1
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Favaloro EJ. The Role of the von Willebrand Factor Collagen-Binding Assay (VWF:CB) in the Diagnosis and Treatment of von Willebrand Disease (VWD) and Way Beyond: A Comprehensive 36-Year History. Semin Thromb Hemost 2024; 50:43-80. [PMID: 36807283 DOI: 10.1055/s-0043-1763259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
The von Willebrand factor (VWF) collagen binding (VWF:CB) assay was first reported for use in von Willebrand diagnostics in 1986, by Brown and Bosak. Since then, the VWF:CB has continued to be used to help diagnose von Willebrand disease (VWD) (correctly) and also to help assign the correct subtype, as well as to assist in the monitoring of VWD therapy, especially desmopressin (DDAVP). However, it is important to recognize that the specific value of any VWF:CB is predicated on the use of an optimized VWF:CB, and that not all VWF:CB assays are so optimized. There are some good commercial assays available, but there are also some "not-so-good" commercial assays available, and these may continue to give the VWF:CB "a bad reputation." In addition to VWD diagnosis and management, the VWF:CB found purpose in a variety of other applications, from assessing ADAMTS13 activity, to investigation into acquired von Willebrand syndrome (especially as associated with use of mechanical circulatory support or cardiac assist devices), to assessment of VWF activity in disease states in where an excess of high-molecular-weight VWF may accumulate, and lead to increased (micro)thrombosis risk (e.g., coronavirus disease 2019, thrombotic thrombocytopenic purpura). The VWF:CB turns 37 in 2023. This review is a celebration of the utility of the VWF:CB over this nearly 40-year history.
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Affiliation(s)
- Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
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2
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Marumo A, Sugihara H, Omori I, Morishita E. Relapse of Acquired Hemophilia A after COVID-19 Infection. J NIPPON MED SCH 2024; 90:474-479. [PMID: 36823120 DOI: 10.1272/jnms.jnms.2023_90-609] [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] [Indexed: 02/22/2023]
Abstract
Acquired hemophilia A (AHA) is a rare disease in which an autoantibody causes bleeding by interacting with and inhibiting the coagulation activity of endogenous factor VIII (FVIII). Most cases of AHA are idiopathic; known causes include autoimmune diseases, malignant tumors, pregnancy, drugs, and viral infections. An 86-year-old man was diagnosed with AHA based on the following results: an activated partial thromboplastin time (aPTT) extension of 130.7 seconds, presence of an inhibitor pattern in a mixing study, an endogenous factor VIII (FVIII) level of <1%, and an FVIII inhibitor titer of >5.1 Bethesda units (BU). The activity of von Willebrand factor (vWF) was diminished (<10%), which was considered a complication of acquired von Willebrand syndrome (AVWS). The patient was started on prednisolone, and the inhibitor level eventually became negative. vWF values also became normal. However, 1 year later, he was hospitalized for treatment of coronavirus disease 2019 (COVID-19). Blood testing showed an aPTT extension of 110.5 seconds, FVIII level of 4%, and FVIII inhibitor titer of 0.8 BU; thus, a relapse of AHA was diagnosed. After administration of corticosteroid and remdesivir, he recovered from COVID-19 and AHA. The inhibitor level became negative on the 9th day of admission. Several studies have implicated COVID-19 infection and vaccination in AHA. We recommend that aPTT be measured when patients with AHA are infected with SARS-CoV2, to confirm AHA relapse.
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Affiliation(s)
- Atsushi Marumo
- Division of Internal Medicine, Fussa Hospital
- Department of Hematology, Nippon Medical School
| | | | - Ikuko Omori
- Division of Internal Medicine, Fussa Hospital
- Department of Hematology, Nippon Medical School
| | - Eriko Morishita
- Department of Clinical Laboratory Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Faculty of Health Sciences, Kanazawa University
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3
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Owari M, Harada-Shirado K, Togawa R, Fukatsu M, Sato Y, Fukuchi K, Endo M, Takahashi H, Kimura S, Osaki T, Souri M, Ichinose A, Shibata Y, Hashimoto Y, Ikezoe T. Acquired von Willebrand Syndrome in a Patient with Multiple Comorbidities, Including MALT Lymphoma with IgA Monoclonal Gammopathy and Hyperviscosity Syndrome. Intern Med 2023; 62:605-611. [PMID: 35871597 PMCID: PMC10017253 DOI: 10.2169/internalmedicine.9815-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Acquired von Willebrand syndrome (aVWS) develops with various underlying diseases. We herein report an individual with aVWS associated with mucosa-associated lymphoid tissue lymphoma in the lungs complicated by hyperviscosity syndrome, Sjögren's syndrome, and hypothyroidism. This patient developed life-threatening hemorrhaging during a lung biopsy despite transfusion of concentrate of plasma-derived VWF/factor VIII. The use of rituximab caused remission of the lymphoma and hyperviscosity syndrome in parallel with the resolution of aVWS. Thus, lymphoma and hyperviscosity might result in aVWS. Invasive procedures with a risk of bleeding should be avoided in individuals with aVWS.
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Affiliation(s)
- Mai Owari
- Department of Hematology, Fukushima Medical University, Japan
| | | | - Ryuichi Togawa
- Department of Pulmonary Medicine, Fukushima Medical University, Japan
| | | | - Yuki Sato
- Department of Hematology, Fukushima Medical University, Japan
| | | | - Mamiko Endo
- Department of Hematology, Fukushima Medical University, Japan
| | | | - Satoshi Kimura
- Department of Hematology, Fukushima Medical University, Japan
| | - Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Japan
- The Japanese Collaborative Research Group (JCRG) on Acquired Coagulopathies supported by the Japanese Ministry of Health, Labor, and Welfare, Japan
| | - Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Japan
- The Japanese Collaborative Research Group (JCRG) on Acquired Coagulopathies supported by the Japanese Ministry of Health, Labor, and Welfare, Japan
| | - Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Japan
- The Japanese Collaborative Research Group (JCRG) on Acquired Coagulopathies supported by the Japanese Ministry of Health, Labor, and Welfare, Japan
| | - Yoko Shibata
- Department of Pulmonary Medicine, Fukushima Medical University, Japan
| | - Yuko Hashimoto
- Department of Diagnostic Pathology, Fukushima Medical University, Japan
| | - Takayuki Ikezoe
- Department of Hematology, Fukushima Medical University, Japan
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4
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Lai Y, Xu H, Su Q, Zhou Z. A breath-taking total knee arthroplasty in a patient with acquired von willebrand syndrome: A case report and literature review. Asian J Surg 2023; 46:896-898. [PMID: 35963683 DOI: 10.1016/j.asjsur.2022.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/15/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Yahao Lai
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, PR China
| | - Hong Xu
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, PR China
| | - Qiang Su
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, PR China
| | - Zongke Zhou
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue Road, Chengdu, PR China.
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5
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Osaki T, Souri M, Yokoyama C, Magari Y, Ichinose A. Unmet Need for Reliable Immunological Detection Method for Anti-von Willebrand Factor Autoantibodies. Thromb Haemost 2023; 123:478-481. [PMID: 36539201 DOI: 10.1055/a-2002-2394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Iida-Nishi, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Iida-Nishi, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Chikako Yokoyama
- The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Biochemical Engineering, Graduate School of Science and Engineering, Yamagata University, Yonezawa, Japan.,Department of Chemistry and Bioengineering, Graduate School of Engineering, Osaka Metropolitan University, Osaka, Japan
| | | | - Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Iida-Nishi, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan
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6
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Perioperative diagnosis and impact of acquired von Willebrand syndrome in infants with congenital heart disease. Blood 2023; 141:102-110. [PMID: 36054926 DOI: 10.1182/blood.2022015699] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/06/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Acquired von Willebrand syndrome (aVWS) has been reported in patients with congenital heart diseases associated with shear stress caused by significant blood flow gradients. Its etiology and impact on intraoperative bleeding during pediatric cardiac surgery have not been systematically studied. This single-center, prospective, observational study investigated appropriate diagnostic tools of aVWS compared with multimer analysis as diagnostic criterion standard and aimed to clarify the role of aVWS in intraoperative hemorrhage. A total of 65 newborns and infants aged 0 to 12 months scheduled for cardiac surgery at our tertiary referral center from March 2018 to July 2019 were included in the analysis. The glycoprotein Ib M assay (GPIbM)/von Willebrand factor antigen (VWF:Ag) ratio provided the best predictability of aVWS (area under the receiver operating characteristic curve [AUC], 0.81 [95% CI, 0.75-0.86]), followed by VWF collagen binding assay/VWF:Ag ratio (AUC, 0.70 [0.63-0.77]) and peak systolic echocardiographic gradients (AUC, 0.69 [0.62-0.76]). A cutoff value of 0.83 was proposed for the GPIbM/VWF:Ag ratio. Intraoperative high-molecular-weight multimer ratios were inversely correlated with cardiopulmonary bypass (CPB) time (r = -0.57) and aortic cross-clamp time (r = -0.54). Patients with intraoperative aVWS received significantly more fresh frozen plasma (P = .016) and fibrinogen concentrate (P = .011) than those without. The amounts of other administered blood components and chest closure times did not differ significantly. CPB appears to trigger aVWS in pediatric cardiac surgery. The GPIbM/VWF:Ag ratio is a reliable test that can be included in routine intraoperative laboratory workup. Our data provide the basis for further studies in larger patient cohorts to achieve definitive clarification of the effects of aVWS and its potential treatment on intraoperative bleeding.
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7
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Ghariani I, Braham N, Veyradier A, Bekir L. Acquired von Willebrand syndrome: Five cases report and literature review. Thromb Res 2022; 218:145-150. [PMID: 36049419 DOI: 10.1016/j.thromres.2022.08.025] [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: 05/12/2022] [Revised: 07/22/2022] [Accepted: 08/23/2022] [Indexed: 10/15/2022]
Abstract
Acquired von Willebrand syndrome is a rare bleeding disorder with laboratory findings similar to those of inherited von Willebrand disease. Principal factors distinguishing acquired von Willebrand syndrome from the latter condition include lack of prior bleeding disorders, diagnosis at older age, negative family history and association with underlying conditions. METHODS Retrospective, monocentric descriptive case series of acquired von Willebrand syndrome diagnosed between 2010 and 2020. Diagnostic criteria included a recent history of bleeding, a negative family history and a presence of underlying disorders. RESULTS Five men were diagnosed with acquired von Willebrand syndrome. All of them presented with recent mucocutaneous bleeding. The biological phenotype was a type 2 von Willebrand disease in all cases, with decreased VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag ratios (<0.7). Lymphoproliferative, autoimmune and cardiovascular diseases were the main underlying conditions identified. Screening for an anti-von Willebrand factor inhibitor was positive in two patients. Four patients received treatment for the underlying disorder. High-dose intravenous immunoglobulins were the most frequent treatment administrated. Improvement of plasma von Willebrand factor levels was observed in four cases. CONCLUSION Acquired von Willebrand syndrome is a rare but potentially serious disease. The diagnostic should be suspected in adults with unusual mucocutaneous bleeding associated with lymphoproliferative, myeloproliferative, autoimmune and cardiovascular disorders.
