (RBDs) comprise inherited deficiencies of factors I (fibrinogen), II (prothrombin), V, VII, X, XI, and XIII as well as combined factor V + VIII and vitamin K-dependent factors. They represent 3-5% of all congenital bleeding disorders and are usually transmitted as autosomal recessive traits. These disorders often manifest during childhood and have varied clinical presentations from mucocutaneous bleeding to life-threatening symptoms such as central nervous system and gastrointestinal bleeding. Bleeding manifestations generally vary within the same RBD and may also vary from 1 RBD to the other. Laboratory diagnosis is based on coagulation screening tests and specific factor assays, with molecular techniques providing diagnostic accuracy and enabling prenatal counseling. The approach to treatment of bleeding episodes and invasive procedures needs to be individualized and depends on the severity, frequency and procedure-related risk of bleeding. The first line of treatment of RBDs is replacement of the deficient factor, using specific plasma-derived or recombinant products and using fresh frozen plasma or cryoprecipitate when specific products are not available or in resource-limited countries. Prophylaxis may be considered in individuals with recurrent serious bleeding and especially after life-threatening bleeding episodes. Novel no-replacement strategies promoting hemostasis by through different mechanisms need to be studied in RBDs as alternative therapeutic options.
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Affiliation(s)
- Shilpa Jain
- Division of Pediatric Hematology-Oncology, Women and Children's Hospital of Buffalo and Hemophilia Center of Western New York, Buffalo, NY, 14209, United States.
| | - Suchitra S Acharya
- Bleeding Disorders and Thrombosis Program, Cohen Children's Medical Center of New York and Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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Kuperman AA, Barg AA, Fruchtman Y, Shaoul E, Rosenberg N, Kenet G, Livnat T. Primary prophylaxis for children with severe congenital factor VII deficiency — Clinical and laboratory assessment. Blood Cells Mol Dis 2017; 67:86-90. [DOI: 10.1016/j.bcmd.2016.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/18/2016] [Accepted: 12/18/2016] [Indexed: 10/20/2022]
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Rare bleeding disorders-old diseases in the era of novel options for therapy. Blood Cells Mol Dis 2017; 67:63-68. [PMID: 28222949 DOI: 10.1016/j.bcmd.2017.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 02/12/2017] [Indexed: 12/20/2022]
Abstract
Rare diseases are defined as life-threatening or chronically debilitating diseases with a prevalence of less than one per 2000 according to the European Union or one per 1250 according to the USA. Congenital rare bleeding disorders RBD are reported in most populations, with incidence varying from 1 in 5000 (Hemophilia A), 1:30,000 (Hemophilia B) to much rarer (1:500,000 for FVII deficiency, 1-3 million for Prothrombin or FXIII deficiency). Acquired Hemophilia A is also a rare bleeding disorder with estimated frequency of 1 in million. Most RBDs are inherited as autosomal recessive (AR); however, heterozygous carriers with varying degrees of corresponding factor deficiency may render an unpredictable propensity for bleeding. In patients with bleeding symptoms, laboratory assessment and especially molecular techniques currently enable accurate diagnosis and may provide tools for prenatal and family counseling. Currently hemostasis control is mainly based upon replacement of the missing coagulation factors (unless presence of inhibitors renders it impossible), however future gene therapy and disruptive, non-replacement alternatives may be promising for patients with RBD.
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Shigekiyo T, Sekimoto E, Shibata H, Ozaki S, Okumura T, Fujinaga H, Shibata H, Aihara KI, Akaike M. Factor VII Tokushima: the first case of factor VII Cys22Gly with the development of myocardial infarction in the proband receiving recombinant factor VIIa replacement therapy. Blood Coagul Fibrinolysis 2015; 26:956-8. [PMID: 26517065 DOI: 10.1097/mbc.0000000000000346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
An 81-year-old man was referred to our department because of suspected factor VII (FVII) deficiency. His FVII activity was under 1%, whereas the FVII activity levels of his son and granddaughter were 65 and 109%, respectively. The nucleotide at position 3886 of his FVII gene was homozygous for G. A single T to G substitution results in the replacement of wild-type Cys at residue 22 by Gly. His son was heterozygous for G and T at position 3886, whereas his granddaughter was homozygous for wild-type T. These results suggest that he was homozygous for FVII Cys22Gly. He underwent radiofrequency ablation (RFA) for hepatocellular carcinoma, receiving 20 μg/kg of recombinant FVIIa prior to RFA and 10 μg/kg of recombinant FVIIa twice after RFA. He showed no bleeding tendency; however, a myocardial infarction was diagnosed and percutaneous coronary intervention was performed.
