Breakthrough venous thromboembolic events in five patients with COVID-19 on direct oral anticoagulants

Case report: a transcatheter aortic valve replacement failure secondary to COVID-19 infection

Background

Valve thrombosis is a well-documented cause of bioprosthetic valve failure. Case reports have been published of prosthetic valve thrombosis secondary to COVID-19 infection. This is the first case report of COVID-19 associated valve thrombosis in a patient with transcatheter aortic valve replacement (TAVR).

Case summary

A 90-year-old female with atrial fibrillation on therapeutic apixaban and status-post TAVR presented with COVID-19 infection and was found to have severe bioprosthetic valvular regurgitation with features suggestive of valve thrombosis. She underwent valve-in-valve TAVR with resolution of valvular dysfunction.

Discussion

This case report contributes to a growing body of evidence describing the occurrence of thrombotic complications in patients with valve replacement and COVID-19 infection. Increased vigilance and continued investigation are warranted to better characterize thrombotic risk and to inform optimal antithrombotic strategies during COVID-19 infection.

Venous thromboembolism in COVID-19: A meta-summary of cases

OBJECTIVES

To summarize cases of venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT) among coronavirus disease (COVID-19) patients and discuss their symptoms, diagnostic method, clinical features, and prognosis.

METHODS

All major databases were searched for relevant studies published between December 1, 2019 and May 5, 2021.

RESULTS

A total of 233 articles were identified, 22 describing 48 patients were included. A total of 79.1% had PE and 20.9% had DVT. Most patients were men, with a mean age of 56 years. Comorbidities were present in 70.8%, and 85.4% had at least one risk factor of VTE. 56.3% had received anticoagulation therapy. Most patients were treated in the general ward. Complications occurred in 27.1% of the patients, and recovery was achieved in 80.4%.

CONCLUSION

Venous thromboembolism must be suspected even in patients who had received prior anticoagulant regimens or in stable cases, especially in males, the elderly, and patients with comorbidities and high D-dimer levels.

The pharmacology of anticoagulant drug treatment options in COVID-19 patients: reviewing real-world evidence in clinical practice

INTRODUCTION

The optimal anticoagulation strategy for venous thromboembolism (VTE) prevention among COVID-19 patients, hospitalized or in the community setting, is still challenging and largely based on real-world evidence.

AREAS COVERED

We analyzed real-world data regarding the safety and effectiveness of anticoagulant treatment, both parenteral and oral, for VTE prevention or atrial fibrillation (AF)/VTE treatment among COVID-19 patients.

EXPERT OPINION

The efficacy of low-molecular-weight heparin (LMWH) doses for VTE prevention correlates with COVID-19 disease status. LMWH prophylactic dose may be useful in COVID-19 patients at the early stage of the disease. LMWH intermediate or therapeutic dose is recommended in COVID-19 patients with an advanced stage of the disease. COVID-19 patients on VKAs therapy for atrial fibrillation (AF) and VTE should switch to NOACs in the community setting or LMWH in the hospital setting. No definitive data on de-novo starting of NOACs or VKAs therapy for VTE prevention in COVID-19 outpatients are available. In patients at high risk discharged after hospitalization due to COVID-19, thromboprophylaxis with NOACs may be considered.

A fatal case of extensive gastrointestinal necrosis due to portal and mesenteric vein thrombosis in the post-acute phase of COVID-19

Portal vein thrombosis (PVT) is considered a relatively rare thrombotic complication in coronavirus disease 2019 (COVID-19). Most reported cases of PVT develop within 2 weeks from COVID-19 onset. We report a fatal case of extensive gastrointestinal necrosis due to portal and mesenteric vein thrombosis approximately 6 weeks after the onset of critical COVID-19. Excessive elevation of his plasma D-dimer level had continued for weeks during the hospitalization contrary with improvement of respiratory failure. Thrombotic complication should be cautiously paid attention even in the post-acute phase of COVID-19, especially in patients with persistent elevation of plasma D-dimer level.

Edoxaban for the treatment of pulmonary embolism in hospitalized COVID-19 patients

PURPOSE

We aimed to investigate the clinical performance of edoxaban for the treatment of pulmonary embolism (PE) in hospitalized COVID-19 patients.

METHODS

We conducted a retrospective analysis selecting hospitalized patients with COVID-19 admitted to our Institution from 20 May 2020 to 20 November 2020 with computer tomography (CT) detected PE at admission, treated with edoxaban after initial parenteral therapy. Clinical outcomes were compared between patients with and without ARDS at admission and between those with and without CT confirmed PE resolution.

RESULTS

50 patients were included. Mean follow-up was 42.5 ± 10 days. No baseline differences were found between patients with ARDS (30%) and those without ARDS at admission. Patients with PE resolution (84%) were younger (P = 0.03), had a shorter duration of fondaparinux therapy (9.9 ± 3.8 vs 15.8 ± 7.5 days; P = 0.0015) and length of hospitalization (36 ± 8 vs 46 ± 9 days: P = 0.0023) compared with those without PE resolution. 2 patients experienced major bleedings. At multivariate analysis the time to edoxaban switch was the only predictor of the PE resolution (HR: 0.92; 95% C.I. 0.86 to 0.99).

CONCLUSION

Edoxaban was an effective and safe treatment for acute PE in COVID-19 setting.

Similarities and perspectives on the two C's-Cancer and COVID-19

COVID-19 continues to dominate the health-care burden in the twenty-first century. While health-care professionals around the world try their best to minimize the mortality from this pandemic, we also continue to battle the high mortality from different types of cancer. For the hemostasis and thrombosis specialist, these two conditions present some unusual similarities including the high rate of thrombosis and marked elevation of D-dimers. In this forum article, we discuss these similarities and provide some considerations for future research and therapeutic trials.

Update on drug interactions with non-vitamin-K-antagonist oral anticoagulants for stroke prevention in elderly patients

Introduction: We update the knowledge, since the last review in 2017, about drug-drug interactions (DDI) of non-vitamin-K-antagonist oral anticoagulants (NOAC) in patients ≥75 years.Areas covered: The literature was searched for: 'dabigatran,' 'rivaroxaban,' 'edoxaban,' or 'apixaban' and drugs, affecting platelet function, CYP3A4-, CYP2C9-, or P-Gp-activity. Pharmacodynamic DDI of NOAC with drugs affecting platelet function like nonsteroidal anti-inflammatory drugs and antiplatelet agents occur most frequently. Pharmacokinetic DDI with NOAC were found for 37 of 117 drugs. Reports about DDI with NOAC were found for 51% of P-gp-affecting, 38% for CYP2C9-affecting and 27% for CYP3A4-affecting drugs. Reports about DDI of cardiovascular drugs with NOAC were the most prevalent, followed by anti-infective and nervous system drugs. NOAC plasma levels were measured in retrospective and cohort studies and were associated with concomitant medication. Reports about DDI of NOAC were found in 71 patients ≥75 years.Expert opinion: The knowledge about DDI of NOAC in elderly patients is very limited. Studies should be carried out to investigate the role of drugs potentially interacting with NOAC, which until now have not been investigated. When studying DDI of NOAC, care should be taken to include elderly patients with impaired renal function and patients on polymedication.