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Affiliation(s)
- Ines Ghariani
- Department of Laboratory Hematology, University Hospital of Mongi Slim, La Marsa, Tunisia; University of Pharmacy, Monastir, Tunisia.
| | - Néjia Braham
- University of Pharmacy, Monastir, Tunisia; Department of Laboratory Hematology, University Hospital of Farhat Hached, Tunis, Tunisia
| | - Agnès Veyradier
- Department of Laboratory Hematology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Leila Bekir
- Department of Laboratory Hematology, University Hospital of Mongi Slim, La Marsa, Tunisia; University of Pharmacy, Monastir, Tunisia
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8
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Janjetovic S, Rolling CC, Budde U, Schneppenhem S, Schafhausen P, Peters MC, Bokemeyer C, Holstein K, Langer F. Evaluation of different diagnostic tools for detection of acquired von Willebrand syndrome in patients with polycythemia vera or essential thrombocythemia. Thromb Res 2022; 218:35-43. [PMID: 35988442 DOI: 10.1016/j.thromres.2022.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/04/2022] [Accepted: 08/03/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Patients with myeloproliferative neoplasms (MPNs) are at increased risk of both thromboembolic and hemorrhagic complications. Among the risk factors for bleeding is the development of an acquired qualitative von Willebrand factor defect with loss of larger VWF plasma multimers, resulting in acquired von Willebrand syndrome (aVWS). The diagnosis of aVWS is challenging, because no single automated test is sufficient to prove or exclude aVWS. We aimed to compare different diagnostic tools used for the detection of MPN-associated aVWS in daily practice. METHODS Patients with polycythemia vera (PV) or essential thrombocythemia (ET), who had been routinely assessed for quantitative and qualitative abnormalities of plasma VWF, were retrospectively studied. RESULTS Sixty-four patients (37 with PV and 27 with ET) were analyzed. Using multimer analysis of plasma VWF, aVWS with a loss of VWF high-molecular-weight multimers was detected in 51.4 % and 55.6 % of PV and ET patients, respectively. A VWF GPIbM/Ag threshold of <0.8 was defined as useful screening tool for aVWS, with acceptable sensitivity (88.2 %) and specificity (76.7 %) and good agreement with VWF multimer analysis (κ = 0.653). VWF:GPIbM/Ag showed better performance than VWF:CB/Ag. Regarding hematological parameters, there was no difference in hematocrit between patients with and without aVWS. However, leukocyte and platelet counts were significantly increased in the aVWS cohort. CONCLUSION For the first time, we identified a VWF:GPIbM/Ag ratio of <0.8 as simple screening tool for aVWS in patients with PV or ET. This observation, however, should be confirmed in a larger patient cohort.
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Affiliation(s)
- Snjezana Janjetovic
- Department of Oncology and Hematology, BMT with section of Pneumology, Hubertus Wad Tumorzentrum - University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Clinic of Hematology and Stem Cell Transplantation, HELIOS Clinic Berlin-Buch, 13125 Berlin, Germany.
| | - Christina Charlotte Rolling
- Department of Oncology and Hematology, BMT with section of Pneumology, Hubertus Wad Tumorzentrum - University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Ulrich Budde
- Department of Haemostaseology, Medilys Laborgesellschaft mbH, Hamburg, Germany
| | - Sonja Schneppenhem
- Department of Haemostaseology, Medilys Laborgesellschaft mbH, Hamburg, Germany
| | - Philippe Schafhausen
- Department of Oncology and Hematology, BMT with section of Pneumology, Hubertus Wad Tumorzentrum - University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mia Carlotta Peters
- Department of Oncology and Hematology, BMT with section of Pneumology, Hubertus Wad Tumorzentrum - University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Bokemeyer
- Department of Oncology and Hematology, BMT with section of Pneumology, Hubertus Wad Tumorzentrum - University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Holstein
- Department of Oncology and Hematology, BMT with section of Pneumology, Hubertus Wad Tumorzentrum - University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Langer
- Department of Oncology and Hematology, BMT with section of Pneumology, Hubertus Wad Tumorzentrum - University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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9
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Ichinose A, Osaki T, Souri M, Favaloro EJ. A Review of Autoimmune Acquired von Willebrand Factor Deficiency in Japan. Semin Thromb Hemost 2022; 48:911-925. [PMID: 35803264 DOI: 10.1055/s-0042-1749088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
von Willebrand factor (VWF) forms high-molecular-weight multimers and plays an essential role in hemostasis, and thus its deficiency leads to bleeding symptoms. Acquired von Willebrand syndrome (AVWS) is rare, but potentially underdiagnosed, and develops in various underlying disorders. AVWS caused by anti-VWF autoantibodies is a rare subcategory of AVWS that can also be referred to as autoimmune VWF deficiency (AiVWFD). We performed a search of patients with autoimmune coagulation factor deficiencies in our nationwide survey in Japan. Among these, suspected cases of AiVWFD were extremely few, with only 11 case consultations in the last 10 years. Of these, three and five were respectively positive for anti-VWF autoantibodies (anti-VWF-Ab) and VWF inhibitor (VWF-inh). We also performed an extensive literature search of other cases from Japan, and in total, 40 cases were finally identified to have AiVWFD, with mean age of 55.0 years. Most underlying disorders were lympho- or myeloproliferative diseases, followed by autoimmune diseases. The major bleeding sites were subcutaneous and mucosal, the bleeding severity was moderate, and there were no hemorrhagic deaths. Bleeding time was prolonged; factor VIII activity, VWF antigen, and VWF activity were decreased, and high-molecular-weight VWF multimers were absent or decreased. These are similar to the common abnormal laboratory findings observed among general AVWS cases. Hemostatic therapy often involved VWF concentrates and vasopressin, and antibody eradication therapy often included corticosteroids and achieved remission. Notably, of all cases, 68% had anti-VWF-Abs, and 83% of anti-VWF-Ab-positive patients were also VWF-inh positive. To accumulate precise clinical information on AiVWFD, it is necessary to verify and improve the measurement methods for both anti-VWF-Ab and anti-VWF-inh. These findings from Japan should be confirmed in other geographic localities.
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Affiliation(s)
- Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan
| | - Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan.,The Japanese Collaborative Research Group (JCRG) on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare (MHLW), Yamagata, Japan.,Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Iida-Nishi, Yamagata, Japan
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead, New South Wales, Australia.,Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
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10
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Kubo M, Sakai K, Hayakawa M, Kashiwagi H, Yagi H, Seki Y, Hasegawa A, Tanaka H, Amano I, Tomiyama Y, Matsumoto M. Increased cleavage of von Willebrand factor by ADAMTS13 may contribute strongly to acquired von Willebrand syndrome development in patients with essential thrombocythemia. J Thromb Haemost 2022; 20:1589-1598. [PMID: 35352474 DOI: 10.1111/jth.15717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/28/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with essential thrombocythemia (ET) often experience bleeding associated with acquired von Willebrand syndrome (AVWS) when the platelet count is markedly increased. OBJECTIVE We investigated whether von Willebrand factor (VWF) degradation is enhanced in patients with ET. METHODS Seventy patients with ET underwent VWF multimer (VWFM) analysis and measurement of VWF-related parameters. We calculated the VWFM index, defined as the ratio of intensities of a patient's molecular weight-categorized VWFMs, and those of a healthy subject's, using densitometric analysis. VWF degradation product (DP) was measured via ELISA using a monoclonal antibody that specifically recognizes Y1605 at the C-terminal boundary, which is exposed following ADAMTS13-mediated cleavage of the Y1605-M1606 bond of the VWF A2 domain. RESULTS Patients with higher platelet counts had a significantly reduced high molecular weight (HMW)-VWFM index and an increased VWF-DP:VWF antigen (Ag) ratio compared to those with lower platelet counts. On multivariate analysis, the VWF-DP/VWF:Ag ratio was an independent predictor of the HMW-VWFM index. Patients who underwent cytoreductive therapy had a significantly higher HMW-VWFM index and lower VWF-DP/VWF:Ag ratio than those who did not. Among individual patients, there was also a significant increase in the HMW-VWFM index and a decrease in the VWF-DP/VWF:Ag ratio after cytoreductive therapy compared to pre-therapy values. CONCLUSION In patients with ET, an increased platelet count is associated with enhanced cleavage of VWF at the Y1605-M1606 bond, primarily by ADAMTS13, leading to AVWS. Cytoreductive therapy reduces the platelet count, prevents excessive VWF cleavage, and improves VWFM distributions.
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Affiliation(s)
- Masayuki Kubo
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
- Department of Hematology, Nara Medical University, Kashihara, Japan
| | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Masaki Hayakawa
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Hirokazu Kashiwagi
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Japan
- Department of Blood Transfusion, Osaka University Hospital, Suita, Japan
| | - Hideo Yagi
- Department of Hematology and Oncology, Nara Prefecture General Medical Center, Nara, Japan
| | - Yoshinobu Seki
- Department of Hematology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minamiuonuma, Japan
| | - Atsushi Hasegawa
- Department of Hematology, Nara Medical University, Kashihara, Japan
| | - Haruyuki Tanaka
- Department of Hematology, Nara Medical University, Kashihara, Japan
| | - Itsuto Amano
- Department of Hematology, Nara Medical University, Kashihara, Japan
| | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital, Suita, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
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Berntorp E, Trakymienė SS, Federici AB, Holstein K, Corrales-Medina FF, Pierce GF, Srivastava A, Prondzinski MVD, Johnsen JM, Zupan IP, Halimeh S, Nummi V, Roberts JC. Sixth Åland Island Conference on von Willebrand disease. Haemophilia 2022; 28 Suppl 5:3-15. [PMID: 35861919 PMCID: PMC9543245 DOI: 10.1111/hae.14495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 01/19/2023]
Abstract
Introduction The sixth Åland Islands Conference on von Willebrand disease (VWD) on the Åland Islands, Finland, was held from 20 to 22 September 2018. Aim The meeting brought together experts in the field of VWD from around the world to share the latest advances and knowledge in VWD. Results and discussion The topics covered both clinical aspects of disease management, and biochemical and laboratory insights into the disease. The clinical topics discussed included epidemiology, diagnosis and treatment of VWD in different countries, management of children with VWD, bleeding control during surgery, specific considerations for the management of type 3 VWD and bleeding control in women with VWD. Current approaches to the management of acquired von Willebrand syndrome were also discussed. Despite significant advances in the understanding and therapeutic options for VWD, there remain many challenges to be overcome in order to optimise patient care. In comparison with haemophilia A, there are very few registries of VWD patients, which would be a valuable source of data on the condition and its management. VWD is still underdiagnosed, and many patients suffer recurrent or severe bleeding that could be prevented. Awareness of VWD among healthcare practitioners, including non‐haematologists, should be improved to allow timely diagnosis and intervention. Diagnosis remains challenging, and the development of fast, simple assays may help to facilitate accurate and rapid diagnosis of VWD.
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Affiliation(s)
- Erik Berntorp
- Centre for Thrombosis and Haemostasis, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Sonata S Trakymienė
- Clinic of Children's Diseases, Vilnius University Hospital Santaros Klinikos, Vilnius University, Vilnius, Lithuania
| | - Augusto B Federici
- Department of Oncology and Oncologic Haematology, Haematology and Transfusion Medicine, L. Sacco University Hospital, University of Milan, Milan, Italy
| | - Katharina Holstein
- Department of Hematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Fernando F Corrales-Medina
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, University of Miami - Miller School of Medicine and University of Miami - Hemophilia Treatment Center, Miami, Florida, USA
| | | | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Jill M Johnsen
- Research Institute, Bloodworks, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Irena P Zupan
- Department of Haematology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Vuokko Nummi
- Coagulation Disorders Unit, Helsinki University Hospital, Helsinki, Finland
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12
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Tiede A, Zieger B, Lisman T. Acquired bleeding disorders. Haemophilia 2022; 28 Suppl 4:68-76. [PMID: 35521729 DOI: 10.1111/hae.14548] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/19/2022]
Abstract
Acquired bleeding disorders can accompany hematological, neoplastic, autoimmune, cardiovascular or liver diseases, but can sometimes also arise spontaneously. They can manifest as single factor deficiencies or as complex hemostatic abnormalities. This review addresses (a) acquired hemophilia A, an autoimmune disorder characterized by inhibitory autoantibodies against coagulation factor VIII; (b) acquired von Willebrand syndrome in patients with cardiovascular disorders, where shear stress abnormalities result in destruction of von Willebrand factor; and (c) liver function disorders that comprise complex changes in pro- and anti-hemostatic factors, whose clinical implications are often difficult to predict. The article provides an overview on the pathophysiology, diagnostic tests and state-of-the-art treatment strategies.