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Affiliation(s)
- Toshio Shigekiyo
- aDepartment of Hematology bDepartment of Cardiovascular Medicine cDepartment of Gastroenterology, Tokushima Prefectural Central Hospital dDepartment of Medicine and Bioregulatory Sciences eDepartment of Medical Education, Graduated School of Health Biosciences, The University of Tokushima, Tokushima, Japan
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Zhang XH, Zhu XL, Niu T, Sun J, Liu H, Feng R, Yang LH, Wei Q, Ma QH, Wang QM, Feng FE, Fu HX, Mo XD, Lv M, Huang XJ. Combination of FVIII and low-dose rFVIIa improves haemostasis in acquired haemophilia A patients: a collaborative controlled study. Thromb Res 2015; 135:835-40. [PMID: 25747536 DOI: 10.1016/j.thromres.2015.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 02/11/2015] [Accepted: 02/17/2015] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is an autoimmune disease that potentially leads to severe bleeding and has a high rate of mortality. This collaborative study aimed to assess the efficacy of the co-administration of FVIII and low-dose rFVIIa in patients with AHA. MATERIALS AND METHODS This study retrospectively compared the combined FVIII/low-dose rFVIIa therapy (initial dose range of 25-55μg/Kg) with the combined FVIII/PCC therapy and low-dose rFVIIa monotherapy. Adverse drug reactions and recurrent bleeding episodes were also monitored. Crude comparisons and the exact conditional logistic regression were performed to compare the outcomes between three treatment groups. RESULTS First bleeding episodes of 56 consecutive patients from 5 centres were analyzed, and 37 bleeding episodes (66.1%) were determined to be severe. Specifically, the rate of bleeding control was significantly higher with the FVIII/low-dose rFVIIa therapy compared to that of the low-dose rFVIIa alone therapy or the FVIII/PCC therapy (58.3% vs. 41.7% vs. 95.0%, respectively). Analyzing of total 236 bleeding episodes showed a clear positive association between the early initiation of haemostatic treatment and efficacy. No therapy-related adverse events in which thrombosis predominated were reported. CONCLUSIONS The combination of FVIII and low-dose rFVIIa offers an ideal haemostatic cover and may be promoted as a feasible and safe therapy protocol for patients with AHA.
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Affiliation(s)
- Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C..
| | - Xiao-Lu Zhu
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Ting Niu
- Department of haematology, West China Hospital, West China School of Clinical Medicine, Sichuan University, Chengdu, Sichuan, P.R.C
| | - Jing Sun
- Department of haematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R.C
| | - Hui Liu
- Department of haematology, Beijing Hospital, Beijing, P.R.C
| | - Ru Feng
- Department of haematology, Beijing Hospital, Beijing, P.R.C
| | - Lin-Hua Yang
- Department of haematology, the Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, P.R.C
| | - Qing Wei
- Department of haematology, West China Hospital, West China School of Clinical Medicine, Sichuan University, Chengdu, Sichuan, P.R.C
| | - Qing-Hui Ma
- Department of haematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R.C
| | - Qing-Ming Wang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Fei-Er Feng
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Meng Lv
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C..
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Miyata N, Isaka M, Kojima H, Maniwa T, Takahashi S, Takamiya O, Ohde Y. Continuous infusion of recombinant activated factor VII for bleeding control after lobectomy in a patient with inherited factor VII deficiency. Gen Thorac Cardiovasc Surg 2014; 64:177-80. [DOI: 10.1007/s11748-014-0455-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 07/11/2014] [Indexed: 11/30/2022]
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