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Affiliation(s)
- Andreas Tiede
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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13
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The Intriguing Connections between von Willebrand Factor, ADAMTS13 and Cancer. Healthcare (Basel) 2022; 10:healthcare10030557. [PMID: 35327035 PMCID: PMC8953111 DOI: 10.3390/healthcare10030557] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/06/2022] [Accepted: 03/14/2022] [Indexed: 12/21/2022] Open
Abstract
von Willebrand factor (VWF) is a complex and large protein that is cleaved by ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13), and together they serve important roles in normal hemostasis. Malignancy can result in both a deficiency or excess of VWF, leading to aberrant hemostasis with either increased bleeding or thrombotic complications, as respectively seen with acquired von Willebrand syndrome and cancer-associated venous thromboembolism. There is emerging evidence to suggest VWF also plays a role in inflammation, angiogenesis and tumor biology, and it is likely that VWF promotes tumor metastasis. High VWF levels have been documented in a number of malignancies and in some cases correlate with more advanced disease and poor prognosis. Tumor cells can induce endothelial cells to release VWF and certain tumor cells have the capacity for de novo expression of VWF, leading to a proinflammatory microenvironment that is likely conducive to tumor progression, metastasis and micro-thrombosis. VWF can facilitate tumor cell adhesion to endothelial cells and aids with the recruitment of platelets into the tumor microenvironment, where tumor/platelet aggregates are able to form and facilitate hematogenous spread of cancer. As ADAMTS13 moderates VWF level and activity, it too is potentially involved in the pathophysiology of these events. VWF and ADAMTS13 have been explored as tumor biomarkers for the detection and prognostication of certain malignancies; however, the results are underdeveloped and so currently not utilized for clinical use. Further studies addressing the basic science mechanisms and real word epidemiology are required to better appreciate the intriguing connections between VWF, ADAMTS13 and malignancy. A better understanding of the role VWF and ADAMTS13 play in the promotion and inhibition of cancer and its metastasis will help direct further translational studies to aid with the development of novel cancer prognostic tools and treatment modalities.
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14
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Kulkarni BP, Ghargi K, Shanmukhaiah C, Shetty SD. Rare Occurrence of Inhibitors in Von Willebrand Disease: A Case Report. Front Med (Lausanne) 2022; 8:807664. [PMID: 35087851 PMCID: PMC8787104 DOI: 10.3389/fmed.2021.807664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Type 3 Von Willebrand Disease (VWD) is the least common but the most severe form of a disease, with a prevalence of about 0. 5 to 1 per million in Western countries. The prevalence of type 3 VWD in the developing countries, with a high degree of consanguinity, is about 6 per million. Moreover, due to underdiagnosis of the milder cases, the prevalence of type 3 VWD is about 50% of the cases. Rarely, some patients develop the Von Willebrand Factor (VWF) inhibitors, which may subsequently develop severe anaphylactic reactions on further exposure to the VWF containing factor replacement therapy. The prevalence of inhibitor development in patients with type 3 VWD has been shown to be in the range of 5.8 to 9.5%. In the absence of a gold standard assay for the quantitation of VWF inhibitors, a correct diagnosis and management of these patients are often challenging. Objectives: The objective of this study is to standardize the Bethesda assay for the VWF inhibitors and to estimate the VWD inhibitor titer in two cases of congenital type 3 VWD, which developed the VWF inhibitors. Results and Conclusions: We could successfully standardize the Bethesda assay for the quantitation of VWF inhibitors in two patients with congenital type 3 VWD with inhibitors.
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Affiliation(s)
- Bipin P Kulkarni
- ICMR- National Institute of Immunohaematology, KEM Hospital Campus, Mumbai, India
| | - Kirti Ghargi
- ICMR- National Institute of Immunohaematology, KEM Hospital Campus, Mumbai, India
| | | | - Shrimati D Shetty
- ICMR- National Institute of Immunohaematology, KEM Hospital Campus, Mumbai, India
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15
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Sullivan RT, Lo C, Martin E, Kameny RJ, Hopper RK. A Case of Acquired von Willebrand Disease in Severe Pediatric Pulmonary Hypertension Contributing to Bleeding following Reverse Potts Shunt. Pulm Circ 2022; 12:e12042. [PMID: 35506098 PMCID: PMC9052962 DOI: 10.1002/pul2.12042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/04/2022] [Accepted: 01/18/2022] [Indexed: 11/10/2022] Open
Abstract
The reverse Potts shunt is increasingly used as a palliative measure for end‐stage pulmonary arterial hypertension (PAH) as a means to offload the right ventricle and improve functional status. This case report describes a child who developed significant hemothorax after reverse Potts shunt that required surgical exploration, blood product administration, and prolonged intensive care hospitalization. Despite lack of preoperative bleeding symptoms, testing revealed acquired von Willebrand disease (aVWD), with subsequent resolution of bleeding. Alterations in von Willebrand factor, including aVWD, have been reported in children with severe PAH but have not previously been associated with bleeding after reverse Potts shunt procedure. As bleeding is a recognized postoperative morbidity in PAH patients undergoing reverse Potts shunt, we highlight a potential role for preoperative testing for aVWD as perioperative factor replacement therapy may improve postoperative outcomes.
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Affiliation(s)
- Rachel T Sullivan
- Department of Pediatrics, Division of Pediatric Cardiology Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford Palo Alto CA
| | - Clara Lo
- Department of Pediatrics, Division of Pediatric Hematology/Oncology Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford Palo Alto CA
| | - Elisabeth Martin
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford Palo Alto CA
| | - Rebecca J Kameny
- Department of Pediatrics, Division of Pediatric Cardiology Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford Palo Alto CA
| | - Rachel K Hopper
- Department of Pediatrics, Division of Pediatric Cardiology Stanford University School of Medicine, Lucile Packard Children's Hospital Stanford Palo Alto CA
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16
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Wieland I, Diekmann F, Carlens J, Hinze L, Lambeck K, Jack T, Hansmann G. Acquired von Willebrand syndrome (AVWS) type 2, characterized by decreased high molecular weight multimers, is common in children with severe pulmonary hypertension (PH). Front Pediatr 2022; 10:1012738. [PMID: 36452355 PMCID: PMC9701817 DOI: 10.3389/fped.2022.1012738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/14/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Emerging evidence suggests that increased degradation of von Willebrand factor and decrease in high molecular weight multimers occurs in patients with pulmonary hypertension (PH). However, the link between acquired von Willebrand Syndrome (AVWS) type 2 and PH remains poorly understood. MATERIAL AND METHODS We retrospectively evaluated the charts of 20 children with PH who underwent bilateral lung transplantation (LuTx) between 2013 and 2022. Von Willebrand variables were determined in 14 of these patients; 11 patients had complete diagnostics including multimer analysis. RESULTS We confirmed AVWS in 82% of the children studied (9 of 11 patients by multimer analysis). The two remaining patients had suspected AVWS type 2 because of a VWF:Ac/VWF:Ag ratio of <0.7. Platelet dysfunction or suspicion of VWD type 1 were found in two separate patients. All but one of the 14 children with severe PH had a coagulation disorder. Most patients (9 proven, 2 suspected) had AVWS type 2. Notably, 3 of 5 patients (60%) with normal VWF:Ac/VWF:Ag ratio >0.7 had abnormal VWF multimers, indicating AVWS type 2. Hemostatic complications were observed in 4 of 12 (33%) patients with VWS and 3 of 6 (50%) patients without diagnostics and therapy. CONCLUSION For children with moderate to severe PH, we recommend systematic analysis of von Willebrand variables, including multimer analysis, PFA-100 and platelet function testing. Awareness of the diagnosis "AVWS" and adequate therapy may help to prevent these patients from bleeding complications in case of surgical interventions or trauma.
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Affiliation(s)
- Ivonne Wieland
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Franziska Diekmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Julia Carlens
- Department of Pediatric Pulmonology, Allergology, and Neonatology, Hannover Medical School, Hannover, Germany
| | - Laura Hinze
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Katharina Lambeck
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Thomas Jack
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
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17
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Icheva V, Budde U, Magunia H, Jaschonek K, Hinterleitner C, Neunhoeffer F, Schlensak C, Hofbeck M, Wiegand G. Acquired von Willebrand syndrome is common in infants with systemic-to-pulmonary shunts: Retrospective case-series. Front Pediatr 2022; 10:1040128. [PMID: 36568413 PMCID: PMC9768211 DOI: 10.3389/fped.2022.1040128] [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: 09/09/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although acquired von Willebrand syndrome (aVWS) has been described in congenital heart disease before, anatomical features leading to aVWS with characteristic reduction or loss of high molecular weight von Willebrand multimers (HMWM) are not well known. This study assesses the prevalence and effects of aVWS in infants with systemic-to-pulmonary shunts (SPS). METHODS This retrospective single-center study analyzes diagnostic data of infants with complex congenital heart defects requiring palliation with SPS. During the study period between 12/15-01/17 fifteen consecutive patients were eligible for analysis. Results of von Willebrand factor antigen (VWF:Ag), collagen binding activity (VWF:CB) and von Willebrand factor multimer analysis were included. RESULTS In all 15 patients with SPS an aVWS could be found. Blood samples were collected between 5 and 257 days after shunt implantation (median 64 days). None of the patients demonstrated increased bleeding in everyday life. However, 6 out of 15 patients (40%) showed postoperative bleeding complications after SPS implantation. Following shunt excision multimeric pattern normalized in 8 of 10 (80%) patients studied. CONCLUSIONS This study shows that in patients undergoing SPS implantation aVWS might emerge. Pathogenesis can be explained by shear stress resulting from turbulent flow within the shunt. Knowledge of aVWS existence is important for the consideration of replacement therapy with von Willebrand factor containing products and antifibrinolytic treatment in bleeding situations. Implementation of methods for rapid aVWS detection is required to achieve differentiated hemostatic therapy and reduce the risk of complications caused by empiric replacement therapy.
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Affiliation(s)
- Vanya Icheva
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | | | - Harry Magunia
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Karl Jaschonek
- Department of Hematology, Oncology, Clinical Immunology and Rheumatology (Internal Medicine II), University Hospital Tübingen, Tübingen, Germany
| | - Clemens Hinterleitner
- Department of Medical Oncology and Pneumology (Internal Medicine VIII), University Hospital Tübingen, Tübingen, Germany
| | - Felix Neunhoeffer
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Gesa Wiegand
- Department of Pediatric Cardiology and Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
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18
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Oezkur M, Reda S, Rühl H, Theuerkauf N, Kreyer S, Duerr GD, Charitos E, Silaschi M, Medina M, Zimmer S, Putensen C, Treede H. Role of acquired von Willebrand syndrome in the development of bleeding complications in patients treated with Impella RP devices. Sci Rep 2021; 11:23722. [PMID: 34887445 PMCID: PMC8660831 DOI: 10.1038/s41598-021-02833-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 11/16/2021] [Indexed: 11/09/2022] Open
Abstract
Axial flow pumps are standard treatment in cases of cardiogenic shock and high-risk interventions in cardiology and cardiac surgery, although the optimal anticoagulation strategy remains unclear. We evaluated whether laboratory findings could predict bleeding complications and acquired von Willebrand syndrome (avWS) among patients who were treated using axial flow pumps. We retrospectively evaluated 60 consecutive patients who received Impella devices (Impella RP: n = 20, Impella CP/5.0: n = 40; Abiomed Inc., Danvers, USA) between January 2019 and December 2020. Thirty-two patients (53.3%) experienced major or fatal bleeding complications (Bleeding Academic Research Consortium score of > 3) despite intravenous heparin being used to maintain normal activated partial thromboplastin times (40–50 s). Extensive testing was performed for 28 patients with bleeding complications (87.5%). Relative to patients with left ventricular support, patients with right ventricular support were less likely to develop avWS (87.5% vs. 58.8%, p = 0.035). Bleeding was significantly associated with avWS (odds ratio [OR]: 20.8, 95% confidence interval [CI]: 3.3–128.5; p = 0.001) and treatment duration (OR: 1.3, 95% CI 1.09–1.55; p = 0.003). Patients with avWS had longer Impella treatment than patients without avWS (2 days [1–4.7 days] vs. 7.3 days [3.2–13.0 days]). Bleeding complications during Impella support were associated with avWS in our cohort, while aPTT monitoring was not sufficient to prevent bleeding complications. A more targeted anticoagulation monitoring might be needed for patients who receive Impella devices.
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Affiliation(s)
- Mehmet Oezkur
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany. .,Department of Cardiovascular Surgery, University Hospital Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Sara Reda
- Department of Haematology, University Hospital of Bonn, Bonn, Germany
| | - Heiko Rühl
- Department of Haematology, University Hospital of Bonn, Bonn, Germany
| | - Nils Theuerkauf
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Bonn, Bonn, Germany
| | - Stefan Kreyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Bonn, Bonn, Germany
| | - Georg Daniel Duerr
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany.,Department of Cardiovascular Surgery, University Hospital Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Efstratios Charitos
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Miriam Silaschi
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Marta Medina
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Department of Cardiology, University Hospital of Bonn, Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Bonn, Bonn, Germany
| | - Hendrik Treede
- Department of Cardiovascular Surgery, University Hospital of Bonn, Bonn, Germany.,Department of Cardiovascular Surgery, University Hospital Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
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19
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Pikta M, Banys V, Szanto T, Joutsi-Korhonen L, Vaide I, Varik M, Lehtinen AE, Giangrande P, Laane E. Von Willebrand Factor Multimeric Assay in Acquired von Willebrand Disease Diagnosis: A Report of Experience from North Estonia Medical Centre. J Lab Physicians 2021; 13:195-201. [PMID: 34602781 PMCID: PMC8478502 DOI: 10.1055/s-0041-1730818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Objectives
Acquired von Willebrand syndrome (AVWS) is a rare and frequently underdiagnosed bleeding disorder with an unknown prevalence. The diagnosis of AVWS is made based on laboratory investigations and the presence of clinical symptoms. Evaluation and management of affected patients are complex due to the need for multiple laboratory assays.
Materials and Methods
Here, we describe the clinical and laboratory data of seven patients with a diagnosis of AVWS. All patients met the criteria for AVWS based on laboratory findings, bleeding symptoms, and the absence of any previous history of a bleeding disorder.
Results
In all cases, the laboratory findings, lack of bleeding anamnesis, and family history suggested the presence of AVWS. Von Willebrand factor multimeric analysis showed decreased high-molecular weight (HMW) multimers in six cases. Patients with lower HMW multimers experienced more severe bleeding complications.
Conclusions
The diagnosis of AVWS is complex and requires extensive laboratory evaluation. Interdisciplinary collaboration and complex laboratory evaluations are of paramount importance for the early recognition of AVWS and optimal AVWS diagnosis as well as successful clinical management.
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Affiliation(s)
- Marika Pikta
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia.,Department of Laboratory Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Valdas Banys
- Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Timea Szanto
- Research Program Unit of Systems Oncology, Helsinki University Hospital, Unit of Coagulation Disorders, Helsinki, Finland
| | - Lotta Joutsi-Korhonen
- Department of Clinical Chemistry, Unit of Coagulation Disorders, HUSLAB Laboratory Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ines Vaide
- Hemato-Oncology Clinic, Institute of Clinical Medicine, Tartu University, Tartu, Estonia
| | - Mirja Varik
- Hematology Department, North Estonia Medical Centre, Tallinn, Estonia
| | - Anna-Elina Lehtinen
- Department of Hematology, Unit of Coagulation Disorders, Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Helsinki, Finland
| | - Paul Giangrande
- Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Edward Laane
- Hemato-Oncology Clinic, Institute of Clinical Medicine, Tartu University, Tartu, Estonia
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20
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Woelke E, Mager I, Schmitz-Rode T, Steinseifer U, Clauser JC. Validation of a Miniaturized Test Loop for the Assessment of Human Blood Damage by Continuous-Flow Left-Ventricular Assist Devices. Ann Biomed Eng 2021; 49:3165-3175. [PMID: 34431015 PMCID: PMC8671281 DOI: 10.1007/s10439-021-02849-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/04/2021] [Indexed: 11/29/2022]
Abstract
Despite improved hemocompatibility of left-ventricular assist devices (LVADs), assessment of blood damage remains mandatory in preclinical testing as standardized by ASTM-F1841. The most relevant test fluid is fresh, non-pooled human blood, but the limited volume of a standard donation requires significantly smaller loops than those commonly used with animal blood. In a recent study with porcine blood, we verified a miniaturized test loop with only 160 mL for the ASTM-conform paired testing of at least two LVADs and a static reference. Here, we validated this mini test loop for standardized assessment of blood damage with one 450-mL single donation of fresh human blood. Blood damage was assessed for HeartMate 3 and BPX-80 in 9 experiments with heparinized human blood for 6 hours. We analyzed plasma free hemoglobin, von Willebrand factor (vWF) concentration and collagen-binding functionality and calculated indices of hemolysis and vWF-ratios. Overall, we observed less blood damage compared to our previous study; however, the differences in mean indices of hemolysis and in mean normalized vWF-ratio between BPX-80 and HeartMate 3 were consistent for human blood. Thus, our mini test loop proved to be valid for preclinical standardized assessment of blood damage with only 450 mL of fresh human blood.
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Affiliation(s)
- Eva Woelke
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany
| | - Ilona Mager
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany
| | - Thomas Schmitz-Rode
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany
| | - Johanna C Clauser
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Pauwelsstr. 20, 52074, Aachen, Germany.
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21
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Abstract
Acquired von Willebrand syndrome can occur in the setting of myeloproliferative neoplasms; plasma cell dyscrasias and other lymphoproliferative disorders; autoimmune conditions; and causes of increased shear forces, such as aortic stenosis or other structural heart disease and mechanical circulatory support. The depletion of von Willebrand factor, especially high-molecular-weight multimers, can lead to mucocutaneous bleeding and the formation of arteriovenous malformations, particularly in the gastrointestinal tract. Management focuses on correction of the underlying cause when possible, but may include intravenous immunoglobulins, von Willebrand factor concentrate, rituximab, or antiangiogenic therapy depending on the clinical context.
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Affiliation(s)
- Arielle L Langer
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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22
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Carter-Febres M, Smock KJ, Ware AL, Afify Z. Improvement of bleeding manifestations of acquired von Willebrand syndrome after balloon aortic valvoplasty in a child with aortic stenosis. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2020.101334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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23
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Mondal S, Hollander KN, Ibekwe SO, Williams B, Tanaka K. Heyde Syndrome-Pathophysiology and Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 35:3331-3339. [PMID: 33132021 DOI: 10.1053/j.jvca.2020.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/02/2020] [Accepted: 10/04/2020] [Indexed: 11/11/2022]
Abstract
Gastrointestinal (GI) bleeding in patients with calcific aortic valve stenosis (AVS), termed Heyde syndrome, was first described by Edward C. Heyde. The strong association between valvular replacement and the eradication of clinically significant GI bleeding confirmed an underlying pathophysiologic relationship. The rheologic stress created by AVS increases proteolysis of von Willebrand factor (VWF), resulting in loss of predominantly high-molecular-weight VWF (Hmw VWF). Angiodysplastic vessels present in patients with AVS, coupled with the lack of functioning Hmw VWF, increase the risk for GI bleeds. Aortic valve replacement, both surgical and transcatheter-based, is often a definitive treatment for GI bleeding, leading to recovery of Hmw VWF multimers. Perioperative management of patients involves monitoring their coagulation profiles with relevant laboratory tests and instituting appropriate management. Management can be directed in the following two ways: by improving internal release of VWF or by administration of external therapeutics containing VWF. It is important for perioperative physicians to obtain an understanding of the pathophysiology of this disease process and closely monitor the bleeding pattern so that targeted therapies can be initiated.
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Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, Cardiac Anesthesia Division, University of Maryland School of Medicine, Baltimore, MD.
| | - Kimberly N Hollander
- Department of Anesthesiology, Cardiac Anesthesia Division, University of Maryland School of Medicine, Baltimore, MD
| | - Stephanie O Ibekwe
- Department of Anesthesiology, Cardiovascular Division, BTGH, Baylor College of Medicine, Houston, TX
| | - Brittney Williams
- Department of Anesthesiology, Cardiac Anesthesia Division, University of Maryland School of Medicine, Baltimore, MD
| | - Kenichi Tanaka
- Department of Anesthesiology, Cardiac Anesthesia Division, University of Maryland School of Medicine, Baltimore, MD
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24
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Kubicki R, Stiller B, Kroll J, Siepe M, Beyersdorf F, Benk C, Höhn R, Grohmann J, Fleck T, Zieger B. Acquired von Willebrand syndrome in paediatric patients during mechanical circulatory support. Eur J Cardiothorac Surg 2020; 55:1194-1201. [PMID: 30590475 DOI: 10.1093/ejcts/ezy408] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/15/2018] [Accepted: 11/01/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Bleeding signs can become life-threatening complications in patients on mechanical circulatory support (MCS). Clinical phenotyping and comprehensive analyses of the cause of bleeding are, therefore, essential, especially when risk-stratifying patients during MCS workup. We conducted coagulation analyses and determined von Willebrand factor (VWF) parameters in a paediatric cohort on temporary extracorporeal life support, extracorporeal membrane oxygenation or long-term ventricular assist device support. METHODS We carried out an observational single-centre study including 30 children with MCS (extracorporeal life support, n = 13; extracorporeal membrane oxygenation, n = 5; and ventricular assist device, n = 12). We also assessed the acquired von Willebrand parameters of each study participant: collagen binding capacity (VWF:CB), the ratio of collagen-binding capacity to VWF antigen (VWF:CB/VWF:Ag) and high-molecular-weight VWF multimers. We also documented bleeding events, transfusion requirement, haemolysis parameters and surgical interventions. RESULTS All children developed AVWS (acquired von Willebrand syndrome) during MCS, usually during the early postoperative course. They presented no AVWS after device explantation. We detected a loss of high-molecular-weight VWF multimers, decreased VWF:CB/VWF:Ag ratios and reduced VWF:CB levels. Twenty of the 30 patients experienced bleeding complications; approximately 53% of them required surgical revision. There were no deaths due to bleeding during support. CONCLUSIONS The AVWS prevalence in paediatric patients on MCS is 100% regardless of the types of devices tested in this study. The bleeding propensity of AVWS patients widely varies.
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Affiliation(s)
- Rouven Kubicki
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Kroll
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - René Höhn
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochen Grohmann
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thilo Fleck
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Schneider MF, Fallah MA, Mess C, Obser T, Schneppenheim R, Alexander-Katz A, Schneider SW, Huck V. Platelet adhesion and aggregate formation controlled by immobilised and soluble VWF. BMC Mol Cell Biol 2020; 21:64. [PMID: 32917131 PMCID: PMC7488753 DOI: 10.1186/s12860-020-00309-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 08/26/2020] [Indexed: 11/21/2022] Open
Abstract
Background It has been demonstrated that von Willebrand factor (VWF) mediated platelet-endothelium and platelet-platelet interactions are shear dependent. The VWF’s mobility under dynamic conditions (e.g. flow) is pivotal to platelet adhesion and VWF-mediated aggregate formation in the cascade of VWF-platelet interactions in haemostasis. Results Combining microfluidic tools with fluorescence and reflection interference contrast microscopy (RICM), here we show, that specific deletions in the A-domains of the biopolymer VWF affect both, adhesion and aggregation properties independently. Intuitively, the deletion of the A1-domain led to a significant decrease in both adhesion and aggregate formation of platelets. Nevertheless, the deletion of the A2-domain revealed a completely different picture, with a significant increase in formation of rolling aggregates (gain of function). We predict that the A2-domain effectively ‘masks’ the potential between the platelet glycoprotein (GP) Ib and the VWF A1-domain. Furthermore, the deletion of the A3-domain led to no significant variation in either of the two functional characteristics. Conclusions These data demonstrate that the macroscopic functional properties i.e. adhesion and aggregate formation cannot simply be assigned to the properties of one particular domain, but have to be explained by cooperative phenomena. The absence or presence of molecular entities likewise affects the properties (thermodynamic phenomenology) of its neighbours, therefore altering the macromolecular function.
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Affiliation(s)
- Matthias F Schneider
- Department of Physics, Medical and Biological Physics, Technical University Dortmund, Emil-Figge-Str. 50, 44227, Dortmund, Germany
| | - Mohammad A Fallah
- Department of Chemistry, University of Konstanz, Universitätsstr. 10, 78457, Constance, Germany
| | - Christian Mess
- University Medical Centre Hamburg-Eppendorf, Centre for Internal Medicine, Martinistr. 52, 20246, Hamburg, Germany
| | - Tobias Obser
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Reinhard Schneppenheim
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Alfredo Alexander-Katz
- Department of Materials Science and Engineerin, Massachusetts Institute of Technology, 400 Technology Sq. (NE46-605), Cambridge, MA, 02139, USA
| | - Stefan W Schneider
- University Medical Centre Hamburg-Eppendorf, Centre for Internal Medicine, Martinistr. 52, 20246, Hamburg, Germany
| | - Volker Huck
- University Medical Centre Hamburg-Eppendorf, Centre for Internal Medicine, Martinistr. 52, 20246, Hamburg, Germany. .,Heidelberg University, Medical Faculty Mannheim, Experimental Dermatology, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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26
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Flannery KM, Kamra K, Maeda K, Shuttleworth P, Almond C, Navaratnam M. Management of a Pediatric Patient With a Left Ventricular Assist Device and Symptomatic Acquired von Willebrand Syndrome Presenting for Orthotopic Heart Transplant. Semin Cardiothorac Vasc Anesth 2020; 24:355-359. [PMID: 32772894 DOI: 10.1177/1089253220949386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
We present the successful perioperative management of an 11-year-old patient presenting for heart transplant with a left ventricular assist device, symptomatic acquired von Willebrand syndrome, and recent preoperative intracranial hemorrhage. A brief review of the pathophysiology of acquired von Willebrand syndrome is included. As the number of pediatric patients supported with ventricular assist devices continues to increase, the management of symptomatic acquired von Willebrand syndrome during the perioperative period is an important consideration for anesthesiologists.
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27
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Noncanonical type 2B von Willebrand disease associated with mutations in the VWF D'D3 and D4 domains. Blood Adv 2020; 4:3405-3415. [PMID: 32722784 DOI: 10.1182/bloodadvances.2020002334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 06/22/2020] [Indexed: 11/20/2022] Open
Abstract
We observed a 55-year-old Italian man who presented with mucosal and cutaneous bleeding. Results of his blood analysis showed low levels of von Willebrand factor (VWF) antigen and VWF activity (both VWF ristocetin cofactor and VWF collagen binding), mild thrombocytopenia, increased ristocetin-induced platelet aggregation, and a deficiency of high-molecular-weight multimers, all typical phenotypic hallmarks of type 2B von Willebrand disease (VWD). The analysis of the VWF gene sequence revealed heterozygous in cis mutations: (1) c.2771G>A and (2) c.6532G>T substitutions in the exons 21 and 37, respectively. The first mutation causes the substitution of an Arg residue with a Gln at position 924, in the D'D3 domain. The second mutation causes an Ala to Ser substitution at position 2178 in the D4 domain. The patient's daughter did not present the same fatherly mutations but showed only the heterozygous polymorphic c.3379C>T mutation in exon 25 of the VWF gene causing the p.P1127S substitution, inherited from her mother. The in vitro expression of the heterozygous in cis VWF mutant rVWFWT/rVWF924Q-2178S confirmed and recapitulated the ex vivo VWF findings. Molecular modeling showed that these in cis mutations stabilize a partially stretched and open conformation of the VWF monomer. Transmission electron microscopy and atomic force microscopy showed in the heterozygous recombinant form rVWFWT/rVWF924Q-2178S a stretched conformation, forming strings even under static conditions. Thus, the heterozygous in cis mutations 924Q/2178S promote conformational transitions in the VWF molecule, causing a type 2B-like VWD phenotype, despite the absence of typical mutations in the A1 domain of VWF.
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28
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Tiede A, Zieger B, Lisman T. Acquired bleeding disorders. Haemophilia 2020; 27 Suppl 3:5-13. [PMID: 32476241 DOI: 10.1111/hae.14033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/19/2022]
Abstract
Acquired bleeding disorders can accompany hematological, neoplastic, autoimmune, cardiovascular or liver diseases, but can sometimes also arise spontaneously. They can manifest as single factor deficiencies or as complex hemostatic abnormalities. This review addresses (a) acquired hemophilia A, an autoimmune disorder characterized by inhibitory autoantibodies against coagulation factor VIII; (b) acquired von Willebrand syndrome in patients with cardiovascular disorders, where shear stress abnormalities result in destruction of von Willebrand factor; and (c) liver function disorders that comprise complex changes in pro- and anti-hemostatic factors, whose clinical implications are often difficult to predict. The article provides an overview on the pathophysiology, diagnostic tests and state-of-the-art treatment strategies.
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Affiliation(s)
- Andreas Tiede
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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29
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Steinlechner B, Zeidler P, Dworschak M, Base E, Birkenberg B, Ankersmit HJ, Spannagl M, Quehenberger P, Hiesmayr M, Jilma B. Corrigendum to “Patients With Severe Aortic Valve Stenosis and Impaired Platelet Function Benefit From Preoperative Desmopressin Infusion” [Ann Thorac Surg 91 (2011) 1420-1426]. Ann Thorac Surg 2020. [DOI: 10.1016/j.athoracsur.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ojeda-Uribe M, Rimelen V, Marzullo C. Good Profile of Efficacy/Tolerance of Bortezomib or Idelalisib in Waldenström Macroglobulinemia Associated with Acquired Von Willebrand Syndrome. J Blood Med 2020; 11:67-72. [PMID: 32104129 PMCID: PMC7025649 DOI: 10.2147/jbm.s233059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/23/2020] [Indexed: 11/23/2022] Open
Abstract
Acquired von Willebrand syndrome (AVWS) in the setting of Waldenström macroglobulinemia (WM) is a challenging condition. No real standard of care is recommended for these patients, although the therapeutic strategy should include a rapid approach to the emergency bleeding events and to the underlying malignant lymphoid disorder. We report here our experience treating three elderly patients with these concomitant hematologic entities. The use of a bortezomib-based chemotherapy regimen showed a good profile of tolerance and efficacy even in a long-term follow-up period. These patients were treated for several years before switching their therapy to idelalisib, a targeted oral therapy that inhibits phosphatidylinositol 3-kinase isoform-delta (PI3KD), which is part of the signaling pathway downstream B-cell receptor. This approach was well tolerated and efficacious, although some adverse effects were observed, particularly at hepatic levels, but were all reversible. The same profile of tolerance/efficacy was observed in one very old patient who received idelalisib as a first-line therapy. We think that bortezomib-based therapy could be considered in refractory patients with AVWS associated with WM.
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Affiliation(s)
- Mario Ojeda-Uribe
- Department of Hematology and Cellular Therapy Unit, Groupe Hospitalier Region Mulhouse-Sud-Alsace (GHRMSA), Mulhouse 68070, France
| | - Valérie Rimelen
- Laboratory of Molecular Biology CHRU Strasbourg, Strasbourg 67200, France
| | - Cathérine Marzullo
- Laboratory of Immunology, Groupe Hospitalier Region Mulhouse-Sud-Alsace (GHRMSA), Mulhouse 68070, France
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31
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Menegatti M, Biguzzi E, Peyvandi F. Management of rare acquired bleeding disorders. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:80-87. [PMID: 31808848 PMCID: PMC6913473 DOI: 10.1182/hematology.2019000066] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Autoantibodies toward clotting factors may develop in people suffering from autoimmune or neoplastic diseases, after drug intake or even in subjects without apparent conditions. They are more commonly directed against factor VIII (FVIII) or von Willebrand factor leading to acquired hemophilia A or acquired von Willebrand syndrome, respectively. Rarely, autoantibodies develop against other clotting factors, such as fibrinogen, FII, FV, FVII, FX, FXI, and FXIII. The clinical picture of an acquired bleeding disorder includes a wide spectrum of clinical manifestations ranging from minimal or no bleeding to life-threatening events. Patients with no previous personal or family history of bleeding may have sudden-onset hemorrhagic manifestations, sometimes fatal, especially if an early diagnosis is not made. On the other hand, some patients may not have hemorrhagic symptoms at onset, and their diagnosis can therefore be delayed. The laboratory diagnostic assessment is performed by screening coagulation tests followed by specific factor-level measurement and inhibitor-titrating assays. An early diagnosis of acquired coagulopathies is mandatory for starting the appropriate treatment aimed at both controlling the acute bleeding episode mainly using the bypassing agents, and eradicating the anticlotting factor autoantibody, using immunosuppressive treatment. Therefore, prompt intervention by an expert and a specialized center is needed for immediate recognition and treatment of the disease.
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Affiliation(s)
- Marzia Menegatti
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; and
| | - Eugenia Biguzzi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; and
| | - Flora Peyvandi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; and
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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32
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Hinterleitner C, Pecher AC, Kreißelmeier KP, Budde U, Kanz L, Kopp HG, Jaschonek K. Disease progression and defects in primary hemostasis as major cause of bleeding in multiple myeloma. Eur J Haematol 2019; 104:26-35. [PMID: 31541609 DOI: 10.1111/ejh.13331] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/12/2019] [Accepted: 09/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES In patients with multiple myeloma (MM), unexpected bleeding complications remain a major issue. Since routine coagulation parameters are often inconspicuous, diagnosis and treatment of the underlying coagulation disorders are challenging. PATIENTS AND METHODS In our single-center observational study, we analyzed 164 patients with MM for coagulation disorders and bleeding complications. RESULTS Prolonged closure times (CTs), measured by PFA-100, were the most common, abnormal coagulation test, found in 66% of bleeding patients vs 5% in non-bleeding, followed by qualitative defects of von Willebrand factor (VWF:CB/VWF:Ag ratios), found in 34% vs 1% in the non-bleeding group. Increased serum free light chains (SFLC) and SFLC ratios were significantly associated with prolonged CTs and acquired von Willebrand syndrome (AVWS). Prolonged CTs and AVWS were associated with disease progression, determined by dynamics of SFLC ratios (P < .001), serum creatinine level (P = .013), Beta-2 microglobulin (P = .03), LDH (P = .016), and bone marrow infiltration (P < .001). Of note, response to myeloma therapy was frequently correlated with normalization of coagulation parameters. CONCLUSIONS Bleeding complications in MM are predominantly caused by defects in primary hemostasis and associated with disease progression. In a peri-interventional workup, determination of CTs and VWF:CB/VWF:Ag ratios are of significant importance to assess bleeding risk.
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Affiliation(s)
- Clemens Hinterleitner
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| | - Ann-Christin Pecher
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| | - Klaus-Peter Kreißelmeier
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| | - Ulrich Budde
- Medilys Laborgesellschaft mbH, Asklepios Klinik Hamburg-Altona, Hamburg, Germany
| | - Lothar Kanz
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| | - Hans-Georg Kopp
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
| | - Karl Jaschonek
- Department of Medical Oncology, Hematology, Immunology, Rheumatology and Pulmonology, Eberhard-Karls University, Tuebingen, Germany
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Miniaturized Test Loop for the Assessment of Blood Damage by Continuous-Flow Left-Ventricular Assist Devices. Ann Biomed Eng 2019; 48:768-779. [PMID: 31724071 DOI: 10.1007/s10439-019-02404-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/06/2019] [Indexed: 01/22/2023]
Abstract
Although the hemocompatibility of left-ventricular assist devices (LVADs) has continuously improved, assessment of hemolysis remains mandatory in pre-clinical testing. The ASTM-F1841 has standardized this assessment since 1997. However, the recommended usage of fresh, non-pooled human blood is hardly feasible with the test loop volume specified therein, when testing the device under test versus a predicate device as required by the international standard 10993-4. In this study, we compared ASTM-conforming (ASTM) and downscaled (mini) test loops with a one-third priming volume for the assessment of blood damage at the ASTM operating point. Blood damage was assessed for HeartMate 3 and BPX-80 in 6 experiments with heparinized porcine slaughterhouse blood for 6 h. We analyzed plasma free hemoglobin (pfHb), von Willebrand factor (vWF) concentration and collagen-binding functionality and calculated indices of hemolysis and vWF-ratios. The mini test loops provided significantly higher pfHb increase and consistently stronger vWF-ratio decrease and yielded a significantly better differentiation of the pumps. Interestingly, indices of hemolysis were generally lower in the mini set-up, indicating less adverse effects by the mini loop itself. Thus, we propose our mini test loop as suitable tool for clinically relevant standardized assessment of blood damage by future LVADs with single-donation human blood.
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Kornhuber KTI, Seidel H, Pujol C, Meierhofer C, Röschenthaler F, Pressler A, Stöckl A, Nagdyman N, Neidenbach RC, von Hundelshausen P, Halle M, Holdenrieder S, Ewert P, Kaemmerer H, Hauser M. Hemostatic abnormalities in adult patients with Marfan syndrome. Cardiovasc Diagn Ther 2019; 9:S209-S220. [PMID: 31737529 DOI: 10.21037/cdt.2019.08.09] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Aortic root ectasia might induce hemostatic disorders in patients with Marfan syndrome (MFS) via altered blood flow and rheology. The aim of this study was to explore the hemostasis in patients with MFS compared with healthy controls. Methods In this cross-sectional case-control study we included patients with verified MFS (n=51) and sex- and age-matched healthy controls (n=50). Main criteria were the aortic root in echocardiography and cardiac magnetic resonance imaging (MRI), and the coagulation status. Results When compared with healthy controls, patients with MFS showed significantly increased diameters of the aortic roots (43.0±7.72 vs. 28.8±3.74 mm, P<0.001) and aortic Z-scores (4.36±2.77 vs. 0.948±1.09, P<0.001), considerably higher values of Multiplate® tests (e.g., MP-ADP: 878.4±201.7 vs. 660.4±243.6 AU*min, P<0.001) and PFA-100® tests (PFA Col/ADP: 102.5±45.5 vs. 91.1±46.2 s, P<0.05), PTT (30.0±3.91 vs. 28.7±2.50 s, P<0.05) and D-dimers (0.488±0.665 vs. 0.254±0.099 mg/L, P<0.001). In MFS von Willebrand factor (VWF) activity (81.9%±41.8% vs. 106.3%±41.5%, P<0.05) and antigen (93.8%±43.9% vs. 118.8%±47.8%, P<0.05) and factor VIII activity (108.9%±29.6% vs. 126.7%±28.4%, P<0.05) were reduced. Significant positive correlations were found between aortic diameters and D-dimers (all P<0.05), as well as PFA Col/ADP (all P<0.01) in MFS patients. Factor VIII activity correlated significantly negatively with the diameter of the aortic root in MFS (r=-0.55, P<0.05). Conclusions In conclusion, our study reveals hemostatic deviations in patients with MFS. Further studies are necessary to understand the causal relationship and the exact pathomechanism.
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Affiliation(s)
- Katharina T I Kornhuber
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Heide Seidel
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany.,Institute of Human Genetics, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Claudia Pujol
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Christian Meierhofer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Franz Röschenthaler
- Institute of Laboratory Medicine, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Axel Pressler
- Outpatients' Clinic for Prevention, Rehabilitation and Sports Medicine, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Alexander Stöckl
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Nicole Nagdyman
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Rhoia C Neidenbach
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Philipp von Hundelshausen
- Institute for Cardiovascular Prevention, Faculty of Medicine, Ludwig Maximilian University, Munich, Germany
| | - Martin Halle
- Outpatients' Clinic for Prevention, Rehabilitation and Sports Medicine, Klinikum Rechts der Isar, Technical University Munich, Munich, Germany
| | - Stefan Holdenrieder
- Institute of Laboratory Medicine, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Harald Kaemmerer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
| | - Michael Hauser
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University Munich, Munich, Germany
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Hawken J, Knott A, Alsakkaf W, Clark A, Fayyaz F. Rituximab to the rescue: novel therapy for chronic gastrointestinal bleeding due to angiodysplasia and acquired von Willebrand syndrome. Frontline Gastroenterol 2019; 10:434-437. [PMID: 31656571 PMCID: PMC6788123 DOI: 10.1136/flgastro-2018-101116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/19/2018] [Accepted: 12/14/2018] [Indexed: 02/04/2023] Open
Abstract
Identification of acquired von Willebrand syndrome (AVWS) was key to treating a patient with chronic gastrointestinal (GI) bleeding due to angiodysplasia. After exhausting endoscopic and pharmacological options, the patient was successfully treated with rituximab. A 78-year-old man developed chronic GI bleeding from caecal and jejunal angiodysplasia. Red cell transfusion was required weekly despite argon plasma coagulation. A diagnosis of AVWS was made from analysis of clotting factors. Therapies including von Willebrand factor concentrate, thalidomide and tranexamic acid were unsuccessful. With failed endoscopic therapy and no viable surgical option, the patient was given intravenous immunoglobulins (IVIGs). Haemoglobin remained stable from this point. The impact on the patient and hospital of attending for IVIG every 3 weeks necessitated consideration to longer-term therapy. After a single course of rituximab, no further blood products, IVIG or rituximab were required. This case is the first to describe the use of rituximab in AVWS-associated angiodysplasia.
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Affiliation(s)
- James Hawken
- Department of Gastroenterology, Weston General Hospital, Weston-super-Mare, UK,Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Amy Knott
- Bristol Haematology Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Wesam Alsakkaf
- Department of Haematology, Weston General Hospital, Weston-super-Mare, UK
| | - Amanda Clark
- Bristol Haematology Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Faisal Fayyaz
- Department of Gastroenterology, Weston General Hospital, Weston-super-Mare, UK
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Abstract
Cancer can be associated with several distinct coagulation defects which can lead to bleeding complications. The primary hyperfibrinolytic syndrome associated with acute promyelocytic leukemia has been well recognized and is one of the most severe bleeding disorders. Acquired hemophilia, while rare and not only seen in the oncology setting, can be triggered by a malignancy and must be promptly recognized in order to prevent catastrophic hemorrhage. Other, less serious coagulopathic states have been linked to cancer, including acquired von Willebrand disease. Finally, several anti-neoplastic drugs can alter hemostasis and increase the risk of bleeding. A good understanding of this field can help mitigate the risk of complications in the cancer patient.
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Affiliation(s)
- Simon Mantha
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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37
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Pineau-Vincent F, Legout A, Besancon-Bergelin A, Alani M, Laribi K, Lemaire P. Diagnosis and immediate treatment of acquired von Willebrand syndrome revealed by recurrent cerebral hemorrhage. Transfus Clin Biol 2019; 26:356-358. [PMID: 31262628 DOI: 10.1016/j.tracli.2019.05.006] [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: 02/28/2019] [Accepted: 05/25/2019] [Indexed: 11/16/2022]
Abstract
We report the case of a French woman with acquired von Willebrand syndrome who presents recurrent subarachnoid and intra-cerebral hemorrhage since 2012. She had no family or personal bleeding history. In the biologic explorations, APTT was abnormally high with no anticoagulant drugs (it was normal, historically). Two monoclonal IgG and IgM kappa proteins were detected without any lymphoproliferative disorder. Intravenous infusion of immunoglobulin is very effective in AVWS with immunoglobulin G monoclonal gammapathie of undetermined significance. We had a satisfactory correction of coagulation factors for about 30 days. The exploration of APTT is surely essential for the diagnosis and treatment.
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Affiliation(s)
- F Pineau-Vincent
- Hemostasis, Hospital Center Le Mans, 194, avenue Rubillard, 72037 Le Mans, France.
| | - A Legout
- Neurology, Hospital Center Le Mans, 194, avenue Rubillard, 72037 Le Mans, France.
| | - A Besancon-Bergelin
- Hematology, Hospital Center Le Mans, 194, avenue Rubillard, 72037 Le Mans, France.
| | - M Alani
- Hematology, Hospital Center Le Mans, 194, avenue Rubillard, 72037 Le Mans, France.
| | - K Laribi
- Hematology, Hospital Center Le Mans, 194, avenue Rubillard, 72037 Le Mans, France.
| | - P Lemaire
- Hemostasis, Hospital Center Le Mans, 194, avenue Rubillard, 72037 Le Mans, France.
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38
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Pardos-Gea J, Martínez F, Abrisqueta P, Santamaría A, Bosch F. Acquired von Willebrand syndrome in a patient with small lymphocytic lymphoma and Sjögren's syndrome: which associated condition should be prioritized? Blood Coagul Fibrinolysis 2019; 30:239-242. [PMID: 31157683 DOI: 10.1097/mbc.0000000000000814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
: Acquired von Willebrand syndrome (AVWS) is a rare hemorrhagic condition that poses both a diagnostic and a therapeutic challenge. Here we report a singular case of AVWS with two associated conditions, small lymphocytic lymphoma (SLL) and Sjögren's syndrome. The patient presented with recurrent and severe digestive bleeding that forced us to raise a curative attempt of AVWS. A first immunosuppressive therapy with immunoglobulins was unsuccessful and it was later decided to treat lymphoproliferative entity with bendamustine and rituximab effectively achieving SLL and AVWS remission. On the basis of our case and through literature review, we discuss potential strategies to achieve AVWS remission when it appears in the setting of several causative associated conditions.
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Affiliation(s)
| | | | - Pau Abrisqueta
- Department of Hematology and Vall d'Hebrón Institute of Oncology (VHIO), Vall d'Hebrón University Hospital, Barcelona, Spain
| | | | - Francesc Bosch
- Department of Hematology and Vall d'Hebrón Institute of Oncology (VHIO), Vall d'Hebrón University Hospital, Barcelona, Spain
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Abstract
Heyde described aortic stenosis and gastrointestinal bleeding in the 1950s. Since then, a link with intestinal angiodysplasia and abnormalities of von Willebrand factor (VWF) has been noted. Loss of the highest-molecular-weight multimers of VWF and bleeding also have been described in subaortic stenosis in hypertrophic cardiomyopathy, in isolated mitral and aortic insufficiency, in endocarditis, in patients with prosthetic valve stenosis or regurgitation, and in patients with left ventricular assist devices (LVADs). Bleeding tends to recur with local treatment of angiodysplasias, whereas cardiac repair or removal of LVAD eliminates VWF dysfunction is curative of bleeding in the majority.
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40
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Matsunaga Y, Ishimura M, Nagata H, Uike K, Kinjo T, Ochiai M, Yamamura K, Takada H, Tanoue Y, Hayakawa M, Matsumoto M, Hara T, Ohga S. Thrombotic microangiopathy in a very young infant with mitral valvuloplasty. Pediatr Neonatol 2018. [PMID: 29523490 DOI: 10.1016/j.pedneo.2018.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathies (TMA) are microvascular occlusive disorders characterized by systemic or intrarenal platelet aggregation, thrombocytopenia, and red cell fragmentation. Post-operative TMA mostly occurs in adult patients with cardiovascular surgery, with the distinct pathophysiology from classical thrombotic thrombocytopenic purpura (TTP) although the exact pathophysiology remains unclear. CASE PRESENTATION A one-month-old infant developed TMA after the initial surgery of double outlet right ventricle. ADAM metallopeptidase with thrombospondin type 1 motif 13 (ADAMTS13) activity was sustained (64%) with the undetectable inhibitor. Von Willebrand factor (VWF) multimer analyses showed absent high-molecular weight multimers. Echocardiography disclosed severe mitral regurgitation. The mitral valve repair 32 days after the initial valvuloplasty led to prompt resolution of TMA. These suggested that TMA occurred in association with valvulopathy-triggered turbulent shear flow, mechanical hemolysis and endothelial damage. The consumption of large VWF multimers might account for the vascular high shear stress shown in Heyde syndrome. CONCLUSION The youngest case of post-operative TMA underscores the critical coagulopathy after the first surgical intervention for congenital heart disease.
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Affiliation(s)
- Yuka Matsunaga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masataka Ishimura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan.
| | - Hazumu Nagata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Kiyoshi Uike
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Tadamune Kinjo
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masayuki Ochiai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Kenichiro Yamamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Hidetoshi Takada
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan; Department of Perinatal and Pediatric Medicine, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yoshihisa Tanoue
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Masaki Hayakawa
- Department of Blood Transfusion Medicine, Nara Medical University, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Japan
| | | | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Japan
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41
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Rottenstreich A, Kleinstern G, Amsalem H, Kalish Y. The course of acquired von Willebrand syndrome during pregnancy among patients with essential thrombocytosis. J Thromb Thrombolysis 2018; 46:304-309. [PMID: 29654448 DOI: 10.1007/s11239-018-1663-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
To investigate the course of acquired type 2A von Willebrand syndrome (AVWS) in relation to patient management and outcomes among pregnant patients with essential thrombocytosis (ET). A review of pregnant women with ET evaluated for AVWS at the beginning of pregnancy and at the third trimester. Eighteen women with 24 pregnancies were included in this study. A history of bleeding was noted in 8 (44%) patients. In 20 (83%) pregnancies AVWS was evident at the initial testing. Following initial testing, antithrombotic therapy was administered in 22 (92%) pregnancies (aspirin, n = 20 and low-molecular-weight heparin, n = 2). In the remaining two pregnancies, VWF:RCo levels were below 30%; thus, aspirin was given only after repeat testing at 14-16 weeks. At third trimester testing, median VWF:RCo levels were significantly higher than at the initial testing (86 vs. 48%, P < 0.001), with no evidence of AVWS in any of the patients. Significant increases were also observed in the VWF:Ag level (127 vs. 84%, P < 0.001), the VWF:RCo/VWF:Ag ratio (0.75 vs. 0.54, P < 0.001) and the FVIII level (103 vs. 68%, P < 0.001); while platelet count (359 vs. 701 × 109/l, P < 0.001) and hemoglobin level (11.6 vs. 13.4 g/dl, P < 0.001) decreased. Neuraxial anesthesia was safely performed in 17 (71%) pregnancies. No significant bleeding events occurred during pregnancy and delivery. AVWS-related abnormalities in women with ET mostly improved during pregnancy, with favorable maternal and fetal outcomes. VWF parameters should be tested at early pregnancy and repeated at the third trimester, to guide pregnancy and delivery management.
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Affiliation(s)
- Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Geffen Kleinstern
- Braun School of Public Health and Community Medicine, Faculty of Medicine of the Hebrew University and Hadassah, Jerusalem, Israel.,Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Hagai Amsalem
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yosef Kalish
- Department of Hematology, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel.
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Deconinck S, Tersteeg C, Bailleul E, Delrue L, Vandeputte N, Pareyn I, Itzhar‐Baikian N, Deckmyn H, De Meyer SF, Vanderheyden M, Vanhoorelbeke K. Differences in von Willebrand factor function in type 2A von Willebrand disease and left ventricular assist device-induced acquired von Willebrand syndrome. Res Pract Thromb Haemost 2018; 2:762-766. [PMID: 30397685 PMCID: PMC6178689 DOI: 10.1002/rth2.12150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/10/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Patients with von Willebrand disease (VWD) type 2A or acquired von Willebrand syndrome (aVWS) as a consequence of implantation of left ventricular assist devices (LVAD) are both characterized by a loss of von Willebrand factor (VWF) function. Loss of VWF function is however more severe in VWD type 2A than in LVAD patients. OBJECTIVES To compare VWF function in patients with VWD type 2A and LVAD-induced aVWS to highlight the differences in VWF activity and to stress the importance of VWF multimer analysis for correct diagnosis of aVWS in LVAD patients. PATIENTS/METHODS Plasma samples from nine VWD type 2A, nine LVAD patients, and 20 healthy donors (HD) were analyzed for VWF function (VWF:CB/VWF:Ag and VWF:RCo/VWF:Ag) and loss of high molecular weight (HMW) VWF multimers. RESULTS A severely impaired VWF function was indeed confirmed in all VWD 2A patients. HMW VWF multimers were severely reduced compared to HD (0% [0, 12.29] vs 34.19% [31.68, 38.88] for HD, P < 0.001) and this loss was reflected by VWF:CB/VWF:Ag and VWF:RCo/VWF:Ag ratios <0.7. In contrast, VWF function was less affected in LVAD patients. Although HMW VWF multimers were reduced in all patients (20.31% [15.84, 21.71], vs 34.19% [31.68, 38.88] for HD, P < 0.001), six out of nine LVAD patients had normal VWF:CB/VWF:Ag or VWF:RCo/VWF:Ag ratios (>0.7). CONCLUSIONS VWF:CB/VWF:Ag or VWF:RCo/VWF:Ag analysis allows detection of impaired VWF function in VWD type 2A but not always in LVAD-induced aVWS patients. In contrast, VWF multimeric analysis allows detection of the loss of HMW VWF multimers in both groups of patients. Hence, performing VWF multimer analysis is crucial to detect aVWS in LVAD patients.
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Affiliation(s)
- Shannen Deconinck
- Laboratory for Thrombosis ResearchIRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | - Claudia Tersteeg
- Laboratory for Thrombosis ResearchIRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | - Els Bailleul
- Cardiovascular Center AalstOLV HospitalAalstBelgium
| | - Leen Delrue
- Cardiovascular Center AalstOLV HospitalAalstBelgium
| | - Nele Vandeputte
- Laboratory for Thrombosis ResearchIRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | - Inge Pareyn
- Laboratory for Thrombosis ResearchIRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | - Nathalie Itzhar‐Baikian
- Service d'hématologie biologique, Hôpital Lariboisière and EA3518‐Institut universitaire d'hématologieGroupe Hospitalier Saint Louis‐LariboisièreAssistance Publique‐Hôpitaux de ParisUniversité Paris DiderotParisFrance
| | - Hans Deckmyn
- Laboratory for Thrombosis ResearchIRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | - Simon F. De Meyer
- Laboratory for Thrombosis ResearchIRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
| | | | - Karen Vanhoorelbeke
- Laboratory for Thrombosis ResearchIRF Life SciencesKU Leuven Campus Kulak KortrijkKortrijkBelgium
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43
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Pelland-Marcotte MC, Humpl T, James PD, Rand ML, Bouskill V, Reyes JT, Bowman ML, Carcao MD. Idiopathic pulmonary arterial hypertension - a unrecognized cause of high-shear high-flow haemostatic defects (otherwise referred to as acquired von Willebrand syndrome) in children. Br J Haematol 2018; 183:267-275. [PMID: 30141279 DOI: 10.1111/bjh.15530] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/21/2018] [Indexed: 02/06/2023]
Abstract
Acquired von Willebrand syndrome (AVWS) is reported in high-flow high-shear congenital cardiac disorders. We hypothesized that the narrowed pulmonary vasculature in idiopathic pulmonary arterial hypertension (IPAH) may induce AVWS. We conducted a cross-sectional evaluation of children with IPAH. Patients with bleeding symptoms and/or laboratory abnormalities (thrombocytopenia, anomalies in coagulation screening tests) were tested in-depth for haemostatic defects. Fourteen children were followed with IPAH of which 8 were eligible. Four children exhibited abnormal bleeding scores (International Society on Thrombosis and Haemostasis Bleeding Assessment Tool: 3-5). All 8 patients showed very prolonged platelet function analyser (PFA)-100 closure times. Six children demonstrated either mild thrombocytopenia or low-normal von Willebrand factor (VWF) antigen (VWF:Ag) or VWF activity [mean (range), in iu/dl: VWF:Ag: 70 (61-91); VWF activity: 57 (34-70)]. Average VWF collagen binding capacity (VWF:CB) was 64 iu/dl (range: 53-123 iu/dl), with low-normal VWF activity/VWF:Ag or VWF:CB/VWF:Ag ratios occurring in five patients. All children had normal multimers distribution patterns. One patient underwent a lung transplantation, with normalization of haemostatic abnormalities post-surgery. Overall, 8 out of 14 children with IPAH had mild to moderate bleeding symptoms and/or laboratory abnormalities in keeping with AVWS. Normalization of the haemostatic defects following lung transplantation and lack of family history of bleeding attests to the acquired nature of their defects.
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Affiliation(s)
- Marie-Claude Pelland-Marcotte
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Tilman Humpl
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Margaret L Rand
- Division of Haematology/Oncology, Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Departments of Laboratory Medicine & Pathobiology, Biochemistry and Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Vanessa Bouskill
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.,Department of Nursing, The Hospital for Sick Children, Toronto, ON, Canada
| | - Janette T Reyes
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.,Department of Nursing, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mackenzie L Bowman
- Department of Medicine, Queen's University, Kingston, ON, Canada.,Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Manuel D Carcao
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
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44
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Mohamed M. Waldenstrom macroglobulinaemia manifesting as acquired von Willebrand syndrome. Intern Med J 2018; 48:888-891. [PMID: 29984508 DOI: 10.1111/imj.13941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/29/2017] [Accepted: 12/14/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Muhajir Mohamed
- Northern Cancer Service, Launceston General Hospital, Launceston, Tasmania, Australia.,Launceston Clinical School, University of Tasmania, Launceston, Tasmania, Australia
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45
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Sugase T, Akimoto T, Kimura T, Yagisawa T, Kusano E, Nagata D. Acquired von Willebrand Syndrome Complicating Nephrotic Syndrome: A Case of a Patient With Membranous Nephropathy. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2018; 11:1179547618763371. [PMID: 29568223 PMCID: PMC5858607 DOI: 10.1177/1179547618763371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/14/2018] [Indexed: 01/28/2023]
Abstract
Acquired von Willebrand syndrome (AVWS) is a rare clinical entity presenting with heterogeneous hemorrhagic manifestations, although some subsets of patients with AVWS may be asymptomatic until they are exposed to major trauma, an invasive procedure, or surgery. We herein report one such case in a 73-year-old male patient with nephrotic syndrome with a prolonged active partial thromboplastin time. We initially did not deal with this distinct abnormal clotting profile seriously, but persistent bleeding after a retroperitoneoscopic-assisted renal biopsy that allowed us to ascribe his nephrotic syndrome to membranous nephropathy fortuitously led to the discovery of concurrent AVWS. We feel that an accurate and prompt diagnosis as well as awareness of the disease remain a challenge for physicians and therefore strongly recommend the further accumulation of experiences similar to our own in a prospective manner. This report underscores the pitfalls associated with determining the bleeding risk, including an insufficient assessment and improper weighting of an abnormal clotting profile prior to the invasive procedure. Several management concerns that emerged in the current case are also discussed.
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Affiliation(s)
- Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takaaki Kimura
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Shimotsuke, Japan
| | - Takashi Yagisawa
- Division of Renal Surgery and Transplantation, Department of Urology, Jichi Medical University, Shimotsuke, Japan
| | - Eiji Kusano
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
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46
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Blackshear JL. Gastrointestinal Bleeding in Native and Prosthetic Valve Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:6. [PMID: 29397472 DOI: 10.1007/s11936-018-0595-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Gastrointestinal bleeding with severe aortic stenosis was originally described in the 1950s by Heyde, although for years, the association was debated. Further discovery of mechanisms and the ubiquity and severity of acquired von Willebrand syndrome in the left ventricular assist device therapy have removed any doubts. At this time, gastrointestinal bleeding from intestinal angiodysplasia in patients with turbulence-related proteolysis of the highest molecular weight multimers of von Willebrand factor is now known to occur in patients with aortic stenosis, and also subaortic obstruction and associated mitral insufficiency in hypertrophic cardiomyopathy, isolated mitral and aortic insufficiency, endocarditis, and in patients with prosthetic valve dysfunction, either from stenosis or insufficiency. The degree of loss of high molecular weight multimers correlates with lesion severity, and tests of von Willebrand factor function have been proposed as important biomarkers of the severity of valve dysfunction, including in-lab testing for paravalvular leak during transcatheter aortic valve replacement. Bleeding tends to recur after endoscopic or surgical therapy, but cardiac repair is curative in the great majority.
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Affiliation(s)
- Joseph L Blackshear
- Department of Cardiovascular Diseases, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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47
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Heilmann C, Trummer G, Beyersdorf F, Brehm K, Berchtold-Herz M, Schelling J, Geisen U, Zieger B. Acquired Von Willebrand syndrome in patients on long-term support with HeartMate II. Eur J Cardiothorac Surg 2017; 51:587-590. [PMID: 28082469 DOI: 10.1093/ejcts/ezw348] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 08/19/2016] [Indexed: 01/15/2023] Open
Abstract
Objectives Impaired binding of Von Willebrand factor (VWF) to platelets and to collagen due to acquired Von Willebrand syndrome (AVWS) is associated with support from a ventricular assist device (VAD) and can contribute to bleeding tendencies in patients with VADs. The onset of AVWS has been shown to occur immediately after VAD implantation. Our aim was to determine long-term data on AVWS in VAD patients. Methods We analysed 278 data sets of 74 patients on HeartMate II (HMII) support for 3-80 months after implantation (11.2 ± 12.1, median 6.3 months.). Ristocetin cofactor activity (VWF:RCo), collagen binding capacity (VWF:CB), VWF antigen (VWF:Ag) and the ratios of VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag were determined. Further, the presence of high molecular weight (HMW) multimers of VWF was investigated. Results Abnormally low values of VWF:RCo/VWF:Ag and VWF:CB/VWF:Ag were found in 69% and 97% of blood samples, respectively. Only ten of 181 multimer analyses showed a normal pattern, and HMW multimers were present in both specimens in only one of the 74 patients. No significant changes in these parameters were observed over time. The VWF:CB/VWF:Ag ratio correlated with the multimer patterns, whereas the VWF:RCo/VWF:Ag ratio seemed to be less sensitive for AVWS. Conclusions Our data indicate that AVWS is a typical phenomenon in patients with VAD support and that there are no time-dependent changes in these parameters apparent in most patients on long-term support with HMII.
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Affiliation(s)
- Claudia Heilmann
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Kerstin Brehm
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Freiburg, Germany
| | - Johannes Schelling
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Geisen
- Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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48
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Lad D, Jain A, Varma S. Complications and management of coagulation disorders in leukemia patients. Blood Lymphat Cancer 2017; 7:61-72. [PMID: 31360085 PMCID: PMC6467343 DOI: 10.2147/blctt.s125121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with leukemia are predisposed to various coagulation abnormalities. Thrombosis and bleeding continue to be a major cause of morbidity and mortality in leukemias. The pathophysiology of these disorders is unique, and not only the disease but also the treatment and other factors play a role. There has been an increase in the understanding of these disorders in leukemias. However, it is still difficult to predict when and which patients will have these complications. The evidence for the management of coagulation abnormalities in leukemias is still evolving and not as established as in solid malignancies. The management of these disorders is complex, and making clinical decisions is often challenging. In the era of specialization, where there are different hematologists looking after benign- and malignant-hematology patients, opinions of thrombosis experts are often sought by leukemia specialists. This review aims to bridge the gap in the knowledge of these disorders between these specialists.
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Affiliation(s)
- Deepesh Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Arihant Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India,
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49
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Novel insights into the clinical phenotype and pathophysiology underlying low VWF levels. Blood 2017; 130:2344-2353. [PMID: 28916584 DOI: 10.1182/blood-2017-05-786699] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/01/2017] [Indexed: 11/20/2022] Open
Abstract
Critical clinical questions remain unanswered regarding diagnosis and management of patients with low von Willebrand factor (VWF) levels (30-50 IU/dL). To address these questions, the Low VWF Ireland Cohort (LoVIC) study investigated 126 patients registered with low VWF levels. Despite marginally reduced plasma VWF levels, International Society of Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH BAT) confirmed significant bleeding phenotypes in the majority of LoVIC patients. Importantly, bleeding tendency did not correlate with plasma VWF levels within the 30 to 50 IU/dL range. Furthermore, bleeding phenotypes could not be explained by concurrent hemostatic defects. Plasma factor VIII to VWF antigen (VWF:Ag) ratios were significantly increased in LoVIC patients compared with controls (P < .0001). In contrast, VWF propeptide to VWF:Ag ratios >3 were observed in only 6% of the LoVIC cohort. Furthermore, platelet-VWF collagen binding activity levels were both significantly reduced compared with controls (P < .05). In response to 1-desamino-8-D-arginine vasopressin (DDAVP), peak VWF:Ag levels exceeded 100 IU/dL in 88% of patients and was sustained >100 IU/dL after 4 hours in 72% of subjects. In conclusion, our novel data suggest that low VWF levels can be associated with significant bleeding and are predominantly due to reductions in VWF synthesis and/or constitutive secretion. Although enhanced VWF clearance may contribute to the pathophysiology in some individuals, the absolute reduction in VWF plasma half-life is usually mild and not sufficient to significantly impact upon the duration of DDAVP-induced VWF response. This trial was registered at www.clinicaltrials.gov as #NCT03167320.
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Jones MB, Ramakrishnan K, Alfares FA, Endicott KM, Oldenburg G, Berger JT, Shankar V, Nath DS, Diab YA. Acquired von Willebrand Syndrome: An Under-Recognized Cause of Major Bleeding in the Cardiac Intensive Care Unit. World J Pediatr Congenit Heart Surg 2017; 7:711-716. [PMID: 27834763 DOI: 10.1177/2150135116658011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/13/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acquired von Willebrand syndrome (AvWS) in the setting of congenital heart disease is an under-recognized cause of bleeding in the pediatric cardiac critical care unit. METHODS Fourteen patients diagnosed with AvWS admitted to the cardiac intensive care unit at the Children's National Health System between December 2009 and September 2015 were identified with subsequent chart review and case analysis. RESULTS Of the 14 patients included in this study, 4 patients were on ventricular-assist devices, 6 patients were on extracorporeal membrane oxygenation, and 4 were patients with congenital heart disease not receiving any mechanical circulatory support. All patients identified manifested persistent severe bleeding, despite appropriate management of anticoagulation and blood product administration based on the established protocols. Detailed hemostatic testing including quantitative von Willebrand factor (vWF) multimer analysis revealed decreased high-molecular-weight multimers (HMWMs) and absent ultra-HMWM, consistent with AvWS in all patients. Eight patients received treatment with vWF concentrate, one patient with desmopressin, and five recovered without specific treatment. Bleeding ceased in all but one patient. CONCLUSIONS Acquired von Willebrand syndrome is an uncommon but important cause of bleeding in pediatric patients with cardiac disease. A high index of clinical suspicion with knowledge of the characteristic clinical scenario in addition to low levels of vWF multimers is required to manage and diagnose AvWS. Although the optimal management of AvWS in this patient population is unclear, vWF concentrates are available and appear to be efficacious for controlling life-threatening bleeding.
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Affiliation(s)
- Melissa B Jones
- Division of Critical Care, Children's National Health System, Washington, DC, USA
| | - Karthik Ramakrishnan
- Division of Cardiothoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Fahad A Alfares
- Division of Cardiothoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Kendal M Endicott
- Division of Cardiothoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Gary Oldenburg
- Division of Critical Care, Children's National Health System, Washington, DC, USA
| | - John T Berger
- Division of Critical Care, Children's National Health System, Washington, DC, USA
| | - Venkat Shankar
- Division of Critical Care, Children's National Health System, Washington, DC, USA
| | - Dilip S Nath
- Division of Cardiothoracic Surgery, Children's National Health System, Washington, DC, USA
| | - Yaser A Diab
- Division of Hematology, Children's National Health System, Washington, DC, USA
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